New Insights Into Nasal Saline

In-between nasal surgery cases today in the operating room, my resident asked me why the standard over-the-counter isotonic nasal saline preparation said .65% saline, rather than .9% saline.
The normal salt concentration in our bodies is 0.9%, which can also be mimicked by adding 9 grams of salt into 1 liter of water. This is called isotonic saline.
Nasal saline rinses are a helpful way of helping you to clear out your nose and open up your sinuses. There are a number of different concentrations, formulations, and ways of getting saline into your nose. Most physicians recommend isotonic saline, which is the same salt concentration as what’s in your body. There are certain reasons for use more or less concentrated versions.
Hypertonic saline is saltier than your body’s salt concentration, so irrigating your nose will cause water to leave your nasal membranes into the saline to equalize the salt concentrations. It’s like what happens when you add salt to a cucumber. Water leaves the cucumber and it shrivels up, like what happens to your nasal membranes. Swimming in ocean water also does the same thing. This process is called osmosis. Using hypotonic (less saltier) saline  will cause water to enter your nasal membranes, causing more swelling and congestion. 
In theory, you should use isotonic saline to flush out nasal mucous and cause some mild shrinkage of your nasal membranes. This is why nasal saline irrigation can make you feel and breathe much better. Then why do many products say that .65% is “isotonic”?
After doing some research, it turns out that one of the common brand names (Ayr®) is isotonic at .9%, but only .65% is salt. The rest is made up of a buffering agent (sodium hydroxide) to make it less irritating, with two other preservatives. The first one is EDTA, which acts to bind to heavy metals, and also has antibacterial and anti fungal properties. It’s also used in a number of other applications, as a food stabilizer to cosmetics and even for lead poisoning. The other one is benzalkonium chloride, which is used in many eye drops and nasal sprays as a preservative. It also has antimicrobial properties.
Neilmed®, on the other hand, comes in dry packets which you use to make your own isotonic saline. It contains only sodium chloride and sodium bicarbonate. 
If you also look at the list of ingredients for Ayr gel, it contains a lot more ingredients that you may normally see in hand lotions:
  • water
  • methyl gluceth-10
  • glycerin
  • propylene glycol
  • aloe barbadensis leaf juice (aloe vera gel)
  • PEG/PPG-18/18 dimethicone
  • carbomer,
  • sodium chloride
  • xanthan gum
  • glyceryl polymethacrylate
  • sodium hydroxide
  • poloxamer 184
  • diazolidinyl urea
  • methylparaben,
  • propylparaben
  • glycine soja (soybean) oil
  • geranium maculatum oil
  • tocopheryl acetate
  • blue 1.
This may explain why I personally can’t tolerate any kind of nasal saline, since it burns too much, even with added buffering agents. However, most people do well with nasal saline irrigation. 
There’s also some concern about long-term use of nasal saline, but for short bursts or intermittent use, it should be safe. 
The least expensive way is to make your own saline. Mix 2 cups of distilled water or boiled tap water that’s been cooled to lukewarm  temperature with one teaspoon of sea salt or Kosher salt and one teaspoon of baking soda. Don’t use regular table salt, as it may contain iodine. You can recycle one of the over-the-counter bottles or containers, or even use a very large medical syringe or even a turkey basting syringe. Baby suction bulbs can also work. You can store homemade saline at room temperature for 3 days.
The bottom line is that not all saline is the same. If you walk down the aisle in the pharmacy, you’ll see many more options. Take a look at all the ingredients. Not only are the ingredients different, the way you get the salt water into your nose is also different. This ranges from squeeze bottles, to Neti-pots, and syringes, and even aerosol cans. There are even pressurized irrigation systems.
What you’re experience with nasal saline washes? Are you sensitive to various added ingredients? If you make your own, what helpful tips can you offer? Please enter your experiences and suggestions in the text box below.

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5 thoughts on “New Insights Into Nasal Saline

  1. Interesting that you bring this up. I have noticed that on the nights my daughter uses saline she is better able to tolerate Cpap nasal pillows . When first applying nasal pillow she sometimes complains of having difficulty breathing easily. I am believe its when she exhales. After the saline spray, it seems to help.
    I assume it opens up passages, cleans out dust and particles etc, but may also be a placebo effect. Her tolerance of the machine has increased and we are noticing differences in her focus . Placebo or not, we will take it.

    Do you think saline is something that should be used on a spread out basis? Instead of nightly?

  2. I’ve used neil-med for years every night before bed time and it helps with my CPAP. At times of high pollen levels I repeat in the morning. It’s made a significant difference in my life. My allergist says use of a CPAP can be drying to the sinuses even with the humidifier at the maximum setting. I wonder what Dr Park thinks about this practice.

  3. Linda,

    Anything you can do to improve nasal breathing will only help with CPAP. My general advice is, if it works for you, keep doing it.

  4. I have not been able to find a single nasal saline gel product without benzalkonium chloride. therefore I cannot use it. benzalkonium chloride is in Lysol and caused me to develop steroid dependent asthma; it is a known asthma sensitizer and exacerbator. I don’t believe it should be sprayed into anyone’s respiratory tract. it is in most steroid nasal sprays as well. the only ones I have found without it are Rhinocort and Omnaris.

  5. Why did you highlight sodium chloride and sodium hydroxide in your ingredients list?

    Sodium chloride is also known as plain old table salt. It also happens to be the main type of salt in your saliva, mucus and blood plasma (sodium ions). You mention that 0.9% is the concentration found ‘wiithin the body’… however that means INTERNAL fluids, not saliva or mucus, which is significantly lower. So the lower level of 0.65% is the correct one to use. Trying to use standard intravenous saline solution (i.e. OK for putting inside your body) on your nose membranes… well, heck, yeah, you’re pickling them.

    Sodium hydroxide sounds nasty because it’s also known as “lye”, also known as oven cleaner, etc. etc. This is because when it’s highly concentrated it is so alkaline that it destroys (unzips) organic molecules, such as the burned food in your oven. However in lower concentrations it’s not at all nasty – in fact it’s the most “pure” alkaline substance you can use in the body, being simply that same essential sodium ion coupled with a simple hydroxyl (OH) group. This means that when it reacts with excess acid (H+) you get a reaction of H+ OH = H20… water. Because it’s so pure in this sense it is used in all cosmetics and even foods to counteract any excess acidity from the other ingredients that may be present, in order that the final product has the same pH level as your body.

    As for PEG/PPG, glycerin and propylene glycol: these are humectants, i.e. moisturizers. They are used widely in cosmetics and also in foodstuffs (e.g. to keep low-fat cakes moist). They are harmless . What they serve to do in a saline solution, is to maintain a level of moisture in your nasal tissues because in hosing them down with salty water, you’re stressing them by ALSO removing the protective mucus and fatty acids which are normally present.

    The xanthan gum is used because it is a gel – it has a very similar structure (and works in the exact same way) as mucus. In fact xanthan gum is the prototype for making artificial mucus (eirther for medical reasons or for grossing out kids).

    Tocopheryl acetate is also known as Vitamin E oil. Enough said.

    Aloe is probably someting I’d advise against though. People put it in things because it has an undeserved reputation as a “soothing agent” and people have gotten carried away with the idea that it’s good for soothing everything, inside and out. This is NOT true – aloe should never be used internally and various countries’ health bodies advise against such use. Many people find aloe irritating internally and in fact it is a mucus membrane irritant! So this is probably what you’re reacting to. ironically it’s the “natural ingredient” here which is the problematic one :)

    Hope this helps.