It's Not the Neti Pot That's Dangerous, But the Water Used With It: Public Health Watch

December 12, 2018
Brian Dunleavy

The recent death of a nasal irrigation user may have more to do with dirty water and/or improper use of the device, rather than a flaw with the approach.

Those dealing with sinus issues have gone to pot—as in the neti pot, a modern twist on an ancient Indian approach to nasal irrigation.

However, while some people prefer the natural benefits of “neti” (the Sanskrit word for “nasal cleansing”) to Western medical options such as prescription drugs and over-the-counter nasal sprays, the traditional method is not without risks. In fact, an extreme example of the hazards associated with neti pots is described in a case report published in the December issue of the International Journal of Infectious Diseases, in which a 69-year-old woman was diagnosed with granulomatous amoebic encephalitis caused by the Balamuthia mandrillaris amoeba found in soil and fresh water.

The authors of the report linked her condition, which proved fatal, to her use of a neti pot. Not surprisingly, and unfortunately, the consumer press has used the woman’s story as fodder for headlines warning against “brain-eating amoebas.”

“In theory, the rise in neti pot use is a good thing,” Ahmad R. Sedaghat, MD, PhD, assistant professor, department of otolaryngology, Harvard Medical School and Massachusetts Eye and Ear Infirmary, told Contagion®. “Normal saline is natural. [But] I don’t think users are fully aware of the risks, which are primarily infectious. There are several studies in the scientific literature that have characterized just how dirty with bacteria neti pots can become.”

Indeed, although “brain-eating” amoebas may be low-hanging fruit for headline writers, the more common risks associated with neti pot use are less attention-grabbing, but no less dangerous. According to Vijay R. Ramakrishnan, MD, associate professor, departments of otolaryngology and neurosurgery, and co-director, CU Skull Base Program, University of Colorado, most commercial manufacturers of neti pots “carry a warning to use only sterile water for irrigations,” as recommended by the US Centers for Disease Control and Prevention.

“Medical providers are generally aware of this recommendation; however, many patients using sinus rinses use tap water…under the assumption that municipal water treatment ‘sterilizes’ tap water,” he added. “It does not.”

Which is why, as Contagion® reported last year, the US Food and Drug Administration has cautioned neti pot users on the importance of cleaning the device properly and, above all, ensuring that the water used is clean as well. However, no one is saying not to use the traditional method of nasal irrigation, despite the fact that a meta-analysis published in 2015 found limited evidence for the efficacy of the practice in resolving congestion associated with upper respiratory tract infections.

In fact, as Drs. Sedaghat and Ramakrishnan note, using a neti pot may offer the safest option for addressing the increasing incidence of atopic disorders such as allergic rhinitis caused by growing amounts of airborne irritants (read: pollutants and others, such as wildfire smoke) the world is currently experiencing. Importantly, devices such as neti pots are also convenient, inexpensive, and easy-to-use.

“Saline nasal irrigation has been around for thousands of years, and it’s an effective way to treat rhinitis symptoms without having to use medications,” Dr. Ramakrishnan explained. He expects the use of neti pots to continue to increase, despite the eye-grabbing headlines.

Evelyn Y. Ho, PhD, professor of Communication Studies/Asian Pacific American Studies/Critical Diversity Studies at the University of San Francisco, and co-author of a 2016 paper entitled “A Case Study of the Neti Pot's Rise, Americanization, and Rupture as Integrative Medicine in US Media Discourse,” agrees. She believes the approach first gained wide exposure via Dr. Oz on the “Oprah Winfrey Show” in 2007, and it’s grown in popularity since, even after 2 deaths in 2012 were linked to its use.

“The neti pot has always had a tinge of orientalism and/or exoticizing affiliated with it, especially in the news and popular media, [which is] the argument we make in [our] article,” she noted. “It’s both alluring and repulsive, and treated as sexy until it’s sinister. What is most fascinating [is when there’s an issue, the danger is always about the pot]—the use of the neti pot is what has killed people”—as opposed to the improper use of the device and/or our contaminated water supply.

In other words, before you call the pot black, remember that its use isn’t the problem, but rather how it’s used.