Are oral decongestants recommended for sinus infections?

Oral Decongestants for Sinus Infection

Oral decongestants may be used for symptomatic relief of nasal congestion in acute bacterial rhinosinusitis (ABRS), though no randomized controlled trials specifically demonstrate their efficacy for this indication, and topical decongestants appear superior to oral agents. 1

Evidence Quality and Limitations

The American Academy of Otolaryngology-Head and Neck Surgery acknowledges that there are no RCTs that specifically study the efficacy of decongestants for ABRS. 1 The theoretical rationale is that both topical and oral decongestants might widen the sinus ostia and reduce turbinate swelling, thus promoting sinus and nasal ventilation. 1

Topical vs. Oral Decongestants

• Topical decongestants (xylometazoline nasal spray) are superior to oral pseudoephedrine based on small studies showing reduced congestion of sinus and nasal mucosa on imaging studies. 1

• One small, nonrandomized study showed improved outcomes when xylometazoline spray was added to antibiotics for ABRS. 1

• Topical decongestants should not be used more than 3 to 5 consecutive days due to their propensity to cause rebound congestion and rhinitis medicamentosa. 1, 2

Oral Decongestant Considerations

Efficacy

• Oral decongestants (pseudoephedrine, phenylephrine) have a modest effect in decreasing nasal airway resistance in adults with the common cold. 1

• Pseudoephedrine is significantly more effective than phenylephrine due to better oral bioavailability, as phenylephrine undergoes extensive first-pass metabolism in the gut. 3

• The FDA label indicates pseudoephedrine temporarily relieves sinus congestion and pressure. 4

Safety Profile

• Oral decongestants cause small increases in systolic blood pressure (0.99 mmHg) and heart rate (2.83 beats/min) but generally no significant effect on diastolic blood pressure. 3

• Use with caution in patients with hypertension, arrhythmias, coronary artery disease, cerebrovascular disease, hyperthyroidism, and glaucoma. 1, 3

• Other potential adverse effects include central nervous system stimulation, insomnia, urinary retention, and mydriasis. 1

• Avoid during the first trimester of pregnancy due to reported fetal heart rate changes. 2, 3

Clinical Algorithm for Sinus Infection

1. First-line symptomatic relief: Consider intranasal corticosteroids and nasal saline irrigation for ABRS. 1, 2

2. For acute severe congestion: Short-term topical decongestant (3-5 days maximum) is preferred over oral agents. 1, 2

3. If topical decongestants are contraindicated or patient preference: Oral pseudoephedrine (60 mg every 4-6 hours) may be used for short-term symptomatic relief, screening for cardiovascular contraindications first. 3, 4

4. Avoid phenylephrine as an oral decongestant due to poor bioavailability and limited efficacy. 3

Important Caveats

• Antihistamines have no role in symptomatic relief of ABRS in non-allergic patients and may worsen congestion by drying the nasal mucosa. 1

• Guaifenesin has no evidence regarding effect on symptomatic relief of ABRS. 1

• Oral decongestants are appropriate for short-term use only, not for long-term daily use. 3

• The clinical relevance of the small positive effect seen with multiple doses of nasal decongestants remains uncertain. 5