(by Dr. Kathleen Summers, 18 May 2010)


Just about everyone’s heard of the neti pot by now. It’s received significant media attention. National Public Radio broadcast a morning story about it1, and it made the Oprah Winfrey show in May of 2007.

Now that it’s main-stream, neti pots are readily available at most pharmacies. Many family physicians, 87 percent in one survey, are prescribing them for chronic sinus and allergy problems.2 Medical guidelines in both the United States and Canada are recommending the nasal saline flush for a variety of sinus conditions.3,4,5

What many people haven’t heard is that the simple, natural, and inexpensive technique of neti originates from within the system of Yoga.

This article begins with a brief exploration of those roots as described in an old Yogic text. Details of the technique follow. We’ll then look at how neti was done according to the traditional teachings, and how it’s currently being taught at the most respected institutions in India. There’s a link to a great instructional site for the currently popular version used in Western medicine. It includes an entertaining video.

To better understand what’s happening when all that salt water goes up your nose, a review of the anatomy and physiology of the nasal and sinus passages has been provided.

And, for those of you who are interested in the science of it all, towards the end there’s a summary of studies supporting the use of neti and of those that determine just how it works. Technical details will be reviewed, things like how much volume, what temperature, the appropriate concentration of salt, and what devices are out there on the market for use with neti.

Where Neti Comes From and What It Is

A descriptive reference of neti and the sinus flush is found in the Gheranda Samhita, a classic Yogic text dating from the late 1600s or early 1700s6. As Yoga was an oral tradition for centuries, how old the techniques are or from where exactly they originate is unknown.

The purpose of neti and other cleaning practices of Danta-dhauti is purification, a prerequisite on the path to Yoga, the ultimate union. The body, meaning both the physical body and the “subtle body” of energy, are to be purified and freed from disease as a preparatory practice for techniques that lead to Liberation6.

As “neti” is specifically described in the Gheranda Samhita, it refers to “sutra neti,” or the cleaning of the nasal passages with a thread. A later verse describing “jala neti,” or the cleaning of the nasal passages with liquid, is referred to as Vyutkrama.

• 1: 25 Cleaning of five – the root of the teeth, the root of the tongue, openings of the two ears, and the sinuses is called Danta-dhauti.

• 1:49 One should insert into a nostril a fine 9 inch thread and pull it out through the mouth. This process is called neti.

• 1:50 Practice of neti facilitates the process of khecari, removes disorders of phlegm, and gives sharp vision.

• 1:57 After drawing water through the two nostrils one should expel it through the mouth. Repeatedly taking in water (in this way), this Vyutkrama cures disease of phlegm.

• 1:58 Sucking water by the mouth so as to produce a hissing sound one should throw it out through the nostrils. By this practice one can become handsome.

• 1:59 Because of this sitkrama old age does not set in, nor does one suffer from fever. The body is brought under control and is free from disorders of phlegm.
  
  

From a metaphysical point of view, according to Swami Satyananda Saraswati of the Bihar School of Yoga, purification through neti helps to sensitize ajna chakra, the third eye, aiding in its awakening and profoundly altering psychic awareness. He recommends neti, both jala and sutra, every morning before any other practices are undertaken. In that way, the free flow of breath may be attained in both nostrils facilitating a meditative state7.

How Neti is Taught Now in India

One of the oldest and most well known modern Yoga institutions in India is Kaivalyadhama at Lonavala, a small city between Mumbai and Pune. The founder, Swami Kuvalayananda, made a strong effort with its establishment in the 1920s to bring current scientific methodology and understanding to traditional practices. Well respected in his day, even Mahatma Gandhi wrote requesting his help.

