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Research

Effectiveness of steam inhalation and nasal irrigation for chronic or recurrent sinus symptoms in primary care: a pragmatic randomized controlled trial

Paul Little, Beth Stuart, Mark Mullee, Tammy Thomas, Sophie Johnson, Gerry Leydon, David Rabago, Samantha Richards-Hall, Ian Williamson, Guiqing Yao, James Raftery, Shihua Zhu and Michael Moore; for the SNIFS Study Team
CMAJ September 20, 2016 188 (13) 940-949; DOI: https://doi.org/10.1503/cmaj.160362
Paul Little
Primary Care Group (Little, Stuart, Moore, Thomas, Johnson, Williamson), Health Economic Analyses Team (Yao, Raftery, Zhu) and Research Design Service South Central (Mullee), Primary Care and Population Sciences Unit (Leydon), University of Southampton, Southampton, UK; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK; Department of Family Medicine and Community Health (Rabago), University of Wisconsin School of Medicine and Public Health, Madison, Wis.
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  • For correspondence: p.little@soton.ac.uk
Beth Stuart
Primary Care Group (Little, Stuart, Moore, Thomas, Johnson, Williamson), Health Economic Analyses Team (Yao, Raftery, Zhu) and Research Design Service South Central (Mullee), Primary Care and Population Sciences Unit (Leydon), University of Southampton, Southampton, UK; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK; Department of Family Medicine and Community Health (Rabago), University of Wisconsin School of Medicine and Public Health, Madison, Wis.
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Mark Mullee
Primary Care Group (Little, Stuart, Moore, Thomas, Johnson, Williamson), Health Economic Analyses Team (Yao, Raftery, Zhu) and Research Design Service South Central (Mullee), Primary Care and Population Sciences Unit (Leydon), University of Southampton, Southampton, UK; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK; Department of Family Medicine and Community Health (Rabago), University of Wisconsin School of Medicine and Public Health, Madison, Wis.
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Tammy Thomas
Primary Care Group (Little, Stuart, Moore, Thomas, Johnson, Williamson), Health Economic Analyses Team (Yao, Raftery, Zhu) and Research Design Service South Central (Mullee), Primary Care and Population Sciences Unit (Leydon), University of Southampton, Southampton, UK; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK; Department of Family Medicine and Community Health (Rabago), University of Wisconsin School of Medicine and Public Health, Madison, Wis.
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Sophie Johnson
Primary Care Group (Little, Stuart, Moore, Thomas, Johnson, Williamson), Health Economic Analyses Team (Yao, Raftery, Zhu) and Research Design Service South Central (Mullee), Primary Care and Population Sciences Unit (Leydon), University of Southampton, Southampton, UK; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK; Department of Family Medicine and Community Health (Rabago), University of Wisconsin School of Medicine and Public Health, Madison, Wis.
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Gerry Leydon
Primary Care Group (Little, Stuart, Moore, Thomas, Johnson, Williamson), Health Economic Analyses Team (Yao, Raftery, Zhu) and Research Design Service South Central (Mullee), Primary Care and Population Sciences Unit (Leydon), University of Southampton, Southampton, UK; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK; Department of Family Medicine and Community Health (Rabago), University of Wisconsin School of Medicine and Public Health, Madison, Wis.
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David Rabago
Primary Care Group (Little, Stuart, Moore, Thomas, Johnson, Williamson), Health Economic Analyses Team (Yao, Raftery, Zhu) and Research Design Service South Central (Mullee), Primary Care and Population Sciences Unit (Leydon), University of Southampton, Southampton, UK; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK; Department of Family Medicine and Community Health (Rabago), University of Wisconsin School of Medicine and Public Health, Madison, Wis.
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Samantha Richards-Hall
Primary Care Group (Little, Stuart, Moore, Thomas, Johnson, Williamson), Health Economic Analyses Team (Yao, Raftery, Zhu) and Research Design Service South Central (Mullee), Primary Care and Population Sciences Unit (Leydon), University of Southampton, Southampton, UK; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK; Department of Family Medicine and Community Health (Rabago), University of Wisconsin School of Medicine and Public Health, Madison, Wis.
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Ian Williamson
Primary Care Group (Little, Stuart, Moore, Thomas, Johnson, Williamson), Health Economic Analyses Team (Yao, Raftery, Zhu) and Research Design Service South Central (Mullee), Primary Care and Population Sciences Unit (Leydon), University of Southampton, Southampton, UK; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK; Department of Family Medicine and Community Health (Rabago), University of Wisconsin School of Medicine and Public Health, Madison, Wis.
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Guiqing Yao
Primary Care Group (Little, Stuart, Moore, Thomas, Johnson, Williamson), Health Economic Analyses Team (Yao, Raftery, Zhu) and Research Design Service South Central (Mullee), Primary Care and Population Sciences Unit (Leydon), University of Southampton, Southampton, UK; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK; Department of Family Medicine and Community Health (Rabago), University of Wisconsin School of Medicine and Public Health, Madison, Wis.
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James Raftery
Primary Care Group (Little, Stuart, Moore, Thomas, Johnson, Williamson), Health Economic Analyses Team (Yao, Raftery, Zhu) and Research Design Service South Central (Mullee), Primary Care and Population Sciences Unit (Leydon), University of Southampton, Southampton, UK; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK; Department of Family Medicine and Community Health (Rabago), University of Wisconsin School of Medicine and Public Health, Madison, Wis.
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Shihua Zhu
Primary Care Group (Little, Stuart, Moore, Thomas, Johnson, Williamson), Health Economic Analyses Team (Yao, Raftery, Zhu) and Research Design Service South Central (Mullee), Primary Care and Population Sciences Unit (Leydon), University of Southampton, Southampton, UK; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK; Department of Family Medicine and Community Health (Rabago), University of Wisconsin School of Medicine and Public Health, Madison, Wis.
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Michael Moore
Primary Care Group (Little, Stuart, Moore, Thomas, Johnson, Williamson), Health Economic Analyses Team (Yao, Raftery, Zhu) and Research Design Service South Central (Mullee), Primary Care and Population Sciences Unit (Leydon), University of Southampton, Southampton, UK; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK; Department of Family Medicine and Community Health (Rabago), University of Wisconsin School of Medicine and Public Health, Madison, Wis.
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Abstract

