What are the treatment options for sinus congestion?

Treatment of Sinus Congestion

Intranasal corticosteroid sprays are the most effective first-line medication for treating sinus congestion and should be initiated immediately for symptomatic relief, regardless of whether the cause is viral or bacterial rhinosinusitis. 1

First-Line Treatment Approach

Intranasal Corticosteroids (Primary Recommendation)

• Intranasal corticosteroids reduce inflammation, decrease vascular permeability, and inhibit inflammatory mediator release, directly addressing the underlying cause of congestion. 1
• These medications are effective for controlling major symptoms including nasal congestion, rhinorrhea, and inflammation. 1
• Unlike topical decongestants, intranasal corticosteroids do not cause rhinitis medicamentosa (rebound congestion) and can be used for extended periods. 1
• For acute sinusitis, use intranasal corticosteroids for 10-14 days. 1
• For chronic sinusitis, longer-term use may be necessary with periodic nasal septum examination to ensure no mucosal erosions develop. 1
• Proper technique is essential: direct sprays away from the nasal septum to minimize local side effects such as irritation and bleeding. 1

Adjunctive Therapies to Use Alongside Intranasal Steroids

Nasal Saline Irrigation:

• Nasal saline irrigation may improve quality of life, decrease symptoms, and decrease medication use, particularly in patients with frequent sinusitis. 2
• Buffered hypertonic (3%-5%) saline irrigation showed modest benefit and may have superior anti-inflammatory effects compared to isotonic saline. 2
• Saline irrigation is considered an important aspect of chronic rhinosinusitis management through mechanical removal of mucus, improvement in mucociliary clearance, and disruption of inflammatory mediators. 2

Analgesics:

• Over-the-counter analgesics such as nonsteroidal anti-inflammatory drugs or acetaminophen are usually sufficient to relieve facial pain associated with acute bacterial rhinosinusitis. 2
• Narcotics are rarely necessary and should be discouraged due to potential adverse events. 2

Decongestants: Use With Caution

Topical Decongestants (Xylometazoline, Oxymetazoline):

• Topical decongestants reduce congestion of sinus and nasal mucosa on imaging studies. 2
• Critical limitation: Topical decongestants should not be used more than 3 to 5 consecutive days without a prolonged intervening drug-free period due to their propensity to cause rebound congestion and rhinitis medicamentosa. 2
• One study showed that combining oxymetazoline with intranasal corticosteroids was more effective than corticosteroids alone without inducing rebound swelling, but this should only be considered temporarily when the nose is very blocked. 2

Oral Decongestants (Pseudoephedrine):

• FDA-approved for temporary relief of sinus congestion and pressure. 3
• Xylometazoline nasal spray is superior to a single orally administered dose of pseudoephedrine. 2
• Should not be used for more than 3 days to avoid worsening congestion. 1

What NOT to Use

Antihistamines:

• Antihistamines have no role in the symptomatic relief of acute bacterial rhinosinusitis in nonatopic patients and may worsen congestion by drying the nasal mucosa. 2
• Antihistamines should not be routinely used for viral rhinosinusitis as they have side effects and do not effectively relieve symptoms. 1
• Exception: Consider second-generation H1-antagonists (like loratadine) only for patients whose symptoms support a significant allergic component, as they cause less sedation than first-generation antihistamines. 2

Guaifenesin:

• There is no evidence regarding the effect, if any, on symptomatic relief of acute bacterial rhinosinusitis. 2

Systemic Corticosteroids for Severe Cases

• A short course (5-7 days) of oral corticosteroids may be appropriate for very severe nasal symptoms. 1
• For severe chronic sinusitis with nasal polyps, consider a short course of oral corticosteroids in addition to intranasal corticosteroids. 1
• Systemic corticosteroid therapy for sinus disease has not been studied systematically in well-controlled or blinded manner, so use cautiously due to potential systemic side effects. 1, 2

When to Consider Antibiotics

• For uncomplicated acute bacterial rhinosinusitis, clinicians should either offer watchful waiting (without antibiotics) or prescribe initial antibiotic therapy. 2
• Watchful waiting should be offered only when there is assurance of follow-up, such that antibiotic therapy is started if the patient's condition fails to improve by 7 days after diagnosis or worsens at any time. 2
• Most patients with acute bacterial rhinosinusitis feel better within 7 days, and by 15 days about 90% are cured or improved. 2

Common Pitfalls to Avoid

• Failure to use proper intranasal corticosteroid technique reduces efficacy and increases side effects. 1
• Overuse of topical decongestants beyond 3-5 days leads to rhinitis medicamentosa. 2
• Prescribing antihistamines for non-allergic sinusitis can worsen congestion. 2
• If symptoms do not improve after 3-4 weeks of appropriate therapy, consider referral to a specialist. 1
• When used at recommended doses, intranasal corticosteroids are not generally associated with clinically significant systemic side effects. 1