**3.1 Efficacy in AR**

Georgitis showed that the use of saline solution in nasal irrigation reduces inflammatory mediators (nasal histamine, prostaglandin D2 and leukotriene C4), while at the same time decreasing nasal symptoms (Georgitis, 1994). It observed that performing nasal lavage is important in the treatment of allergic rhinosinusitis.

Subiza et al, published one of the best and most complete articles in the JACI, which indicated that the action of nasal lavages is simple and known: cleaning of nasal secretions, with anti-inflammatory effect and reduction in basophils and other anti-inflammatory cells. It is a complementary technique for intranasal corticosteroids, but is effective and convenient. Saline irrigation of the nose and sinuses during the pollen season inhibits the IgE response to grass pollen (Subiza et al, 1999).

According to Tomooka et al, patients who use nasal lavage twice a day for 3-6 week periods have statistically significant improvement (23 of the 30 symptoms on The Quality of Well Being scale questionnaires improve or disappear) (Tomooka et al, 2000).

Garavello et al state that the use of nasal irrigation with hypertonic saline serum (3 times a day) decreases the consumption of antihistamines and significantly improves rhinitis, starting from the third week of treatment, and clearly in the fourth and fifth, with a significant reduction in the use of oral antihistamines (Garavello et al, 2003). The study was performed on 20 children, whose ages were not reported, with seasonal AR and sensitisation to *Parietaria judaica*. Irrigation with hypertonic serum was performed on 10 of the children 3 times at day during the entire pollen season (6 weeks). The other 10 were not administered lavages and were used as controls.

Degirmencioglu et al showed that saline irrigation with isotonic or hypertonic solutions improve symptoms during the pollen season (Degirmencioglu et al, 2004).

#### **3.2 Usefulness in sinusitis and chronic rhinitis**

Lavages with isotonic and hypertonic saline serum are one of the mainstays of treatment of rhinosinusal disease, as they are safe, inexpensive and effective. The weight of evidence is such that the Allergy Foundation published an International Consensus article in *Allergy* (International Rhinitis Management Working Group, 1994) recommending the routine performance of these lavages for rhinitis.

Different clinicians confirmed that nasal irrigations with a saline solution along with nasal steroids are the basis of treatment for chronic sinusitis (Aukema & Fokkens, 2004).

Treatment of Allergic Rhinitis:

Chemical class Functional class

Alkylamines Brompheniramine,

chlorpheniramine, dexchlorpheniramine,

meclizine, oxatomide

triprolidine

Piperazines Buclizine, cyclizine, hydroxyzine,

Piperidines Azatadine, cyproheptadine,

Ethanolamines Carbinoxamine, clemastine,

Ethylenediamines Antazoline, pyrilamine,

Simons & Akdis, 2009; Simons & Simons, 2011).

published clinical trials (ARIA).

has a moderate effect.

Phenothiazines Methdilazine, promethazine

dimenhydrinate,

phenyltoloxamine

tripelennamine

dimenthindene, pheniramine,

diphenylpyraline, ketotifen

diphenhydramine, doxylamine,

Others Doxepin\* Azelastine, emedastine,

\* Doxepin has dual H1- and H2- antihistamine activities and is classified as a tricyclic antidepressant. Table 2. H1-antihistamines: chemical and functional classification (modified: Simons, 2004;

(seasonal or perennial) in children or adults is backed by significant evidence from

In the new classification of rhinitis and in the clinical practice guidelines promoted in the ARIA document, oral anti-H1 is recommended for use in intermittent and persistent mild AR, and combined with topical corticosteroids in persistent moderate/severe AR. It shows good response in seasonal AR, where symptoms mediated by histamines predominate and ocular symptoms are common. In persistent AR, in which congestion is significant, anti-H1

Oral antihistamines may cause subclinical side effects not noticed by the patient (somnolence, decreased coordination, etc.). This does not happen with the new non-sedating

Treatment with antihistamines in AR is almost universally accepted. In fact, the treatment of seasonal AR in children: The results of placebo-controlled trials of cetirizine (Allegra et al, 1993; Masi et al, 1993; Ciprandi et al, 1997a; Ciprandi et al, 1997b; Pearlman et al, 1997) and fexofenadine (Wahn et al, 2003) demonstrated significant improvements in symptoms with the study drug compared with placebo. Active-control studies compared cetirizine (Charpin

antihistamines, but generally up to 50% of patients self-medicate (Storms, 1997).

ARIA Document, Nasal Lavage, Antihistamines, Cromones and Vasoconstrictors 71

First (old) generation Second (new) generation

Acrivastine

Cetirizine, levocetirizine

Astemizol, bepotastine, bilastine, desloratadine, ebastine, fexofenadine, levocabastine, loratadine, mizolastine, rupatadine, terfenadine, alcaftadine

epinastine, olopatadine

Nevertheless, is cautioned that nasal irrigation with saline solutions could no longer be considered a mere adjunct treatment of rhinosinusitis (Brown & Graham, 2004). Despite being effective and safe, it is underused.

Metson lends support to the conviction that saline irrigation improves breathing and adds, more importantly, that it lengthens the time between relapses (Metson, 2004). Daily saline irrigation improves the quality of life of patients with sinusitis, decreasing symptoms and the use of medication (Rabago et al, 2002).

Nasal irrigation is a simple and inexpensive treatment that improves symptoms of a variety of sinonasal diseases, reduces the use of resources and helps minimise resistance to antibiotics (Papsin & McTavish, 2003). Also, nasal lavage improves endoscopic imaging of nasal mucosa and the quality of life of patients with chronic rhinosinusitis (Taccariello et al, 1999). The nasal lavage increases mucociliary flow, dilutes thick secretions, relieves irritated mucous membranes, eliminates crusts and foreign bodies, facilitates the healing of mucous membranes, reducing the need for blowing and improving the sense of smell. The sinus irrigation by itself prevented the need for surgery in 58% of patients with chronic sinusitis over a year (Hartog et al, 1997)