According to one of his disciples, Swami Kuvalayananda is responsible for the modernization of neti9. In an article published in the Yoga-Mimamsa, the scientific journal of Kaivalyadhama, the author writes,

“Even then an average man experiences some difficulty in learning it. If the water is snuffed in with force, and if it happens to touch the olfactory mucosa, one gets sneezing. Sometimes the water even enters the bronchial tree and one gets a bout of cough. So a simple method was developed by late Swami Kuvalayananda where a feeding cup is used to accomplish all that is done in Vyutkrama Neti. Luke warm water (about 150 ml or more) with some salt in order to make it slightly hypertonic is taken in a feeding cup or a pot with a long nozzle. The nozzle of the feeding cup is put in one of the nostrils and the head is gradually tilted to the opposite side till, due to gravitational force, water from the feeding cup or pot starts flowing through the upper nostril and comes out through the lower nostril. If the head is slightly tilted forward, no water comes in the mouth. Breathing is continued through the mouth during this period. The same process is repeated through the other nostril. Here one remains passive while in traditional jala neti, water is to be drawn inside. In another variety of this, water taken through the nostril is either brought out through the mouth or is swallowed down. Breathing is continued through another nostril.”

A recent visit to the Kaivalyadhama Yoga Hospital in Lonavala revealed the instructors are still teaching both sutra and jala neti. Every morning a mentor meets anyone who will show up at 6:30 to help them learn the techniques. Sutra neti is performed with a tiny, inexpensive rubber catheter found in their shop. After jala neti, it’s recommended that 10 to 15 forceful expirations, or Kapalabhati, are performed to remove excess liquid.

In contrast, a visit to the The Yoga Institute in Mumbai, another well-established institution of Yoga therapy, revealed that they teach the traditional version of jala neti as described in the Gheranda Samhita. A salt solution is made and then poured into the palm of the hand from where it is sucked up into the nasal cavity and released through the mouth. Unlike the passive version taught at Kaivalyadhama, this version requires active effort to pull in liquid. Training in sutra neti is reserved for more advanced Yoga students.

Instructions: How to Perform Neti and How to Use a Neti Pot

As you can see from the above discussion, there’s more than one way to go about purification of the nose and sinuses.

The traditional method of jala neti, otherwise referred to as Vyutkrama, requires no cup, no pot, no catheter, and no other fancy equipment. It can be done anywhere at almost anytime without the need to be carrying anything with you. All you need is your hand and some salt water. It’s simple, and the mechanical force precipitated by the sucking action likely leads to a better debridement of the nasal mucosa than a passive stream of liquid provided by a neti pot. Just mix up some saline solution by dissolving ½ teaspoon of non-iodinated salt or sea salt into 250 ml of tap water, and then pour the solution into your cupped hand until it is full. Lower your nose to your hand and breathe in deep. Try to pull as much of the liquid in as possible, letting it drain out your mouth. It won’t hurt to swallow it, but it’s not a great idea.

If sucking salt water up your nose doesn’t really work for you, then try the gentler neti pot version. Mix the saline solution as described above and put it into the neti pot. Then place the spout of the neti pot snuggly into one nostril. Lean over the sink, tilting your head to the other side and bend slightly forward. When tilting the neti pot up, saline should drain from the higher nasal passage to the lower one, coming back out that lower nostril, or sometimes out of the mouth.
Either of these techniques can be practiced in a hot shower where the concern over dripping and making a mess is less and the steam will help to open up the sinuses. Be sure to use a saline solution that is made fresh daily to prevent the addition of bacteria to your sinuses rather than their clearance. If your nose burns or stings when you’re finished, then try to use a little less salt in the solution the next time around. Practice Kapalabhati, or forceful expirations, immediately after the saline irrigation to clean it all out, or carry a tissue around with you for the small leak you may have for 15-20 minutes afterwards.

The University of Wisconsin School of Medicine and Public Health has a fantastic instructional site at www.fammed.wisc.edu/research/past-projects/nasal-irrigation. There’s a video of a man performing jala neti, recipes for making saline solutions, directions on how to irrigate, troubleshooting tips, and links to the National Public Radio audio program on neti.

