How should I evaluate and treat nasal congestion?

Evaluation and Treatment of Nasal Congestion

Start with intranasal corticosteroids as first-line therapy for most cases of nasal congestion, as they are the most effective medication class for controlling all major nasal symptoms including congestion, regardless of whether the cause is allergic or nonallergic rhinitis. 1

Initial Diagnostic Evaluation

Key History Elements to Obtain

• Timing and pattern: Determine if symptoms are seasonal (suggesting pollen allergy), perennial (suggesting dust mite, mold, or animal dander allergy), or episodic versus continuous 1
• Specific triggers: Ask about exposure to allergens, irritants, temperature/humidity changes, foods, alcohol, and medications (ACE inhibitors, phosphodiesterase-5 inhibitors, NSAIDs, alpha-blockers) 1
• Associated symptoms: Presence of sneezing, rhinorrhea, nasal itching, and ocular symptoms strongly suggests allergic rhinitis, while isolated congestion may indicate nonallergic rhinitis 1
• Medication history: Specifically ask about use of topical nasal decongestants (oxymetazoline/Afrin), as overuse beyond 3 days can cause rhinitis medicamentosa 1, 2
• Quality of life impact: Assess effects on sleep, work/school performance, and daily functioning 1

Physical Examination Focus

• Nasal mucosa appearance: Pale, boggy mucosa suggests allergic rhinitis; erythematous mucosa suggests infectious or vasomotor rhinitis 1
• Nasal septum inspection: Look for mucosal erosions or perforation, especially in patients using intranasal medications 1
• Presence of nasal polyps: Associated with chronic rhinosinusitis and nonallergic rhinitis with eosinophilia 1

When to Perform Allergy Testing

Obtain skin prick testing (preferred over serum IgE) when history suggests allergic triggers, to guide allergen avoidance and determine candidacy for immunotherapy. 1 Testing is indicated when you need to confirm allergic etiology, identify specific allergens for avoidance, or consider immunotherapy 1.

Treatment Algorithm by Clinical Scenario

Acute Viral Rhinosinusitis (Symptoms <10 Days)

For acute congestion from viral upper respiratory infection, use symptomatic treatment with short-term topical or oral decongestants (≤3-5 days maximum) plus saline irrigation. 3

• Nasal saline irrigation (isotonic or hypertonic): Provides symptomatic relief with minimal adverse effects 3
• Topical decongestants (oxymetazoline): Rapid relief but must limit to 3-5 consecutive days maximum to prevent rebound congestion 3, 4
• Oral decongestants (pseudoephedrine): Can use for 3-5 days for congestion and sinus pressure 3
• Avoid antihistamines: They are ineffective for viral rhinitis and may worsen symptoms by drying nasal mucosa 3
• Consider intranasal corticosteroids if symptoms persist beyond initial viral phase, though onset is slower (12 hours to days) 3

Allergic Rhinitis (Confirmed or Suspected)

Intranasal corticosteroids are the most effective single-agent therapy and should be first-line treatment, particularly when congestion is the predominant symptom. 1

First-Line Treatment

• Intranasal corticosteroids (fluticasone, mometasone): Most effective for all four cardinal symptoms (congestion, rhinorrhea, sneezing, itching), especially congestion 1
  • Dose: 2 sprays per nostril once daily 2
  • Direct spray away from nasal septum to minimize irritation and bleeding 1
  • Onset of action: 12 hours with continued improvement over weeks 2
  • Safe for long-term use without systemic effects at recommended doses 1

Second-Line or Adjunctive Options

• Second-generation oral antihistamines: Effective for rhinorrhea, sneezing, and itching but have minimal effect on congestion 1
• Intranasal antihistamines: More effective for congestion than oral forms 5
• Leukotriene receptor antagonists: Similar efficacy to antihistamines; combination with antihistamines may be additive but less effective than intranasal corticosteroids 1

