The Medical Consumer's Advocate

Nasal Congestion

Douglas Hoffman, M.D., Ph.D., June 1998

Synonyms: Nasal airway obstruction; stuffy, stuffed, stopped-up, or congested nose.

 

Contents

Do I need a doctor?

Conservative measures for new onset nasal congestion.

Over the counter medications for nasal congestion.

What your doctor needs to know.

What to expect from your doctor.

The differential diagnosis of nasal congestion.

Disclaimer: This information is meant to improve the interaction between you and your doctor. It is NOT meant to replace this interaction!There is no substitute for a history and physical examination administered by a competent physician.If you inappropriately use this information to treat yourself, you may be endangering your health.

Do I need a doctor?

The most common causes of nasal congestion (the common cold and allergies) are hardly life-threatening.Nevertheless, nasal congestion can be the initial symptom for a number of serious illnesses.Of particular concern are cancers or aggressive infections involving the nose, sinuses, and facial bones.If any of the following symptoms accompanies your nasal congestion, this may be an indication that you have such a problem.If so, you need to be evaluated by a doctor as soon as possible.

• Redness, pain or swelling around the nose, eyes or forehead

• Double vision or decreased vision

• Facial or dental numbness

• Loose teeth

• Deformity (changed appearance) of the facial bones

• Nose bleeds

• A new, unilateral obstruction that is slowly getting worse (over weeks to months)

• An upper denture that used to fit well, but now does not

• Any sinus symptoms (facial pain, postnasal drainage) in a patient with a compromised immune system (HIV patients, diabetics, some cancer patients, children with immunodeficiency syndromes)

Additionally, any case of acute nasal congestion that has not responded to conservative measures (see below) for 2 weeks or longer (and has no obvious explanation) should prompt you to see your doctor.Your problem is probably not serious, but it may resolve more rapidly if you are under a doctor's care.

 

Wondering how to use this information?

Refer to Symptom Guide Help for a bit of advice.

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Conservative measures for new onset nasal congestion (none of the above symptoms are present):

There are many good over the counter medications for treating nasal congestion.Just a word of warning:some of these medications are not safe to use if you have other medical conditions such as high blood pressure, an enlarged prostate, or glaucoma.In general, you should read the package information on all medications, prescription or otherwise.If you have any medical problems, you should also discuss this with your pharmacist and/or doctor before starting a new medication.

Nasal congestion may be treated with decongestants, antihistamines, and/or a variety of sprays. (The generic names, not the trade names, are used below.The generic names will always be listed on the package under "active ingredients".)

• Always use single agent preparations.Do not use "cold formulas" that have two or more medications combined.Look at the label; you only want to see one item under "active ingredient".By using single agent preparations, you may be able to determine which particular medication "does the job".This way, you'll end up taking fewer drugs.

• Begin by using one medication.Follow the directions, and avoid the temptation to exceed the dosage described on the package.Give this medication at least one to two days before abandoning the drug and trying something else.

• Try to choose your medication based on your exact symptoms.If you have prominent allergic symptoms (watery eyes or nose; itchy eyes, nose or skin; sneezing), begin with an antihistamine or a cromalyn sodium nasal spray (see medication list, below).If allergic symptoms are absent yet congestion is still very troublesome, you may prefer to start with an oral decongestant.

• Nasal spray decongestants (oxymetazoline, phenylephrine hydrochloride) are extremely effective when used according to instructions, but have some significant dangers.If you have any other medical problems, speak to your pharmacist or doctor before using such a spray.Never use the spray more frequently or for a longer period of time than is described on the package instructions.If you do exceed this dosage, you run the risk of developing a particularly nasty condition known as rhinitis medicamentosa.In essence, your nose becomes "addicted" to the spray, and will only remain uncongested if you continue to use the spray.

• Cromalyn sodium nasal spray is extremely effective for allergic symptoms and is relatively free of side effects.It is, unfortunately, more expensive than the typical oral antihistamine.If you have prominent allergic symptoms which respond only in part (or not at all) to antihistamines, consider switching to cromalyn.If you are not on a tight budget, cromalyn is an excellent first choice for allergic symptoms.

• If you have a partial response to a medication and you wish to add a second medication, select a medication from a different class.In other words, do not take two decongestants or two antihistamines.Also, do not combine an oral decongestant with a decongestant spray.This is unnnecessary and potentially harmful. (It is safe to combine an antihistamine with cromalyn sodium spray.)

• Nasal saline spray is very safe (it is a salt solution of the same concentration as your body fluids) and can be quite soothing, particularly for a dry, irritated nose.A hot, steamy shower can also be effective.

• If your symptoms persist for two weeks or longer, or if at any time any of the symptoms described above occur, consult your doctor.

 

Over the counter medications for nasal congestion.

Antihistamines	Decongestants	Decongestant Sprays	Sprays for Allergy
Diphenhydramine Chlorpheniramine Pheniramine Pyrilamine Methapyrilene Phenindamine Loratadine	Pseudoephedrine Phenylpropanolamine	Oxymetazoline Phenylephrine	Cromalyn sodium

What your doctor needs to know.