What’s Up Your Nose – The Anatomy

The nasal cavity and sinuses are together a maze of interconnecting passageways through which air and small particles can traverse. Let’s explore.

Pretend you’re a tiny particle of plant pollen. Someone breathes you in through the external portion of their nose, the part we can see in the mirror. You’ve entered into the vestibule of the right nostril, which is separated from the left side by the nasal septum. This small vestibule is only a portion of the much larger nasal cavity. If you’re lucky you don’t get caught up in its hairs designed to trap you and other dust and contaminants.

You make it past those pesky traps and head for the big opening. Once through, you arrive at a huge cave-like chamber, the largest part of the nasal cavity. The nasal septum is still there, separating the cavity on the right from the one on the left. The lateral walls of the cavity are bumpy with big bony prominences known as the inferior, medial, and superior conchae (pronounded kong-key). Each concha has a meatus, a passageway through which you can travel.

In the middle meatus you find some intriguing, tiny holes called ostia. You slip through one and find yourself in a frontal sinus, a hollow chamber located in the forehead above your host’s eye. It’s a bit small, so you squeeze back out and explore a different opening. This time you find yourself in a maxillary sinus, another hollow chamber in the upper part of your host’s cheek, just below the eye. It’s a bit boring in there and you like adventure, so you try another that leads into one of many small ethmoid sinuses set a little farther posterior. Behind them, in the far back, is the hollow sphenoid sinus.

As you’re having so much fun, you check out the inferior meatus. In there, you see the nasolacrimal ducts. Suddenly, teardrops are raining down from above and flooding you back out.

You fight towards the back opening of the nasal cavity, the choanae. The choana on the right and the one on the left both open into the nasopharynx where there is no longer a dividing septum. Here you can see the Eustachian tubes leading to the ears, and if you’re not careful you’ll travel down into the oropharynx where you may get swallowed or inhaled into the lungs.

You’ve been lucky so far. Nasal mucosa lines the entire nasal cavity and paranasal sinuses except for the vestibule. Goblet cells in the mucosa secrete sticky mucus designed to catch you and expel you with a big blow of snot. The mucus is propelled by cilia, tiny hair-like projections that sweep mucus and foreign particles like you towards the ostia of the sinuses and out the nostrils or into the nasopharynx to be swallowed. After the hairs in the vestibule, this is the next stage of your host’s defense mechanism, and it plays a critical role in protecting it against infection and allergens. The mucociliary clearance rate, or the speed by which foreign particles are removed, is determined by the amount of mucus, its thickness, and the frequency at which the cilia beat back and forth.

When Things Go Wrong: Disease of the Nasal Cavity and Sinuses

Now you, that little piece of pollen floating around inside the nasal cavity and sinuses of some nice host, decide to be a brat.

So you tease a little bit, causing your host to mount an allergic response. Histamine and leukotrienes are released from mast cells triggered by antibodies your host has formed in response to the threat he sees in you, the foreign invader. They cause an increase in blood flow and leaky blood vessels resulting in more mucus production and swelling of the nasal mucosa.

Your host’s nose runs. He feels congested. The histamine makes him itch inside the nasal cavity and the nasopharynx. The palate, which serves as both the roof of the mouth and the floor of the nasal cavity, itches. Hooray. You’ve succeeded in making him miserable.

The continued swelling of the nasal mucosa impairs drainage. Those tiny ostia become so swollen they cannot allow the release of mucus and debris. The sinuses close off, creating pressure and sometimes functioning as an incubator for bacteria. Any increased amount or thickness of the mucus can overwhelm their clearing ability and leads to secondary infection10. With long term inflammation, the cilia become damaged and no longer function correctly.11

Chronic inflammation can eventually develop in a host constantly exposed to allergens. Others develop chronic inflammation of the nasal cavity and sinuses for unclear reasons. “Chronic” essentially means symptoms lasting on a consistent basis for more than 12-weeks.

