Common Causes of Severe Nasal Congestion
The most common causes of severe nasal congestion in otherwise healthy adults are allergic rhinitis, vasomotor rhinitis (idiopathic nonallergic rhinitis), chronic rhinosinusitis, and upper respiratory viral infections. 1
Primary Etiologic Categories
Severe nasal congestion stems from two main pathophysiologic mechanisms that guide both diagnosis and treatment:
Inflammatory Causes
- Allergic rhinitis affects up to 25% of the worldwide population and represents the single most common cause of chronic nasal congestion 2
- Chronic rhinosinusitis (CRS) affects approximately 12% of the population, with symptoms persisting beyond 12 weeks 3
- Viral upper respiratory infections (common colds) cause acute congestion that typically resolves within 2 weeks 1, 3
- Nonallergic rhinitis with eosinophilia shows eosinophils on nasal smear despite negative allergy testing 4
Noninflammatory Causes
- Idiopathic nonallergic rhinitis (formerly vasomotor rhinitis) presents with congestion, postnasal drip, and sneezing triggered by irritant odors, perfumes, wine, and weather changes 4
- Rhinitis medicamentosa results from overuse of topical decongestant sprays 4
- Structural abnormalities including deviated septum or anatomic variations 2, 4
- Hormone-related rhinitis during pregnancy 4
Underlying Pathophysiology
The sensation of severe congestion results from multiple interrelated mechanisms driven by mucosal inflammation 5:
- Venous engorgement of nasal turbinates 5
- Increased nasal secretions and tissue edema 5
- Release of inflammatory mediators (histamine, tumor necrosis factor-alpha, interleukins) 5
- Altered sensory perception from inflammation-induced changes in nasal afferents 5
Initial Evaluation Approach
Perform focused nasal examination with anterior rhinoscopy to assess the septum and inferior turbinates, looking specifically for mucosal edema, polyps, septal deviation, and turbinate hypertrophy. 4
Key diagnostic steps:
- Obtain allergy skin testing for seasonal and perennial aeroallergens to differentiate allergic from nonallergic rhinitis 4
- Assess symptom duration: acute (<12 weeks) versus chronic (>12 weeks) to distinguish viral infections from CRS 3
- Identify trigger patterns: environmental allergens suggest allergic rhinitis, while irritant odors and weather changes suggest idiopathic nonallergic rhinitis 4
- Review medication history for topical decongestant overuse (rhinitis medicamentosa) 4
Critical Clinical Pitfalls
- Nasal polyps occur in 20% of CRS patients and are more common with persistent asthma, aspirin-exacerbated respiratory disease, and cystic fibrosis 3
- Most acute sinus infections are viral; bacterial infection should only be considered if symptoms worsen or fail to improve within 7-10 days 3
- Severe congestion can lead to serious sequelae including sinusitis, otitis media, and obstructive sleep apnea 1
- Screen for contraindications to oral decongestants (hypertension, arrhythmias, insomnia, prostate hypertrophy, glaucoma) before prescribing pseudoephedrine 4