Ayurveda

The Neti pot, described in the Ayurveda, was the first nasal rinsing device. This ceramic pot has been used in Hatha Yoga for thousands of years for Jala Neti (purification with water).^{Reference Rama, Ballentine and Hymes6,Reference Jefferson7} However, the practice of nasal lavage was encouraged for spiritual and hygienic reasons, rather than for the treatment of sinonasal conditions. It was not until 2007, when the American celebrity physician Dr Mehmet Oz appeared on The Oprah Winfrey Show and demonstrated the device, that the Neti pot started to be widely used in Western societies for nasal conditions.^{Reference Ho, Cady and Robles8}

However, currently, there is no evidence that shows a clear clinical benefit of the Neti pot over other lavage systems. For many patients, it is seen as a good option because it is simple to use and inexpensive. Gravity provides the flow, so the sheer force on the mucosa is limited. For some patients, the gentleness of the Neti pot is advantageous as the Eustachian tube orifice closing pressure is not exceeded.

Greek and Roman lavage techniques

Greek and Roman medical literature described the use of syringes for rectal, vaginal, uterine, bladder, ear and sinus douches. A procedure named nasal clyster (nasal enema) is detailed by various Greek and Roman physicians.

Scribonius Largus called the apparatus he used a ‘horn’, to which a fluid-filled bag was attached. Aretaeus wrote about an aulos or tube for a nasal injection of euphorbium and other components, to evacuate phlegm in cases of chronic headache (‘kephalaia’). He describes how an injection is made through a nasal tube consisting of two pipes united by one outlet, so that both nostrils can be injected at one time. He argued that this mechanism prevented the discomfort derived from distention caused by the liquid if each nostril was injected separately. His description does not say whether the liquid was delivered via a bag or a syringe.^{Reference Bliquez9,Reference Milne10}

Galen mentions a nasal syringe in his writings, but does not describe the device he used. Although Hippocrates gave instructions on how to treat nasal polyps, he did not recommend nasal lavage as a treatment for nasal conditions.^{Reference Leopold11}

Dark and Middle Ages to Renaissance and Enlightenment

The progress made by Greek and Roman physicians was largely lost during the Dark and Middle Ages. During these times, bizarre functions were attributed to the sinuses, such as holding lubricant for the motion of the eyeballs, or permitting the brain to drain its malevolent spirits to the external world. The sinuses were termed ‘la cloaca del cerebro’ (the sewer of the nose) by a sixteenth century anatomist.^{Reference Cingi and Muluk12}

The nose was believed to be the entry point for a number of diseases, including the plague. This idea was based on the miasmatic theory, where pestilence originated from invisible fumes that emanated from rotting corpses and contaminated soil or water.

It is, nonetheless, possible that nasal rinsing continued through this period, but it certainly was not considered an important part of the treatment for nasal conditions. However, in the sixteenth century, Petras Forestus claimed to have cured ozaena by ‘copious nasal douching with perfumed white wine in which cypress, roses, and myrrh were dissolved’. He also used silver nitrate and alum rubber mixed with honey, applied with a probe.^{Reference Cingi and Muluk12}

Ivory and bone were used for syringes for aural and nasal use, mainly in the eighteenth century and early nineteenth century. The plunger was made of wood, with either linen or tow binding to provide a seal.^{Reference Bennion13}

Flow by gravity

In order to achieve the principle of high volume and continuous flow, Thudichum described two prototypes in his book entitled ‘On Polypus in the Nose and Other Affections of the Nasal Cavity’.^{Reference Thudichum19} One prototype consisted of a ceramic jug in which a rubber tube was introduced, with a metallic plate in its distal end (Figure 3a). The liquid was initially drawn from the jug by mouth suction through the metallic nozzle, creating a syphon effect. His second model replaced the ceramic jug with an inverted glass bottle opened at the top (Figure 3b),^{Reference Thudichum19} to allow for greater flow.

Fig. 3.

