Can nasal spray cause tinnitus (ringing in the ears)?

Nasal Spray and Tinnitus: Potential Connection and Management

Yes, nasal sprays can cause tinnitus (ringing in the ears) as a side effect, particularly with improper technique or overuse. 1, 2

Types of Nasal Sprays and Tinnitus Risk

Intranasal Corticosteroids

• Generally considered safe when used properly
• Proper administration technique is critical to minimize side effects 1, 2
• Risk factors for side effects include:
  • Improper spray direction (toward septum)
  • Failure to shake bottle before use
  • Incorrect head position during administration

Decongestant Nasal Sprays

• Higher risk of complications with prolonged use
• Can cause rhinitis medicamentosa (rebound congestion) with overuse 3, 4
• Prolonged use of vasoconstrictors with preservatives like benzalkonium chloride (BKC) can cause mucosal damage 3

Intranasal Antihistamines

• May cause side effects including headache, which can be associated with tinnitus 1
• Common side effects include bitter taste, epistaxis, and somnolence

Mechanism of Tinnitus from Nasal Sprays

Tinnitus from nasal sprays may occur through several mechanisms:

1. Direct ototoxicity: Some components may affect inner ear function
2. Eustachian tube dysfunction: Inflammation or changes in nasal/sinus passages can affect middle ear pressure
3. Systemic absorption: Some nasal spray components may enter bloodstream and affect auditory pathways
4. Neurological effects: Changes in neural pathways shared between nasal cavity and auditory system

Proper Nasal Spray Technique to Minimize Risk

The EPOS2020 steering group recommends: 1, 2

• Prime the bottle before first use
• Shake the bottle prior to spraying
• Blow nose before using spray
• Keep head in upright position
• Hold spray in opposite hand relative to nostril being treated (critical to avoid septum)
• Breathe in gently during spraying
• Do not close the opposite nostril

Management of Nasal Spray-Related Tinnitus

If tinnitus develops:

1. Evaluate technique: Ensure proper administration method
2. Consider discontinuation or switching: If using decongestant sprays, switch to intranasal corticosteroids under medical supervision 3, 4
3. Gradual withdrawal: For decongestant sprays, taper use while adding intranasal corticosteroid 3
4. Seek medical evaluation: Persistent tinnitus warrants comprehensive audiologic evaluation, especially if unilateral or lasting >6 months 5

Special Considerations

• Decongestant nasal spray overuse: Recovery from rhinitis medicamentosa can occur within 1 week in 80.6% of cases when properly treated, regardless of duration of previous use 4
• Underlying conditions: Tinnitus may be related to underlying conditions like allergic rhinitis rather than the spray itself 5, 6
• Monitoring: Regular follow-up is important to assess response and side effects 1

When to Seek Medical Attention

Refer to a physician if tinnitus:

• Is unilateral
• Persists beyond 2 weeks after stopping nasal spray
• Is accompanied by hearing loss
• Is pulsatile in nature
• Is associated with neurological symptoms 1, 5

Proper technique, appropriate duration of use, and medical supervision are key to minimizing the risk of tinnitus when using nasal sprays.