For Severe Congestion Requiring Rapid Relief

When severe congestion requires immediate relief, combine short-term oxymetazoline (≤2-4 weeks) with intranasal corticosteroid from the outset to prevent rebound congestion. 2

• Apply oxymetazoline first, wait 5 minutes, then apply intranasal corticosteroid 2
• This combination prevents rebound congestion when used together, unlike oxymetazoline alone 2
• Provides both rapid relief (minutes) and sustained effectiveness 2

Avoid These Common Pitfalls

• Never use oral decongestants as monotherapy for allergic rhinitis; they should only be combined with antihistamines 1
• Monitor blood pressure in hypertensive patients using oral decongestants, though elevation is rare 1
• Do not use topical decongestants alone for >3 days without intranasal corticosteroid coverage 1, 2

Nonallergic Rhinitis (Negative Allergy Testing)

Intranasal corticosteroids remain first-line therapy and are effective for many forms of nonallergic rhinitis. 1

• For profuse watery rhinorrhea (gustatory rhinitis, cholinergic hyperreactivity): Add intranasal ipratropium bromide 1
  • Use with caution in patients with glaucoma or prostatic hypertrophy 1
• For hormonal rhinitis (pregnancy, menstrual): Intranasal corticosteroids are safe and effective 1

Rhinitis Medicamentosa (Rebound Congestion from Overuse)

Immediately discontinue topical decongestant and start intranasal corticosteroid; this is the definitive treatment. 2

Step-by-Step Management

1. Stop all topical nasal decongestants immediately 2
2. Start intranasal corticosteroid (fluticasone 2 sprays per nostril once daily) 2
3. For severe symptoms during withdrawal: Add short 5-7 day course of oral corticosteroids to hasten recovery 1, 2
4. Alternative gradual taper method (if patient cannot tolerate abrupt cessation): Taper one nostril at a time while using intranasal corticosteroid in both nostrils 2
5. Continue intranasal corticosteroid for several weeks as nasal mucosa recovers 2
6. Adjunctive saline irrigation provides symptomatic relief without dependency risk 2

Prevention Education

• Rebound congestion can develop as early as 3-4 days of continuous topical decongestant use 2
• Benzalkonium chloride preservative may worsen damage with prolonged use 2
• Rare complications include nasal septal perforation 2

When Medications Fail: Advanced Options

Allergen Immunotherapy

Consider immunotherapy for patients with confirmed IgE-mediated allergic rhinitis who have inadequate response to pharmacotherapy or wish to avoid long-term medication use. 1

• Indications: Severity/duration of symptoms, medication side effects, patient preference, presence of comorbid asthma/sinusitis 1
• Contraindications: Severe uncontrolled asthma, unstable cardiovascular disease 1
• Use caution with beta-blockers, as they may complicate treatment of systemic reactions 1
• Expect improvement after reaching maintenance dose; discontinue if no improvement after 1 year 1

Surgical Evaluation

Refer for surgical evaluation when medical therapy fails and structural abnormalities (septal deviation, turbinate hypertrophy, nasal polyps) are present. 1

• Septoplasty for anterior septal deviation with nasal valve collapse 1
• Turbinate reduction for persistent turbinate hypertrophy unresponsive to medical therapy 1
• Avoid septoplasty in children due to potential negative effects on nasal growth 1

Referral Indications

Refer to allergy/immunology or ENT when: 1

• Prolonged severe disease despite appropriate pharmacotherapy
• Comorbid conditions (asthma, recurrent sinusitis, nasal polyps)
• Symptoms significantly interfere with quality of life or function
• Medications are ineffective or cause unacceptable adverse reactions
• Patient desires immunotherapy or surgical options

Critical Monitoring Points

• Periodically examine nasal septum in patients using intranasal corticosteroids to check for mucosal erosions, though septal perforation is rare 1
• In children using intranasal corticosteroids: Use lowest effective dose due to theoretical growth concerns 1
• Assess quality of life as part of ongoing treatment evaluation 1