Background: Systematic reviews support nasal saline irrigation for chronic or recurrent sinus symptoms, but trials have been small and few in primary care settings. Steam inhalation has also been proposed, but supporting evidence is lacking. We investigated whether brief pragmatic interventions to encourage use of nasal irrigation or steam inhalation would be effective in relieving sinus symptoms.

Methods: We conducted a pragmatic randomized controlled trial involving adults (age 18–65 yr) from 72 primary care practices in the United Kingdom who had a history of chronic or recurrent sinusitis and reported a “moderate to severe” impact of sinus symptoms on their quality of life. Participants were recruited between Feb. 11, 2009, and June 30, 2014, and randomly assigned to 1 of 4 advice strategies: usual care, daily nasal saline irrigation supported by a demonstration video, daily steam inhalation, or combined treatment with both interventions. The primary outcome measure was the Rhinosinusitis Disability Index (RSDI). Patients were followed up at 3 and 6 months. We imputed missing data using multiple imputation methods.

Results: Of the 961 patients who consented, 871 returned baseline questionnaires (210 usual care, 219 nasal irrigation, 232 steam inhalation and 210 combined treatment). A total of 671 (77.0%) of the 871 participants reported RSDI scores at 3 months. Patients’ RSDI scores improved more with nasal irrigation than without nasal irrigation by 3 months (crude change −7.42 v. −5.23; estimated adjusted mean difference between groups −2.51, 95% confidence interval −4.65 to −0.37). By 6 months, significantly more patients maintained a 10-point clinically important improvement in the RSDI score with nasal irrigation (44.1% v. 36.6%); fewer used over-the-counter medications (59.4% v. 68.0%) or intended to consult a doctor in future episodes. Steam inhalation reduced headache but had no significant effect on other outcomes. The proportion of participants who had adverse effects was the same in both intervention groups.

Interpretation: Advice to use steam inhalation for chronic or recurrent sinus symptoms in primary care was not effective. A similar strategy to use nasal irrigation was less effective than prior evidence suggested, but it provided some symptomatic benefit. Trial registration: ISRCTN, no. 88204146.

  • Accepted May 13, 2016.
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Canadian Medical Association Journal: 188 (13)
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Vol. 188, Issue 13
20 Sep 2016
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Effectiveness of steam inhalation and nasal irrigation for chronic or recurrent sinus symptoms in primary care: a pragmatic randomized controlled trial
Paul Little, Beth Stuart, Mark Mullee, Tammy Thomas, Sophie Johnson, Gerry Leydon, David Rabago, Samantha Richards-Hall, Ian Williamson, Guiqing Yao, James Raftery, Shihua Zhu, Michael Moore
CMAJ Sep 2016, 188 (13) 940-949; DOI: 10.1503/cmaj.160362

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Effectiveness of steam inhalation and nasal irrigation for chronic or recurrent sinus symptoms in primary care: a pragmatic randomized controlled trial
Paul Little, Beth Stuart, Mark Mullee, Tammy Thomas, Sophie Johnson, Gerry Leydon, David Rabago, Samantha Richards-Hall, Ian Williamson, Guiqing Yao, James Raftery, Shihua Zhu, Michael Moore
CMAJ Sep 2016, 188 (13) 940-949; DOI: 10.1503/cmaj.160362
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