From the Guidelines
For sinus congestion in the Emergency Department, I would recommend starting with a combination of an oral decongestant like pseudoephedrine (Sudafed) 60mg every 6 hours for adults, along with an intranasal steroid such as fluticasone (Flonase) 1-2 sprays per nostril daily, as supported by the clinical practice guideline update on adult sinusitis 1. This approach is based on the principle of managing symptoms and avoiding unnecessary antibiotic use, as most cases of sinus congestion are due to viral rhinosinusitis (VRS) rather than bacterial infection 1. Key considerations include:
- Oral decongestants can provide symptomatic relief and are recommended barring any medical contraindications, such as hypertension or anxiety 1.
- Intranasal steroids may have a role in managing VRS, with a systematic review finding that they relieved facial pain and nasal congestion in patients with rhinitis and acute sinusitis, although the magnitude of effect was small 1.
- Saline nasal irrigation can be a useful adjunct for symptom relief, with a Cochrane review reporting minor improvements in nasal symptom scores with its use 1.
- Pain relief can be managed with acetaminophen or ibuprofen, and patients should be advised to stay hydrated, use a humidifier, and elevate the head while sleeping. It's crucial to differentiate between viral and bacterial infections, considering factors like duration, illness pattern, and severity of symptoms, to avoid unnecessary antibiotic use and potential side effects 1.
From the FDA Drug Label
Temporarily relieves nasal congestion due to: common cold hay fever upper respiratory allergies sinusitis shrinks swollen nasal membrances so you can breathe more freely. Purpose: Nasal Decongestant For sinus congestion, consider prescribing oxymetazoline (IN), a nasal decongestant that can help relieve nasal congestion due to common cold, hay fever, upper respiratory allergies, and sinusitis 2 2.
- Key benefits: temporarily relieves nasal congestion, shrinks swollen nasal membranes.
From the Research
Treatment Options for Sinus Congestion
- Intranasal corticosteroids (INSs) are recommended as first-line therapy for patients with moderate-to-severe allergic rhinitis (AR) and nasal congestion 3
- A fixed dose combination of Fluticasone Furoate and Oxymetazoline Hydrochloride Nasal Spray has been shown to be effective in reducing nasal congestion and total nasal symptom score in patients with allergic rhinitis 4
- Nasal decongestants can provide short-term relief of congestion in adults with the common cold, but their use is not recommended in children under 12 years of age due to insufficient data 5
- Antihistamine-decongestant-analgesic combinations may have some benefit in adults and older children with the common cold, but their effectiveness is limited and must be weighed against the risk of adverse effects 6
- A combination of paracetamol and pseudoephedrine has been shown to be effective in treating nasal congestion and pain-related symptoms in upper respiratory tract infections 7
Considerations for Prescribing
- Patient adherence to treatment can affect outcomes, and patient preferences for the sensory attributes of a drug may influence adherence 3
- The efficacy and safety of available pharmacotherapies, as well as barriers to adherence, should be considered when selecting a treatment option 3
- The risk of adverse effects, such as insomnia and rebound congestion, should be considered when prescribing nasal decongestants and other medications 5, 6