To get a little better idea of this donnybrook take a look at David
Rabago's comments about irrigation and
Schied's reply.

http://www.aafp.org/afp/20051101/letters.html

In regard to Axleson's 1975 paper, if you kill off all the Smiths in a
community, there are still all the Joneses.
It is probable that Schied still thinks that a biofilm is something
that is shown on the discovery channel.
If he had ever taken time to look at mucus samples using the stain
available to your adverage water chemist at your sewage treatment
plant, or sections from his surgically removed samples he would
realize that there is a complicated community there, and if you drop a
single antibotic on the biofilm,  vulnerable organisms are quickly
replaced by those with more resistance.
What they all share is adhesion factors and signaling. defeat the
adhesion factors or find the right signal and it drops off.

I also had surgery by Dr. Metson in 2000, and he only advocated the
bulb syringe: as I posted before, I had a bad outcome, a pseudomonas
bone infection, and Dr. Metson was not helpful post-op. My local ENT
did two surgeries to remove dead bone and scars and he was adamant
that the dark wet bulb syringe harbored pseudomonas. He also felt that
the water pik like devices could be harmful, and he had me use the
neti pot: easy to clean and he felt a high volume, low pressure flow
was the best bet. He also likes the head position of the neti for
irrigating. My local ENT actually tries all the irrigation products on
himself.
 I concur that Dr. Grossan's sources are often outdated, and it's
very interesting to have someone actually read a source and find that
it doesn't support the claims.
 One of the best discussions about irrigation was in a comment after
a family practice article on quality of life with irrigation--using
the neti pot--by an ENT from Pitt. She just advocated hypertonic
saline and a device that could be thoroughly cleaned to avoid "water
loving bacteria".
 http://www.annfammed.org/cgi/eletters/4/4/295
Berrylin J Ferguson,
Pittsburgh, USA
M.D., University of Pittsburgh School of Medicine
Send response to journal:
Re: Commentary on: "Qualitative Aspects of Nasal Irrigation Use by
Patients With Chronic Sinus Disease in a Multimethod Study"

Email Berrylin J Ferguson

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

Susan has taken a lot of grief for suggesting that Dr. Grossan's
claims are unproven. I think that often people hold strong beliefs,
based on clinical experience, but have no evidence to support them.

Thanks for reading the Metson book. Personally I had such a bad
experience with him, I couldn't look at it.
Judy