How Does Neti Work?

Nasal irrigation with neti works by:

• Mechanically flushing out bacteria, viruses, dust, and allergens12,13,14,26
• Thinning remaining mucus so that sinuses and ostia don’t clog14,18
• Decreasing swelling of the nasal mucosa14,15,27,29
• Removing histamine, leukotrienes, and other inflammatory substances14,16
• Increasing frequency that cilia beat to remove mucus, crusts and debris17
  
  

Yes, there’s scientific evidence that flushing with salt water works to decrease the symptoms of rhinosinusitis, or inflammation of the mucosa of the nasal cavity and sinuses that occurs in response to viruses, allergens, bacteria and other irritants.

A study published in the Archives of Otolaryngology Head and Neck Surgery in 1997 asked participants a survey of questions known as the SNOT-20. They were asked about 20 symptoms such as the need to blow the nose, sneezing, postnasal drainage, cough, runny nose, congestion, trouble sleeping, and more. Compared to controls that were simply spraying saline into their noses, participants flushing with normal saline (0.9%) using Sinus Rinse irrigations had fewer symptoms, and they experienced those symptoms less often. They achieved a clinically significant improvement in their quality of life as measured by the SNOT-20 while the spray group did not.19

In 2002, Rabago and his group in Wisconsin irrigated the noses of study subjects with 150 ml of 2% buffered saline (1tsp heaping of canning salt, one-half teaspoon of baking soda, and 1 pint of fresh tap water) daily into each nostril for six months. They found a statistically significant reduction of symptom severity and an improved quality of life. Use of antibiotics and medical nasal sprays decreased.20

Heatley et al also noted that patients reduced their use of medicines significantly due to improvement of symptoms with this natural method of healing.21

A study published in Laryngoscope used store-bought dental Water-Pik devices with Grossan nasal adapters (Hydromed or Kenwood Therapeutics) to irrigate both nostrils of subjects with 250 ml of lukewarm tap water with a half teaspoon of table salt twice a day. They reported improved symptoms of congestion, postnasal drainage, allergies and discharge in 23 out of 30 participants after six weeks of use. 92% of the study participants completed the six week program, signifying its practical ease of use.11

A 2009 study looked at the common cold in children. On average, kids get 6-8 per year, and the US Food and Drug Administration recently changed the label on all over-the-counter cold medicines to prohibit their use in kids younger than 6 years of age. In this report, 69 children aged 3-12 years first saw a film on neti and witnessed a facilitator perform it. They then demonstrated proficiency using disposable syringes filled with 15-20 ml of normal saline (0.9%) per nostril, and were instructed to perform the action 1-3 times per day. At the end of the study period, the children showed an overall improvement in nasal air flow, decreased symptoms indicating improved quality of life, and an improvement of pathology noted on sinus X-rays.24

A small randomized controlled trial in children with lab confirmed pollen triggered symptoms found that saline irrigation in addition to antihistamine pills significantly reduced allergy symptoms and the amount of medicine taken. In comparison, when only antihistamine treatment without nasal irrigation was used, kids were noted to obtain less symptom relief and required more medicine to be comfortable.22

Adults with hay fever, have also reported improvement of allergy symptoms when using saline nasal irrigation in clinical trials.23

Pregnancy inhibits many women from using cold and allergy medicine for symptom relief. A recent study asked pregnant women with seasonal allergies to irrigate their sinuses with saline containing a higher than usual concentration of salt. They irrigated 3 times daily for 6-weeks as opposed to a control group who used no local therapy. Those irrigating noted a statistically significant improvement in symptoms from 2-weeks on throughout the remainder of the trial. Rhinomanometry, a measure of nasal airway resistance, also improved, an objective measurement of decreased congestion and ease of breathing through the nose.25

Woodworkers with chronic symptoms from wood dust demonstrated significantly improved mucociliary clearance and nasal air flow on expiration after a program of nasal saline irrigation.28