When did the congestion start?Does it ever vary in quality (is it ever better or worse), or is it constant?If there are times when it is worse, can you think of anything that these times have in common? (E.g., exposure to particular foods, dust, or animal dander; climate changes; time of menstrual cycle; emotional distress...Rack your brains for what these episodes of nasal congestion may have in common!)Is there anything that you can do to make the congestion better or worse?Have you taken any medications to relieve the congestion, and if so, were they effective?

Have you ever had a problem like this before?(If so, how often, how long did the episodes last, and how did they resolve?)Do you have any of the following symptoms:itchy nose, itchy or watery eyes, watery drainage from your nose, or sneezing?Do you have any of the warning signs or symptoms described above?Have you ever had cancer?

Do you have any drainage down the back of your throat, from your nose?What is its color and consistency?Do you have a cough (and if so, is it worse when you wake up or go to bed?)Are you bringing up any mucus (and if so, what is its color and consistency?)Do you have any nasal crusts?

What other medical problems do you have?Have you ever been hospitalized (and if so, for what condition?)Have you ever had surgery (especially nasal or sinus surgery?)Before your nasal congestion first became a problem, did you sustain any facial trauma?What medications are you taking?(Name all of them, prescription and nonprescription drugs, herbal remedies, everything.)Are you allergic to any medications?Do you have any other known allergies (hay fever, cat dander, a food allergy, and so forth)?

Do you smoke, drink, or use any drugs (especially cocaine)-- and if so, how much do you use, and for how long have you smoked/drank/used drugs?What is your occupation, and what other occupations have you held?Do you own any pets?Have you travelled recently in a foreign country (or lived for extended periods of time in a foreign country?)

For infants and children:answers to most of the above questions are still very pertinent.Additionally, some questions are specific to the infant/child:are there any breathing or feeding difficulties?At what age did the problems first arise?Is there any facial deformity?Is there any nasal drainage (and if so, is it unilateral or bilateral?)Is the child in daycare?Is the child exposed to any secondhand smoke?Does the infant/child frequently get ear or lung infections?

What to expect from your doctor.

Your doctor should allow you the time to adequately tell your story. If you are prepared (i.e., if you have read the material in the preceding section and are able to give your doctor a concise history), he should have few additional questions to ask.Your doctor is being paid to consider the full differential diagnosis of nasal congestion (see below); unfortunately, some doctors are content to pigeonhole their patients into the common categories.(In this case, such a doctor would only obtain enough history to determine whether you have a common cold, allergy, or sinus infection.) This approach is fast, easy, and will work for most patients, but will fail if the patient has a problem that is even a bit unusual.

You can learn a great deal about a doctor by the care he shows in taking your history.

Should your doctor examine your nose? If your symptoms very clearly fit one of the common diagnoses such as allergy or the common cold, and if this is your first visit to the doctor for this problem, then it is probably safe to skip the nasal examination. If, however, your problem has persisted despite previous treatment, or if any of the warning signs and symptoms (discussed above) are present, then a nasal examination is necessary.

Most primary care physicians will examine your nose either with an otoscope or with a nasal speculum and pen light. These techniques provide a very limited nasal examination. Nevertheless, such an examination may reveal a deviated septum, polyps, purulent drainage (pus) from a sinus, or a large tumor.

An otolaryngologist (ENT) has the equipment to perform a more thorough nasal examination. We typically first examine the nose using a nasal speculum and headlight.Next, we spray a mixture of a vasoconstrictor (such as Afrin) and a topical anesthetic into each nostril, and after waiting a few moments, we repeat the exam. The vasoconstrictor causes the tissues lining the nose to temporarily decrease in bulk; this improves our ability to examine the interior of the nose.

If any of the warning signs or symptoms are present, or if the patient's problem has proven resistant to conventional treatments, we will also perform an endoscopic nasal exam. (An endoscope is a camera that allows us to examine the deeper portions of the nasal cavity.)In addition, we will usually perform a complete head and neck exam.Along with the nasal exam, this includes an examination of the ears, mouth, throat, larynx (voice box), and neck, and a neurologic exam to test the function of the major peripheral nerves in the head and neck.

This is the limit of what can be examined in the office. Additional tests may be necessary, such as a CT (CAT scan) of the sinuses or a biopsy, but in general, the exam described above yields sufficient information to enable us to diagnose and treat most patients.

The differential diagnosis of nasal congestion.

This list is not intended to fuel the flames of hypochondria. Rather, it is hoped that this will serve to stimulate discussions between you and your doctor, particularly if your nasal congestion has proven difficult to treat.

• Congenital malformations of the nose or nasal cavity

• Infections (viral, fungal, bacterial, parasitic)

• Vasomotor rhinitis

• Congestion as a medication side effect

• Allergy

• Inflammatory polyps

• Other nasal growths (both malignant and benign conditions)

• Altered nasal anatomy due to trauma (accidental or surgical)

• Impaction (by dried crusts or other foreign body)

• Septal deviation, perforation, or other septal problems

• Enlarged adenoids (or other nasopharyngeal masses)