Overview

Who has experienced the feeling of nasal congestion? Pretty much everyone has experienced that throughout their lifetime. If you are wondering about the underlying causes and mechanism of nasal congestion and how to deal with and prevent nasal congestion, this article aims to answer these questions.   

Overview of Nasal Congestion

Nasal congestion is a common symptom encountered in daily practice, best described as a perception of reduced nasal airflow or a sense of facial fullness. It is a predominant symptom of inflammation in the nose, whether allergic or not (allergic rhinitis and nonallergic rhinitis), inflammation in paranasal sinuses (sinusitis), reflect the presence of benign nasal outgrowth (nasal polyps), or even a symptoms of middle ear infection (otitis media) or asthma.¹

Mechanism of Nasal Congestion 

There are a number of mechanisms underlying nasal congestion, these include inflammation involving the mucosal (innermost layer of the nose); problems affecting the structure of nasal passages; changes of sensory perception in the nose.¹

Common Causes 

• Allergies
• Colds and Flu  
• Sinusitis  
• Environmental Irritants 
• Structural Issues (Nasal septal deviation, enlarged nasal turbinates)  

Immediate Relief Methods  

Over-the-Counter Medications  

Decongestant Sprays

Topical decongestants exert their effect and relieve nasal congestion by causing narrowing in the vessels within nasal mucosa (vasoconstriction). 

The most commonly used agents include oxymetazoline and phenylphedrine. The action of these medications usually take around 20 minutes. Topical decongestants should not be used for no more than 3 to 5 days, otherwise, patients are likely to experience rebound congestion after drug withdrawal, and if used for months, produce another form of nasal inflammation called rhinitis medicamentosa.²          

Oral Decongestants  

Oral decongestants work similar to topical decongestants and relieve nasal congestion by causing vasoconstriction (narrowing in the vessels within nasal mucosa). 

A variety of oral decongestants are available, the most commonly used is pseudoephedrine.

Oral route of administration causes these medications to have more pronounced systemic effects compared to topical sprays; these effects may involve central nervous system causing irritability, headache, nervousness, and insomnia; cardiovascular system causing palpitation and elevated blood pressure. The length of time of therapy is based on clinician decision. ³ 

Home Remedies  

Steam Inhalation  

Steam inhalation is an age-old natural practice that many patients find through it relief from discomfort and pain associated with nasal congestion. Steam inhalation causes relief from the symptoms, however, it is not a cure for the underlying causes. Steam inhalation action is induced by the warmth of the steam that helps to relieve congestion, dilates blood vessels of nasal passages and reducing inflammation making it easier to breathe. Moisture of the steam helps with thinning out mucus discharge trapped in the nose, and has a soothing effect on the irritated lining of nasal passages. Beyond that physical relief, inhaling steam can have a psychological very relaxing effect. In addition, adding some oils such as eucalyptus or peppermint can enhance these effects by producing anti-inflammatory and decongestant properties. 

Steam inhalation can simply be performed by bringing a bowel, boiled water, and a towel. Boiled water is poured into the bowel and a towel is put over the head. Then the steam is inhaled slowly and deeply for around 10-15 minutes and after the session, it is recommended to blow the nose gently and to rinse the face with cool water and then pat it dry. It is recommended to include this practice in the daily routine.⁴ 

Saline Nasal Irrigation (SNI)  

The roots of saline nasal irrigation (SNI) belong to Ayurvedic medicine. This technique improves nasal congestion by rinsing the area behind the nose with salt water (saline). The mechanism behind the effect of nasal saline irrigation is not well known but it mainly enhances the nose's ability to resist the irritants, inflammatory mediators and infectious agents through directly cleaning the nose and removing inflammatory mediators with irrigation. 

Saline nasal irrigation (SNI) can be performed by using a commercially available nasal cup pre-packaged salt or mixing salt and water at home (ask the doctor about the amount), lean over a sink and rotate the head slightly and gently insert the spout of nasal irrigation pot into the upper nostril, raise the pot so that the solution enters through the upper nostril and drains through the lower nostril. Remember to breathe through the mouth.⁵ 

Hydration and Diet  

Hydration is a key to an overall healthy bodily function and supporting immune function, in the nose and nasal sinuses. Hydration facilitates the generation of the protective mucus lining of nasal passages. Mucus secreted by the mucus membranes acts as a defense barrier against pathogens, irritants, and foreign particles. Maintaining hydration can be accomplished by consistent adequate water intake, water-rich food like fruits and vegetables, herbal teas, and limiting dehydrating substances such as caffeine and alcohol.⁶ 

Long-term Management and Prevention 

The approach for management of nasal congestion is stepwise and includes 5 main principles, these include:  

• knowing the underlying cause 
• patient education and monitoring
• avoiding trigger factors where possible
• medications
• allergen immunotherapy or surgery⁷

Patient Education and Environmental Control

This includes explaining the condition and the treatment goals including patients preference for interventions and the possible side effects. Regular review of treatment goals and monitoring progress are parts of effective management.⁷ 

Environmental control includes the avoidance of possible trigger irritant factors such as cigarette smoke, smoke, fumes, strong odours, in addition to infectious agents. Environmental control is not always practical and the need for supplemental medications is usually indicated, with the use of nasal saline irrigation alone or combined with medication, this approach usually improves symptoms and quality of life.⁸

Although evidence does not support some of the measures used to avoid dust mites, such as mite-proof impermeable mattresses and pillow covers, air filtration systems, many guidelines still recommend using them.  

