What over-the-counter (OTC) medications can be used to treat frontal sinus and inner ear congestion?

OTC Medications for Frontal Sinus and Inner Ear Congestion

For frontal sinus and inner ear congestion, pseudoephedrine 60 mg every 4-6 hours is the most effective OTC oral decongestant, while short-term topical decongestants (3-5 days maximum) provide superior relief but carry risk of rebound congestion. 1, 2

Primary Treatment Options

Oral Decongestants (First-Line for Inner Ear Congestion)

Pseudoephedrine is significantly superior to phenylephrine due to better oral bioavailability, as phenylephrine undergoes extensive first-pass metabolism in the gut and has questionable efficacy. 3, 1

• Pseudoephedrine 60 mg every 4-6 hours is the optimal adult dose, providing maximal nasal and sinus decongestion without significant cardiovascular effects 1, 4
• Extended-release formulations allow longer dosing intervals, particularly beneficial for nighttime relief 1
• Works through α-adrenergic agonist activity causing vasoconstriction in nasal passages and Eustachian tubes 1, 5
• Particularly effective for inner ear congestion (Eustachian tube dysfunction) where oral treatment is superior to topical agents 5

Important cardiovascular considerations:

• Small increases in systolic blood pressure (0.99 mmHg) and heart rate (2.83 beats/min) occur, but generally no significant effect on diastolic blood pressure 1
• Use with caution in patients with hypertension, arrhythmias, coronary artery disease, cerebrovascular disease, hyperthyroidism, or glaucoma 3, 1
• Avoid during first trimester of pregnancy due to reported fetal heart rate changes 1, 6

Topical Decongestants (Superior for Acute Frontal Sinus Congestion)

Topical decongestants (xylometazoline nasal spray) are superior to oral pseudoephedrine for acute frontal sinus congestion based on imaging studies showing reduced congestion of sinus and nasal mucosa. 2

• Maximum 3-5 consecutive days of use to prevent rebound congestion and rhinitis medicamentosa 3, 2, 6
• Provide faster and more intense decrease in nasal airway resistance than oral agents 7
• Best for acute severe frontal sinus pressure requiring immediate relief 2

Intranasal Corticosteroids (For Prolonged Symptoms)

If symptoms persist beyond a few days, intranasal corticosteroids become the preferred treatment rather than continuing decongestants. 3, 6

• Mometasone furoate, fluticasone propionate, and fluticasone furoate are preferred OTC options with negligible bioavailability and minimal side effects 3
• Onset of action within 12 hours, requiring once-daily dosing 6
• Most effective monotherapy for nasal congestion with minimal adverse effects 6
• Available OTC in most developed countries 3

Adjunctive OTC Treatments

Nasal Saline Irrigation

• Provides symptomatic relief with minimal risk of adverse effects 6
• Particularly useful as adjunct to other therapies 2

Analgesics

• Paracetamol or NSAIDs provide general benefit for sinus pain and pressure in adults 3
• Benefits must be weighed against risk of adverse effects 3

Herbal Medicines (Limited Evidence)

• BNO1016 (Sinupret), Cineole, and Myrtol have shown some benefit for post-viral sinus symptoms without significant adverse events 3
• Zinc lozenges (≥75 mg/day) taken within 24 hours of symptom onset may reduce duration if viral etiology 3

Treatment Algorithm

For acute frontal sinus congestion:

1. Start with topical decongestant (xylometazoline) for immediate relief, maximum 3-5 days 2
2. Add pseudoephedrine 60 mg every 4-6 hours if inner ear congestion present or topical contraindicated 1, 5
3. If symptoms persist beyond 5 days, switch to intranasal corticosteroid (fluticasone or mometasone) once daily 3, 6

For inner ear congestion (Eustachian tube dysfunction):

1. Pseudoephedrine 60 mg every 4-6 hours is preferred as oral treatment reaches Eustachian tube mucosa better than topical agents 5
2. Continue for short-term use only; not recommended for long-term daily use 1

Critical Pitfalls to Avoid

• Never use phenylephrine as oral decongestant - it lacks efficacy due to poor bioavailability despite being substituted in many OTC products 3, 1
• Never continue topical decongestants beyond 5 days - this causes rebound congestion that worsens the original problem 3, 2
• Antihistamines have no role in non-allergic sinus congestion and may worsen symptoms by drying nasal mucosa 2
• Screen for cardiovascular contraindications before recommending pseudoephedrine 1
• Avoid concomitant use with caffeine or other stimulants which may increase adverse effects 1