Neti has also been show to be an effective method for preventing viral infections of the nasal cavity and sinuses. A randomized, controlled study of 60 adults found that those performing daily nasal irrigations had fewer episodes. When they did get infected, their symptoms lasted fewer days.30

There’s also a preventative effect in kids. In a randomized, controlled study of 390 children, those irrigating their sinuses with saline had fewer episodes of sinus congestion and runny noses. Those using neti on a preventative basis were less likely to end up being treated with medication.31

There are many more scientific studies showing positive and genuine results with neti, too many to write about them all.

Which Neti Method Works the Best?

While the nasal cavity is easily accessible and can get a good wash with most any method of flushing, the sinuses are much harder to reach. The saline has to find its way through the tiny ostia into the sinuses. Those small openings are made even smaller by inflammation of the mucosal lining from infection, allergy, or irritation caused by dust or smoke.

The frontal and sphenoid sinuses are virtually inaccessible.32,35 An ostial size of at least 4 mm is required to achieve penetration of saline into the maxillary sinuses. Large volume, high pressure irrigation appears to have the best chance of reaching them.33,34

The neti pot is a large volume device, but it doesn’t provide much pressure. Squeeze bottles (Sinus Rinse), bulbs, syringes, and pressurized spray devices (dental Water-Pik with a nasal adapter) are also large volume devices, and they administer the saline with more force and pressure resulting in the best chance of reaching the sinuses in addition to flushing the nasal cavity.32,33,34

The traditional method of jala neti as described in the Gheranda Samhita can be large volume, and the suction effect of sniffing the saline solution into the nostrils creates pressure. However, this specific technique has not been studied for effectiveness in any clinical trials to date.

There hasn’t been much, if any, research on sutra neti either. A similar rubber catheter, except with a much larger diameter, is frequently used in modern hospitals for a variety of conditions. Known as a naso-gastric tube, or NG tube, it is placed through the nasal cavity and directed down into the stomach. The NG tube frequently kinks and curls, coming out the mouth instead of down into the esophagus, as it is being placed. Its use is considered safe, with the rare exceptions of specific trauma patients and those with severe bleeding disorders.

Theoretically, sutra neti will do less for you than jala neti. The rubber catheter won’t penetrate the small ostia into the sinuses, it won’t thin the existing mucus, and it won’t remove the majority of the thin mucus layer lining the walls of the nasal cavity. It may remove large debris and crusted mucus. Abrasions and bleeding of the nasal mucosa can occur, and those with latex allergy should be careful to use a silicon-based tube.

What’s the Right Amount of Salt to Use With Neti?

Salt is added to the irrigation water to make its passage more comfortable. Our bodies are made of salt water at a concentration generally agreed to be approximately 0.9 percent, or 9 grams of NaCl (common table salt) per liter. Matching that physiological, or normal, concentration makes the solution more comfortable than either plain water or water with a greater amount of salt. A “physiological” solution is made by placing ½ teaspoon of table salt into 250 ml (or approximately 1 measuring cup) of water. In scientific jargon, this concentration of salt water is also called “isotonic saline.”

Adding salt may do more than just provide comfort. A research protocol using fresh water without any NaCl for their placebo had to be stopped when several of the control subjects developed middle ear infections.36

Isotonic saline works to clear mucus and relieve sinus congestion and runny noses11,19,24,31,37. It’s been shown to remove inflammation inducing chemicals like histamine and leukotrienes that the body secretes with allergy.14 Mucociliary clearance rate, the measure of the speed of removal of mucus, was noted to be increased in allergy patients using 4 ml of isotonic saline twice daily to flush their nasal cavities.38

Hypertonic saline, defined as solutions with more than 9 grams per liter of salt, also works.11,20,22,25,39,40 In some studies, a higher salt concentration works better than an isotonic one. Shoseyov and his colleagues used 3.5 percent NaCl, similar to sea water, and achieved better symptom relief in children than when they used a physiological concentration.39

