What is the appropriate management of nasal congestion?

Management of Nasal Congestion

Intranasal corticosteroids are the most effective first-line treatment for nasal congestion, particularly when associated with allergic or chronic rhinitis, with onset of action within 12 hours and superior sustained efficacy compared to all other medication classes. 1, 2

First-Line Treatment Algorithm

For Chronic or Recurrent Nasal Congestion (Allergic Rhinitis, Vasomotor Rhinitis)

• Start with intranasal corticosteroids (fluticasone, mometasone, budesonide) as monotherapy—these control all four major symptoms of rhinitis including congestion, with minimal systemic side effects at recommended doses 1, 2
• Dosing: 2 sprays per nostril once daily for adults; use lowest effective dose in children 3, 2
• Critical technique: Direct sprays away from the nasal septum to prevent irritation, bleeding, and rare septal perforation 1, 3
• Periodically examine the nasal septum for mucosal erosions 1, 3
• Onset within 12 hours with continued improvement over several weeks 3, 2

For Acute Severe Congestion (Common Cold, Acute Sinusitis)

• Topical decongestants (oxymetazoline 0.05%) provide rapid relief within minutes through vasoconstriction 3, 2, 4
• Strict 3-day maximum use to prevent rhinitis medicamentosa (rebound congestion), which can develop as early as day 3-4 of continuous use 1, 3, 2
• For severe congestion with underlying rhinitis: Apply oxymetazoline first, wait 5 minutes, then apply intranasal corticosteroid—this combination can be safely used for 2-4 weeks without causing rebound congestion 3, 2

Second-Line and Adjunctive Options

Oral Decongestants

• Pseudoephedrine 60 mg every 4-6 hours is the only oral decongestant with proven efficacy 2
• Phenylephrine should be avoided due to extensive first-pass metabolism rendering it ineffective 2
• Use with extreme caution or avoid entirely in patients with arrhythmias, angina, coronary artery disease, cerebrovascular disease, uncontrolled hypertension, hyperthyroidism, bladder neck obstruction, or glaucoma 1, 2
• Monitor blood pressure in hypertensive patients, though elevation is rarely noted in normotensive patients 2

Intranasal Antihistamines

• May be considered as first-line treatment and have clinically significant effect on nasal congestion 1
• Equal to or superior to oral second-generation antihistamines for seasonal allergic rhinitis 1
• Generally less effective than intranasal corticosteroids 1
• Can cause sedation and inhibit skin test reactions due to systemic absorption 1

Oral Antihistamines

• Second-generation antihistamines (loratadine, fexofenadine, cetirizine) are less effective for nasal congestion than for other rhinitis symptoms 2, 5
• Combination with oral decongestants provides additional benefit specifically for congestion 2
• Avoid first-generation antihistamines due to significant sedation, performance impairment, and dangerous anticholinergic effects 1, 2

Intranasal Anticholinergics

• Ipratropium bromide effectively reduces rhinorrhea but has no effect on nasal congestion 1
• Can be combined with intranasal corticosteroids for enhanced effect on rhinorrhea without increased adverse events 1

Leukotriene Receptor Antagonists

• Montelukast has similar efficacy to oral antihistamines and may be considered in patients with both rhinitis and asthma 1, 2

Nasal Saline

• Topical saline irrigation is beneficial as sole modality or adjunctive treatment for chronic rhinorrhea and rhinosinusitis 1
• Provides symptomatic relief with minimal risk of adverse effects 3, 2

Management of Rhinitis Medicamentosa (Rebound Congestion)

Recognition

• Develops from prolonged topical decongestant use (>3 days) 1, 3
• Characterized by worsening nasal congestion between doses, tachyphylaxis, reduced mucociliary clearance, and nasal mucosal damage 3
• Benzalkonium chloride preservative may augment pathologic effects when used ≥30 days 3

Treatment Protocol

• Immediately discontinue all topical decongestants 3
• Start intranasal corticosteroids (2 sprays per nostril once daily) and continue for several weeks as nasal mucosa recovers 3
• For patients unable to tolerate abrupt discontinuation: Taper one nostril at a time while using intranasal corticosteroid in both nostrils 3
• For very severe or intractable symptoms: Short 5-7 day course of oral corticosteroids may be added to hasten recovery 1, 3
• Hypertonic saline nasal irrigation provides symptomatic relief during withdrawal without risk of dependency 3

Special Populations

Pregnancy

• Use decongestants with caution during first trimester due to reported fetal heart rate changes 2

Children

• Use topical decongestants with care in children under 1 year due to narrow therapeutic window 2
• Intranasal corticosteroids should be used at lowest effective dose 1

Elderly

• Oral and topical decongestants should be used with caution due to increased risk of cardiovascular and CNS side effects 1

Severe or Refractory Cases

• Short course (5-7 days) of oral corticosteroids for very severe or intractable nasal symptoms or significant nasal polyposis 1
• Single administration of parenteral corticosteroids is discouraged; recurrent administration is contraindicated 1
• Consider allergen immunotherapy for patients with allergic rhinitis who have demonstrable IgE antibodies to clinically relevant allergens 1
• Surgical intervention may be necessary for cases refractory to pharmacotherapy 5, 6

Common Pitfalls to Avoid

• Never use topical decongestants beyond 3 days to prevent rhinitis medicamentosa 1, 3, 2
• Do not prescribe intranasal corticosteroids without proper patient education on directing sprays away from the septum 1, 3
• Avoid oral phenylephrine—it is ineffective due to first-pass metabolism 2
• Do not use oral antihistamines as primary strategy for managing rebound congestion—they are less effective than intranasal corticosteroids 3
• Avoid first-generation antihistamines due to sedation and anticholinergic effects 1, 2