What are the first-line treatments for chronic right nasal congestion?

First-Line Treatments for Chronic Right Nasal Congestion

The first-line treatments for chronic right nasal congestion are saline nasal irrigation and topical intranasal corticosteroids, which should be used either individually or in combination for optimal symptom relief. 1

Initial Approach to Chronic Nasal Congestion

Saline Nasal Irrigation

• Saline irrigation works by improving mucous clearance, enhancing ciliary activity, disrupting and removing antigens, biofilms and inflammatory mediators, and directly protecting the sinonasal mucosa 1
• Can be used as either sole therapy or as an adjunct to other treatments due to its excellent safety profile and minimal side effects 1
• Irrigation is more effective than simple saline spray for expelling secretions and improving quality of life 1
• Both isotonic and hypertonic (3%-5%) solutions can be used, though evidence is insufficient to support superiority of either approach 1

Topical Intranasal Corticosteroids

• Recommended as a first-line therapy for chronic nasal congestion due to their anti-inflammatory effects 1
• Improve nasal patency by reducing inflammation and improving mucociliary clearance 2
• Should be administered properly for maximum effectiveness (see technique below) 1

Proper Technique for Intranasal Corticosteroid Use:

1. Shake the bottle well
2. Look down by bending neck toward the floor
3. Put nozzle just inside nose using right hand for left nostril and left hand for right nostril
4. Aim toward outer wall (not the nasal septum) to prevent irritation and bleeding
5. Change hands and repeat for other side
6. Do not sniff hard 1

Additional Treatment Options

Topical Decongestants (Second-line)

• Can be considered for short-term relief of severe congestion 1
• Examples include oxymetazoline and xylometazoline nasal sprays 1
• Should not be used for more than 3-5 consecutive days due to risk of rebound congestion (rhinitis medicamentosa) 1
• One small study showed that combining oxymetazoline with intranasal corticosteroids was more effective than corticosteroids alone without causing rebound swelling 1
• The European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) 2020 suggests generally not using nasal decongestants in chronic rhinosinusitis, but they may be temporarily added when the nose is very blocked 1

Oral Decongestants

• Pseudoephedrine can temporarily relieve sinus congestion and pressure 3
• Less effective than topical decongestants for nasal congestion 1
• Should be used with caution due to potential systemic side effects 1

Antihistamines

• Generally not recommended as first-line therapy for non-allergic nasal congestion 1
• May worsen congestion by drying the nasal mucosa in non-allergic patients 1
• Should only be considered if there is a significant allergic component to the congestion 1, 4
• Second-generation antihistamines are preferred over first-generation due to less sedation and fewer anticholinergic side effects 1

Treatment Algorithm Based on Underlying Cause

For Chronic Rhinosinusitis (CRS)

1. Start with saline nasal irrigation and topical intranasal corticosteroids 1
2. If symptoms persist, consider adding a short course of oral corticosteroids (especially if nasal polyps are present) 1
3. For severe cases, referral to an otolaryngologist for evaluation for potential surgical intervention may be necessary 1

For Allergic Rhinitis

1. Start with saline nasal irrigation and topical intranasal corticosteroids 5
2. Consider adding a second-generation antihistamine if symptoms persist 1, 4
3. Allergen avoidance measures should be implemented 4

For Non-allergic Rhinitis

1. Intranasal corticosteroids are the mainstay of treatment 4
2. Topical antihistamines may also be effective 4
3. Brief courses of topical decongestants (3-5 days maximum) can be used for temporary relief 1

Important Considerations and Pitfalls

• Unilateral nasal congestion (right-sided only) warrants thorough evaluation to rule out anatomical abnormalities or masses 6
• Chronic use of topical decongestants beyond 3-5 days can lead to rebound congestion and rhinitis medicamentosa 1
• Patient education on proper technique for nasal irrigation and intranasal corticosteroid use is essential for treatment success 1
• For patients with persistent symptoms despite first-line therapy, referral to an otolaryngologist for nasal endoscopy or other diagnostic procedures should be considered 1
• Off-label use of nasal steroid irrigations (combining corticosteroids with saline irrigation) may be more effective than standard nasal sprays for refractory cases 2