While isotonic solutions are thought to work primarily by their mechanical cleaning effect, hypertonic solutions may additionally decrease swelling. Extracellular fluid in the nasal mucosa would theoretically be drawn out towards the area of higher salt concentration by osmosis. There’s conflicting data showing that hypertonic saline may also increase the frequency at which cilia beat, thereby clearing mucus out of the nasal and sinus passageways more rapidly.38

Hypertonic solutions might have a downside. Greiff and his colleagues looked at pieces of nasal mucosa in petri dishes and found that increasing concentrations of saline caused the tissue to secrete more mucus and to react more severely to histamine and another stimulating chemical. As this study was done in dissected tissue and not live people, the results should be interpreted with caution.42

Investigators in another published report did look at the effects of hypertonic solutions in people. They found that increasing concentrations of saline induced dose-dependent increases in the sensations of pain, blockage, and drippy nose.41
In hospitals, hypertonic saline is often used to induce sputum production from the lungs in order to test it for specific bacteria when patients have pneumonia. It has precipitated asthma attacks in some asthmatics and in those with hyper-reactive airways.41 Adults and children with asthma need to be careful to avoid aspirating hypertonic saline nasal irrigation fluid into their lungs.

The bottom line is that physiological saline has been found to work, and it’s the least likely salt concentration to cause problems. If you’re comfortable using a slightly higher concentration of salt, it may give a better response. The higher the concentration goes beyond what is natural to the body, the more likely there are to be side effects. Don’t go any higher than 3.5 percent, the concentration of sea water. Dr. Rabago, a family physician who studies neti, prefers 2 percent. That would be roughly equivalent to 1 teaspoon per 250 ml or 1 measuring cup of water. He advises patients to adjust the concentrations of salt to their own personal preferences.4

Does the Water Temperature Matter?

Steam inhalation, a natural and inexpensive treatment, has been shown to alleviate sinus congestion and to improve other symptoms of the common cold and nasal allergies.43,44,45,46 How it works is unclear. Vaporized water molecules may help to thin mucus similar to neti, but they may reach farther, navigating the ostia into the sinuses.14

While no investigators have looked specifically at the water temperature used with neti, warmer solutions may appear to add benefit and comfort. Care should be taken to avoid burns. Cold water may be okay too. There’s simply no data.

Conclusion

The ancient Yogic technique of Vyutkrama, known also to the Yogis as jala neti, has been shown by modern science to be an effective and well-tolerated form of treatment for sinus congestion and nasal drip due to the common cold, allergies, and sinusitis. It’s also effective prevention.

By using this natural and inexpensive method, people have found they need less medication to control their symptoms. Some are able to abandon pills and steroid sprays completely. That’s great for everyone, and particularly for pregnant women and children under the age of 6 years.

Neti is easy to do at home and elsewhere. Traditionally performed with only a cupped hand of salt water and a sniffing action, the technique has evolved for comfort and efficiency. Modern neti is performed by using a neti pot, syringes, bulbs or even Water-Pik devices. All these choices are effective.

Find a method of nasal irrigation that works for you. Modify the salt concentration and water temperature for your own personal comfort and benefit. If one thing doesn’t work, alter the device, the salt concentration, or the temperature, and give it a good several days. Many people, both adults and small children, have found significant relief from neti. With a little practice and some experimentation, you can too.

References:

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• Karadag A. Nasal saline for acute sinusitis. Pediatrics. 2002;109(1):165
• Kurtaran et al. A reappraisal of nasal saline solution use in chronic sinusitis. Chest. 2003;124(5):2036-2037.
• Georgitis, JW. Nasal Hyperthermia and Simple Irrigation for Perennial Rhinitis: Changes in Inflammatory Mediators. Chest 1994;106:1487-1492.
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Last Updated on Sunday, 11 July 2010