What nasal spray is recommended for a stuffy nose?

Nasal Spray for Stuffy Nose

For acute nasal congestion, use saline nasal spray or irrigation as first-line therapy, with intranasal corticosteroids added for persistent symptoms; reserve topical decongestants (oxymetazoline) for severe congestion only, limiting use to 3-5 days maximum to avoid rebound congestion. 1, 2

First-Line Treatment: Saline Nasal Irrigation

• Saline nasal spray or irrigation should be your initial recommendation for symptomatic relief of nasal congestion, whether from viral upper respiratory infections, acute bacterial sinusitis, or chronic rhinosinusitis 1, 3
• Isotonic (normal) saline is more effective than hypertonic saline for most patients with chronic nasal congestion, showing superior improvement in nasal obstruction, discharge, and overall symptoms 1
• Saline irrigation is safe with no serious adverse events reported, and minor side effects can be avoided through technique adjustment 3
• The American Academy of Otolaryngology recommends saline irrigation for symptomatic relief in both viral and bacterial rhinosinusitis 1

Second-Line: Intranasal Corticosteroids

• Add intranasal corticosteroid sprays (e.g., fluticasone, mometasone) for persistent nasal congestion beyond simple saline use 1
• Intranasal steroids provide symptomatic relief but require approximately 15 days of use to achieve benefit, with a modest effect size (number needed to treat = 14) 1
• These are as safe and effective as antihistamines for controlling rhinitis symptoms when used properly 4
• Side effects include headache, nasal itching, and nosebleeds 1

Topical Decongestants: Short-Term Use Only

• Oxymetazoline or xylometazoline nasal sprays can be used for severe nasal obstruction, but strictly limit to 3-5 consecutive days 1, 2
• The European Rhinologic Society found that combining oxymetazoline with intranasal corticosteroids (mometasone) for up to 4 weeks in chronic rhinosinusitis with nasal polyps was more effective than corticosteroids alone and did not cause rebound congestion 1
• However, rebound congestion (rhinitis medicamentosa) may develop as early as day 3-4 of continuous use, causing paradoxical worsening of nasal obstruction 1, 2
• Package labeling recommends no more than 3 days of use 1

Critical Safety Warnings for Topical Decongestants

• Never use topical decongestants as monotherapy for bacterial sinusitis, which requires systemic antibiotics 2
• Contraindicated in first trimester pregnancy, infants under 1 year, and patients with uncontrolled cardiovascular disease 2
• Rare but serious cerebrovascular events reported include stroke, anterior ischemic optic neuropathy, and "thunderclap" headache 1
• Regular use beyond 5 days leads to rhinitis medicamentosa requiring intranasal or oral corticosteroids for recovery 1

Alternative: Antihistamine Nasal Spray

• Azelastine nasal spray (2 sprays per nostril twice daily) is FDA-approved for allergic rhinitis and vasomotor rhinitis in adults and children ≥5 years for allergic rhinitis, ≥12 years for vasomotor rhinitis 5
• Provides relief of rhinorrhea, nasal congestion, postnasal drip, and sneezing 5
• Symptom improvement reaches statistical significance within 3 hours and persists over 12-hour dosing intervals 5
• This is appropriate when allergic or vasomotor rhinitis is the underlying cause of congestion 5

Clinical Algorithm

1. Start with isotonic saline nasal irrigation (spray or rinse) for all patients with nasal congestion 1, 3
2. If congestion persists beyond 7-10 days, add intranasal corticosteroid spray 1
3. For severe acute congestion preventing sleep or medication delivery, add oxymetazoline for maximum 3-5 days while continuing saline and starting corticosteroids 1, 2
4. If allergic or vasomotor rhinitis is suspected, consider azelastine nasal spray as an alternative to corticosteroids 5
5. Never extend topical decongestant use beyond 5 days without a prolonged drug-free interval 1, 2

Common Pitfalls to Avoid

• Do not recommend over-the-counter topical decongestants without explicit warnings about the 3-5 day limit and risk of rebound congestion 1, 4
• Avoid oral antihistamines for simple nasal congestion without other allergic symptoms, as they do not reliably relieve nasal obstruction 1
• Do not use topical decongestants in children under 6 years due to lack of efficacy data and toxicity concerns 1
• Prolonged topical decongestant use has no place in treating chronic rhinitis and causes significant complications 4, 6