(a) First design by Thudichum with a ceramic jug, rubber tube and metallic nozzle. (b) Upgraded design by Thudichum, with inverted glass bottle opened and superiorly attached to a rubber tube and metallic nozzle. (c) Metallic nozzle with two-way valve to control flow rate.^{Reference Thudichum19}

From this point on, many similar models were developed by other inventors, with containers made either from glass or metal (usually brass). The bottle could be held with one hand (Figure 4a)^{Reference Beard20} or positioned on a shelf higher than the head of the individual (Figure 4b).^{Reference Pierce21}

Fig. 4.

(a) Bottle held with one hand.^{Reference Beard20} (b) Bottle placed on a shelf higher than the patient's head, connected to a tube without a nozzle.^{Reference Pierce21} (c) Assisted nasal rinsing device with collapsible reservoir.^{Reference Davis and Douglass22} (d) Moyle's catarrhal douche.^{Reference Moyle23} (e) Birmingham nasal douche, made of glass. (f) Evans’ nasal douche.¹⁷

In order to achieve control of the flow rate, early models had either a Thudichum's nozzle with a two-way valve (Figure 3c), or no nozzle wherein control of flow rate was achieved by compressing the rubber tube between the finger and thumb (Figure 4b). This last technique was proposed by Dr R V Pierce in 1895, a fervent supporter of nasal rinsing, who wrote; ‘Let no one entertain any feeling of timidity on commencing the use of this instrument, as its operation is perfectly simple and harmless, and, with the fluids which we recommend, is never attended with any strangling, choking, pain or other disagreeable sensations’.^{Reference Pierce21}

An alternative technique was an assisted nasal douche designed by the American otolaryngologists Edward Davis and Beaman Douglas (Figure 4c).^{Reference Davis and Douglass22} With time, smaller and more portable devices (initially made from glass),^{17,Reference Moyle23} appeared on the market (Figure 4d–f).

Some inventors proposed the simultaneous rinsing of both nasal cavities with a bilateral nozzle and pressure provided by gravity (Figure 5a and b).^{Reference Lamport24,Reference Liu25} The scarcity of prototypes makes it difficult to find accounts of their possible benefits over other types of rinsing systems. However, these models had a clear risk of coughing and aspiration when the individual tried to breathe through the mouth.

Fig. 5.

(a & b) Bilateral nasal douches with flow achieved by gravity.^{Reference Lamport24,Reference Liu25}

Squeezing mechanisms (insufflators)

Squeeze bottles were first proposed around the same time as gravity-operated devices. Squeeze bottles are simple to operate and inexpensive, but are limited by their variable flow pressure and low volumes. Despite these shortcomings, they remain one of the mainstays of nasal rinsing today. Before the appearance of plastic bottles in the mid-twentieth century, a rubber bulb or insufflator was used as the propelling mechanism, and models were made for either anterior (Figure 6a and c) or posterior (Figure 6d) nasal rinsing.

Fig. 6.

(a) Pocket bulb with nozzle.¹⁷ (b) Rumbold's nasal spray.^{Reference Robinson26} (c) Bulb with a soft, rubber, perforated nasal tube. (d) Holme's post-nasal device. (e) DeVilbiss No. 36 posterior insufflator. (f) DeVilbiss No. 32 anterior insufflator.¹⁷

In this category, atomisers or spraying devices are included, which have maintained their popularity, regardless of their low shearing force. Models have been developed for anterior (Figure 6f)¹⁷ and posterior (Figure 6e) application. Rumbold's apparatus was intended to rinse the superior nasal cavity (Figure 6b). It appears to have come into disuse because of a painful sensation when actioned.^{Reference Robinson26}

Mouth-actioned devices

These devices use the expiratory pressure to propel the contents of the bottle into the nose. Initial models were made from hard rubber with metallic components (Figure 7a).²⁷As with other types of rinsing devices, glass later became a preferred material for production. A good example is Fowler's nasal douche, which was a one-piece glass container that had an inner tube to increase outflow pressure (Figure 7b).^{Reference Fowler28} Glass was then progressively substituted with hard plastic (Figure 7c).^{Reference Griffin29} A significant advantage of this type of device is that the output pressure can be easily controlled by the user.^{Reference Griffin29}

Fig. 7.

(a) Munyon's medicament vessel.^{Reference Munyon27} (b) Fowler's glass nasal douche.^{Reference Fowler28} (c) Griffin's nasal irrigator.^{Reference Griffin29}