I have the memory and attention span of a gnat, sorry for the
misattribution.  :-)

 Interesting that he follows Family

I think we've seen comparison studies of atomizers vs. pulsatile (Murray
has them posted on his site, I think), but not of all the methods, such
as neti, NeilMed, etc.

Susan

I submitted a comment that I'd like to see RTC's comparing the two
methods: pulsatile vs. non-pulsatile. If the editors find the post
acceptable, it will join Dr. Davidson's. Thanks for directing me to the
right spot.
Judy

P.S. He may not follow family practice lit, Judy, but he may subscribe
to a service that scans the net for new publications re: sinusitis,
frex, and emails them to him.

Susan

I checked and my little (subjective and full of typo's) comment was
posted, but more interesting was the comment by an ENT from Pittsburgh,
Here's her bio page:
http://www.upmc.edu/eyeear/SinoNasal/faculty/Ferguson.htm
Berrilyn Ferguson
She had an interesting take on irrigation, and recommends hypertonic
irrigation as tolerated, no preference for pulsatile irrigation and she
cites Davidson's review article on the topic.
Here's the URL for her post.
http://www.annfammed.org/cgi/eletters/4/4/295
Here's the text:
The authors report on the quality of life improvements and reflections
of over two dozen individuals utilizing hypertonic saline nasal
irrigation on an as needed basis. The findings provide validation of
the anecdotal experience of many rhinologists. Unique to this study was
an apparent added benefit of group training and discussions, which gave
these sufferers an additional benefit conferred from "group
support", a benefit acknowledged in many disease states from cancer
support groups to chronic debilitating diseases. I had not previously
considered that this kind of group support might be helpful for chronic
rhinosinusitis, but from the interviews it appears that it is indeed
appreciated by the participants.

I can think of no way to perform a blinded controlled study of nasal
irrigations, but that doesn't mean they are not effective. In fact,
the efficacy of the irrigation frequently overshadows the efficacy of
any number of added ingredients including antifungals, antibacterials,
and topical steroids.1 The irrigation serves to remove nasal debris in
noses that are not self-cleaning, which is particularly a problem in
patients with nasal polyps or who have undergone extensive sinus/nasal
surgery.

Nasal irrigation can also be helpful as a rinse to remove mucus before
the application of a topical steroid or antibiotic. I commonly
recommend a commercial nasal lavage kit, of which there are a half
dozen or so available to assist with compliance. There are many
commercially available nasal irrigators.2 I also provide our patients
with a "recipe" so that they can make their own saline irrigation.
Patients should be warned to use filtered or boiled water, and to make
sure the device used for irrigation is cleaned frequently to prevent
iatrogenic inoculation with water loving microbes such as Pseudomonas
and Serratia.

The debate of hypertonic versus normal saline irrigation is sure to
continue.3 I usually provide the patient with the recipe for hypertonic
saline and suggest that they reduce the amount of salt they add, if
they find that the hypertonic mixture is irritating. Interestingly,
hypertonic inhaled saline has been shown to be beneficial in cystic
fibrosis.4 Seven percent of patients with chronic rhinosinusitis carry
a mutation for cystic fibrosis compared to 2% of normal controls. Thus
there may be a variance in response to hypertonic versus isotonic
saline irrigations, depending on the cause of the patient's
rhinosinusitis.5

Finally, the authors capture in a qualitative manner the relief that
patients feel with this technique. I still recall the words of a
patient on her return visit, "I can't believe I've been suffering for
30 years with the sinus condition when relief was as easy and
inexpensive as this salt water wash." A trial of hypertonic or isotonic
saline nasal rinse is inexpensive, does not promote bacterial
resistance, and safe. Saline irrigations should be a therapeutic
alternative offered to any patients suffering from chronic
rhinosinusitis.

References

1. Ferguson BJ. Antifungal Nasal Washes for Chronic Rhinosinusitis:
What's Therapeutic -- The Watch or the Antifungal? J Allergy Clin
Immunology 2003;111(11)37-8.

2. Tomooka LT, Murphy C, Davidson TM. Clinical Study Literature Review
of Nasal Irrigation. Laryngoscope 2000;110(11)89-93.

3. Garavello W, Romagnoli M, Gaini RM. Hypertonic or Ice Tonic Saline
for Allergic Rhinitis in Children. Pediatric Allergy and Immunology
2005;16:91.

4. Elkins MR, Robinson M, Rose BR, Harbour C, Moriarty CP, Marks GB,
Belousova EG, Xuan W, Bye PT. National Hypertonic Saline in Cystic
Fibrosis (NHSCF) Study Group. A Controlled Trial of Long-term Inhaled
Hypertonic Saline in Patients with Cystic Fibrosis. N Engl J Med
2006;354:229-240.

5. Wang X, Moylan B, Leopold DA, Kim J, Rubenstein RC, Togias A, Proud
D, Zeitlin PL, Cutting GR. Mutation in the Gene Responsible for Cystic
Fibrosis and Predisposition to Chronic Rhinosinusitis in the General
Population. JAMA 2000;284:1814-1819.

Competing interests:   None declared

Judy

Better results are often obtained by going by objective evidence.

Patients will often fabricate symptoms to get the diagnosis they want.

Obviously this would not be the case with you or me, but a lot of people deal
on the basis of deceit in their daily lives and carry it right into the
doctor's office - particularly manipulative people.

Then there is the placebo effect, etc. etc.

Now I agree with you that I would like the doctor to pusue avenues suggested by
my subjective comments.   Very thoroughly.  

But on occasions, I have been told that there was nothing wrong with me despite
"symptoms."  They were usually right and this was a tremendous relief (when I
heard it from an authoritative enough source after a thorough investigation).

You will find doctors who will listen to your every self-diagnosis and sign off
on it.   They are useful to have available on occasion.

But overall, I think some skepticism is not at all inappropriate on the part of
the doctor in most cases.  

Maybe we need both types of doctor.