ENT Decongestants

ENT decongestants shrink swollen nasal mucosa and relieve blockage in acute rhinitis, sinusitis and Eustachian tube dysfunction. They act within minutes when applied topically and are limited by rebound congestion with repeated use. Oral decongestants have a weaker effect and more systemic risk.

Mechanism. Sympathomimetic stimulation of alpha 1 and alpha 2 adrenoceptors on mucosal blood vessels causes vasoconstriction and reduces mucosal volume and secretion. Pseudoephedrine also releases norepinephrine from nerve terminals.

Pharmacokinetics. Topical xylometazoline and oxymetazoline act within 5 to 10 minutes and last 6 to 12 hours; absorption is small but increases with high doses and in children. Oral pseudoephedrine is well absorbed, with onset at 30 minutes, half-life 5 to 8 hours, and renal excretion.

• Xylometazoline 0.1 percent (adult), 0.05 percent (child): 6 to 10 hours.
• Oxymetazoline 0.05 percent: up to 12 hours.
• Phenylephrine 0.25 to 1 percent drops: shorter action.
• Ephedrine 0.5 to 1 percent drops: shorter action; systemic effects; used in epistaxis and procedures.
• Pseudoephedrine oral: 60 mg tablet or 120 mg modified-release.

Regimens.

• Adults: xylometazoline 0.1 percent one or two sprays or two to three drops in each nostril two or three times daily; oxymetazoline 0.05 percent one or two sprays each nostril twice daily; for no more than 5 to 7 days.
• Children 6 to 11 years: xylometazoline 0.05 percent one spray or two drops each nostril once or twice daily; not under 6 years without advice (some products from 2 years).
• Oral pseudoephedrine: 60 mg every 4 to 6 hours (maximum 240 mg daily) or 120 mg modified-release twice daily, for no more than 5 to 7 days.
• Eustachian tube dysfunction and air travel: topical decongestant 30 minutes before descent.
• Anterior epistaxis: gauze or cotton soaked in oxymetazoline or xylometazoline placed in the nose for 10 minutes while the nostrils are pinched.
• Before nasal procedures or endoscopy: decongestant with topical anaesthetic.

Selection. Use for short-term relief in colds, acute sinusitis, and to improve topical drug access; prefer saline irrigation and intranasal steroids for chronic obstruction. Avoid oral decongestants in most patients.

Contraindications. Topical: age under 2 years, hypersensitivity, closed-angle glaucoma (relative), recent nasal surgery. Oral: uncontrolled hypertension, coronary disease, hyperthyroidism, arrhythmia, prostatic hypertrophy with retention, closed-angle glaucoma, monoamine oxidase inhibitor treatment within 14 days, first trimester pregnancy.

Effects. Burning, stinging, sneezing, dryness and epistaxis; rebound congestion (rhinitis medicamentosa) after more than 5 to 7 days of continuous topical use, with chronic obstruction and mucosal damage; with oral drugs, hypertension, palpitation, tremor, insomnia, anxiety, urine retention, and rare stroke and ischaemic colitis.

Interactions. Monoamine oxidase inhibitors, linezolid and other sympathomimetics (hypertensive crisis); beta blockers (unopposed alpha effect); tricyclic antidepressants; antihypertensives (reduced effect).

Monitoring. Limit course length and record duration of use; check blood pressure when oral drugs are used in older adults; stop at the first sign of rebound and substitute an intranasal steroid.

Special groups. Pregnancy: avoid oral pseudoephedrine in the first trimester; topical use for a few days is acceptable. Breastfeeding: oral pseudoephedrine may reduce milk. Children: dose by age and strength; neonates and infants risk overdose and apnoea. Older adults: hypertension and urinary retention. Region: topical decongestants are sold freely and often overused for months, causing rebound obstruction that is mistaken for chronic sinusitis; ask about use before starting antibiotics or surgery.