How to Treat Nasal Congestion

With the FDA announcing that a common cold medicine ingredient was ineffective, an otolaryngologist shares the best treatments to help alleviate a stuffy nose.

Whether it’s caused by a cold, seasonal allergies, or a sinus infection, nasal congestion can create a lot of discomfort that makes it hard to breathe, sleep, and focus.

Treating nasal congestion has always appeared seemingly easy — most people simply head to their local pharmacy to buy over-the-counter cold or allergy medicines. But recently, an advisory committee to the FDA announced that a common ingredient found in many popular cold medicines, phenylephrine, is actually ineffective for treating nasal congestion when taken orally.

So, what is the best way to clear a stuffy nose? Health Matters spoke with Dr. David A. Gudis, an otolaryngologist and chief of the Division of Rhinology and Anterior Skull Base Surgery at NewYork-Presbyterian/Columbia University Irving Medical Center, on what to know about nasal congestion and its treatment options.

Dr. David A. Gudis

What causes nasal congestion?
Dr. Gudis: Common colds or upper respiratory tract infections are generally caused by a group of common viruses, like rhinovirus or adenovirus. Typically, a cold will cause a few days of nasal congestion, fatigue, increased nasal discharge, sore throat, and sometimes a cough or low-grade fever. Many of those symptoms, including congestion, are caused not by the virus itself, but by the immune system’s response to that virus. The immune system’s response to allergens is similar.

Nasal congestion, or feeling like your nose is blocked or stuffy, happens when inflammation causes the lining of the nose to become swollen due to blood filling up all of the tiny capillaries and spaces inside the mucus membranes. This inflammation is an immune response to a virus or allergen entering the nose. When the lining of the nose gets swollen, the air passages become very constricted, and it feels hard to breathe.

Can nasal congestion be a sign of something more serious than a cold or allergy?
Congestion from a common cold should start to improve after three to five days.  If symptoms are not improving after a week, or if symptoms start to get better but then get worse again, other causes of the symptoms should be considered, like allergies, bronchitis, pneumonia, or a sinus infection.

Our sinuses — the mucus membrane-lined cavities that occupy much of the head — have a surprisingly important job. They constantly interact with our environment to help our immune system understand what to fight and what not to fight. It may sound off-putting, but healthy people make about a pint of mucus per day. Each sinus has a small opening, and if that opening gets blocked or if the sinus gets overwhelmed with a certain bacteria, virus, or fungus, a sinus infection can occur.

Viral rhinosinusitis (a sinus infection caused by a virus) is generally managed with supportive care, rest, hydration, and patience. Bacterial rhinosinusitis is common, and usually causes sinus pain, pressure, nasal congestion, and stuffiness, and increased thick nasal discharge or postnasal drip. These sinus infections may also cause headaches, decreased sense of smell and taste, ear fullness, cough, or low-grade fever. Depending on the symptom severity and duration, treatments may vary, but bacterial sinus infections respond very well to antibiotics. If bacterial sinus infections occur more than three or four times per year, it’s worth seeing a specialist to be sure there is not an underlying condition or cause of recurrent infections. Fungal sinus infections are very rare and potentially very dangerous, and typically occur in people with abnormal immune systems or poorly controlled diabetes. These infections result in severe illness and are treated in the hospital.

How do you choose which over-the-counter medication to use to help relieve nasal congestion?
There are some easy and generally safe treatments that can significantly relieve symptoms of nasal congestion. If symptoms are due to allergies, nasal sprays to reduce inflammation are very effective if used consistently. The best initial treatment is to use a combination of two nasal sprays together in the morning and at night: a nasal corticosteroid spray, like fluticasone, and a nasal antihistamine spray, like azelastine. They are both available over the counter. An oral antihistamine like loratadine or fexofenadine can also be very helpful.

Decongestant nasal sprays are also very helpful for any kind of nasal congestion. They work as vasoconstrictors, meaning that they squeeze blood vessels tighter so that blood and fluid can’t collect inside the lining of the nose. Oxymetazoline and phenylephrine are common over-the-counter nasal decongestant sprays. However, the recent FDA statement concluded that phenylephrine taken orally is not an effective nasal decongestant.

When using nasal decongestant sprays, it is very important to avoid using them for more than two or three days at a time to minimize the risk of rebound congestion. Rebound congestion occurs when the lining of the nose gets used to the medication and becomes dependent on it, so that when you stop using it, you end up more congested than when you started. Rebound congestion may occur if somebody begins using nasal decongestant sprays frequently to treat other problems, like uncontrolled allergies or a deviated nasal septum.

Even though the FDA said oral phenylephrine wasn’t effective, it didn’t flag any safety risks with taking it. Are there any concerns with taking oral medications that contain phenylephrine?
Oral phenylephrine can cause high blood pressure and make the heart rate speed up, so it should generally be avoided unless a doctor determines that it is needed. Nasal sprays result in less systemic absorption than oral medications, meaning nasal decongestant sprays are less likely to result in those problems, but they can still occur occasionally. Talk to your doctor if you’re not sure what the risks are for you.

Are there any at-home remedies for treating congestion?
If your symptoms seem to be due to allergies, in addition to the nasal spray combination mentioned above, consider other measures, like avoiding the allergic triggers, keeping floors and carpets vacuumed, washing linens frequently, and using an air purifier.

If you’re sick, it’s always important to rest and drink plenty of fluids. Neti pots, nasal saline (salt water) sprays, and steam inhalers can also help a lot with relieving symptoms, although they won’t significantly change the course of the illness. Even a hot shower can help; the steam can break up some of the mucus and make it easier to clear. But it really comes down to trial and error and seeing what works for you.

And finally — I have no scientific basis for this — but I’m a big believer that soup is great for colds and congestion. So learn how to make good chicken soup, or find somebody else who can!

David Gudis, MD, is chief of the division of rhinology and anterior skull base surgery in the Department of Otolaryngology – Head and Neck Surgery and the Department of Neurological Surgery at NewYork-Presbyterian/Columbia University Irving Medical Center, and an associate professor of otolaryngology – head and neck surgery at Columbia University Vagelos College of Physicians and Surgeons.

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