Respiratory illness season is here, and with it typically comes snotty, stuffy noses. Earlier this fall a Food and Drug Administration panel concluded that oral phenylephrine—a common active ingredient in cold and allergy medicines—is useless at clearing up congestion. Now that many of these over-the-counter drugs officially don’t work, what are some other remedies and medications adults and children can turn to?
“It is always a hot topic,” says Andrew Lane, a rhinologist and director of the Johns Hopkins Sinus Center. “Whether it's the cold and flu season or allergy season, seems like year-round, congestion is one of the most common things that people come in to see us for.”
Lane treats nose and sinus problems and studies how the specialized cells lining the nasal cavity and sinuses participate in the body’s immune response—and can contribute to chronic inflammation. He talked with Scientific American about what causes nasal congestion, as well as what treatments work and why.
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[An edited transcript of the interview follows.]
What is nasal congestion? What exactly is happening inside our nose when we feel stuffed up?
Basically, congestion is the swelling of the mucous membranes that line the nose.
These mucous membranes help to warm and humidify the air we inhale. The nose is constantly sensing the environment and changing how much air is let through and how much moisture should be added. It does that primarily by dilating or expanding the blood vessels beneath the mucous membranes, which makes the tissue swell.
There’s also swelling that occurs from inflammation as the immune system responds to triggers in the environment. For example, when you have an infection, your body needs to bring inflammatory cells to that tissue to fight it off. The blood vessels swell and become sort of leaky, leading to fluid buildup in the tissue. You might also notice your nose looks red when you are congested—the redness comes in part from these swollen and inflamed blood vessels.
So nasal congestion is not caused by the buildup of mucus but is more about swelling and inflammation?
They do go a little bit hand in hand because mucus helps to moisten the air [before it reaches the lungs], and you typically have more mucus production when there’s inflammation. But I think of the congestion being more from the stuffiness caused by the swelling of the mucous membranes than from the mucus itself.
What triggers nasal congestion?
The most common causes of nasal congestion are allergies and viral infections, such as those that cause the cold or flu. There’s also a form of congestion that has to do with position, where people might complain of being stuffy in one nostril after lying on their side. And then there’s congestion that comes from irritants in the environment [such as perfume or smoke].
What oral decongestant medications still work? How about nasal sprays?
Pseudoephedrine is an excellent decongestant that has been around for a long time. It works by constricting the blood vessels, so it counteracts the stuffiness caused by the dilation of vessels that I talked about earlier. [Because pseudoephedrine is chemically related to the stimulant amphetamine], people started making crystal meth out of it, and it was taken off the shelves and put behind the pharmacy counter. That made the medication harder to access, so some people turned to another oral decongestant, phenylephrine. Unlike pseudoephedrine, which can raise blood pressure and make people feel a little hyped up, phenylephrine has fewer side effects—which makes sense because it basically has no effects at all, as the FDA panel recently concluded. [The panel’s] decision hasn’t changed how we treat nasal congestion because those of us who prescribe these medications know oral phenylephrine never really worked.
Phenylephrine does work when it is delivered directly to the nose as a spray, however, as does another decongestant called oxymetazoline. [The latter is] very strong and fast-acting. You should only use these sprays for three days, though—any longer and you risk making things worse. These medications act on adrenergic receptors on the blood vessels that line the nose’s mucous membranes. If you take the spray around the clock for many days in a row, those receptors get overstimulated and become resistant to the medication. The effects last less and less, and people keep using it more and more frequently, until they feel like they can’t breathe without it. We call that rhinitis medicamentosa, or rebound congestion.
What about nasal steroid sprays?
That’s the long game. If you have allergies, then nasal steroid sprays such as fluticasone can help if you use them consistently over a longer period. Steroid sprays work to reduce inflammation, so they’re not working directly on blood vessel constriction. In that same vein, if your congestion is caused by an allergy, there are other options, such as antihistamine pills and sprays, that aren’t necessarily going to work if your symptoms are instead caused by a cold.
Are there other types of remedies that are effective—such as saline solutions, hot showers, chest rubs or even a comforting bowl of chicken noodle soup?
Saline rinses, which involve moving saltwater through your nasal passages, can be helpful because they can hydrate the nose and eliminate irritants that might be driving inflammation. There are good data to show that symptoms are improved with nasal saline. You can deliver saline using a nasal spray, squeeze bottle or neti pot.
Another popular remedy involves steam. I was taught that steam is perfect for your nose because it’s already warm and moist, so your nose can relax. But I’ve also seen studies showing that cool air helps open the nose. There seem to be mixed data, and it depends on the circumstances. Temperature and ambient humidity seem to impact how congested some people are or at least how congested they feel. A hot shower or a bowl of hot soup can create steam, and I think that could act like a decongestant.
Menthol [an ingredient in Vicks VapoRub, Tiger Balm and other chest rubs] is an interesting one. It does absolutely nothing to any of the objective measures of nasal airflow, but it does improve subjective ones. That’s because the nose has temperature-sensitive sensors inside that can detect air movement: menthol tricks the nose into thinking there’s a lot of airflow because it creates a cooling sensation, even when there’s absolutely no difference in airflow. A bunch of aromatic compounds such as eucalyptus and spearmint have a similar effect.
Another factor that can affect nasal congestion is posture. Your nose will be more congested when you lie down because blood pools in those vessels in the nasal structures and the mucosae [mucous membranes]. If you sleep with your head elevated on a pillow, you’ll probably have less congestion. It’s just gravity, right? If you twisted your ankle, you would want to prop it up to decrease swelling. Keeping your head up above the level of your heart is going to make your nose less inflamed and less swollen.
Do you have any parting advice for people suffering from nasal congestion?
You’re just trying to relieve your symptoms while you wait for the congestion to run its course. Start with things that are least likely to cause side effects, such as saline or chicken soup. There are over-the-counter medications that are effective and generally safe, but some people do experience side effects. If you take a medication once, and it makes you feel sleepy or jittery, just don’t take it again.
Nasal congestion only gets concerning if it becomes a persistent problem. In that case, you want to rule out other causes such as nasal polyps or tumors, and you might need a surgical procedure to open the nasal passages. Not everything is just allergies or a cold, so if it doesn’t really fit that picture, see a doctor.