Allergy Management  

Identifying Triggers  

Optimal treatment includes avoiding the trigger allergen and the use of medications. These allergens may include any of (pollen, dust mites, animal dander, mould spores, cockroach dropping). Practices that can help include: lowering indoor humidity, using special pillows and mattress that are allergen-proof, and minimising contact with fur-bearing pets.⁷

Medications

Intranasal steroids are usually used as a first-line therapy as these are the most effective therapy for persistent symptoms. However, when symptoms are not responding, other second-line medications are indicated, including antihistamines, decongestants, cromolyn, leukotriene receptor antagonists. 

Adverse effects of intranasal steroids may include throat irritation, nose bleed and nose dryness.

Antihistamines used are either first-generation which may cause sedation and fatigue or second-generation which have cause less sedation.⁸

Lifestyle Modifications  

Sleep Positioning  

Some sleep positions might help the sinus to drain better and thus relieve the symptoms of nasal congestion, gravity plays an essential role in how this fluid drains through the sinuses. Accordingly, elevation of the head is a key in finding the best sleep position for this, this can be achieved by using an extra pillow or adjusting the bed. There is a debate between back sleeping and side sleeping, as back sleeping with head elevation can be beneficial to drain sinuses, however, some people prefer side sleeping especially if they have an associated headache. When side sleeping it is recommended to sleep to the side opposite to the congested nose, and if both sides are congested equally, it is recommended to alter sides through the night to promote overall drainage⁹  

Structural Treatments  

When to Consider Surgery 

Surgical treatment for congestion is reserved for persistent conditions that are uncontrolled otherwise after maximal medical therapy or for patients with structural abnormalities that can be corrected with surgery. 

Types of Procedures

The relevant structural sites for surgical interventions include

• Nasal septum: deformed nasal septum can interfere with airflow through the nose causing symptoms of nasal congestion, this can be corrected surgically with a procedure known as “septoplasty”⁷
• Nasal turbinate: enlargement of nasal turbinate can cause symptoms of nasal congestion, surgery to reduce the bulk of these turbinate can improve symptoms, these includes procedures such as turbinectomy (surgical resection and reduction of turbinate), laser or radiofrequency ablation⁷
• Nasal sinuses: a major cause of prolonged nasal congestion is a disease involving nasal sinuses. Endoscopic procedures on nasal sinuses known as “Endoscopic Sinus Surgery (ESS)” can produce significant improvement in symptoms of nasal congestion and obstruction
• Nasal valves (internal and external): collapse of nasal valves with inspiration can cause symptoms of nasal congestion and obstruction, surgical repair of this area can improve symptoms⁷
• Adenoid (pharyngeal tonsil): enlargement of adenoids is a common cause of nasal obstruction in children, Adenoiedectomy (surgical removal of adenoid) can significantly improve the symptoms in children, however, its role is limited in adults⁷

Immunotherapy 

Immunotherapy involves the periodic exposure to incrementally larger doses of the allergen. This is usually done weekly by subcutaneous injections (injection into the fat layer under the skin) or daily by sublingual tablets (dissolved under the tongue). Immunotherapy has been shown to effectively reduce congestion in patients with allergic nasal congestion and its efficacy can be maintained for years after discontinuation. One drawback of this approach is the potential life threatening systemic side effect that is called “anaphylaxis”, this has been reported with cases of subcutaneous injections but not with sublingual tablets. Side effects associated with sublingual tablets may include mild swelling or itching in the mouth, throat, or ears that usually resolve spontaneously after a short period of time.⁷ 

When to Seek Medical Attention  

• When you are feeling very unwell and your symptoms are severe and persistent
• When your symptoms are not responding to medications.
• Having sinusitis (sinus infections) associated with headache not responding to painkillers or symptoms not getting better after 3 weeks, and if you are having recurrent sinus infections
• If you are experiencing difficulties with breathing¹⁰

Seeing your GP first is recommended, your GP will identify the underlying cause of your symptoms and if a referral for a specialist is indicated, your GP will refer you to an ENT (ear, nose, and throat) specialist. 

Summary

Nasal congestion is a common symptom encountered by many people, there are a variety of underlying causes, identifying these is an essential part of management of nasal congestion. The approach for management is broad and includes lifestyle and environmental practices, at-home remedies, over-the-counter-medications, and up to surgical interventions. The approach is different for individual patients. In general, it is manageable and associated complications are not common.