Nasal Congestion

The common causes

• Allergic rhinitis — year-round from house dust mite, pets or mould, or seasonal hay fever. Itch and sneezing point here
• Non-allergic rhinitis — identical symptoms, no allergy. Triggered by temperature change, strong smells, alcohol or spicy food. Allergy tests are negative and antihistamines do little
• Rhinitis medicamentosa — rebound congestion from over-the-counter decongestant sprays. Extremely common, rarely recognised, and entirely reversible
• Chronic sinusitis, with or without polyps
• Viral infection — which should clear within two to three weeks

Structural causes

• Deviated septum — the wall between the nostrils sitting off-centre. Blockage is fixed, one-sided and does not respond to sprays. Common, and often dating back to a childhood knock nobody remembers
• Nasal polyps — soft swellings from inflamed lining. Suspect them when smell is lost early and blockage dominates. Associated with asthma and with aspirin sensitivity, and they shrink with steroid treatment
• Enlarged adenoids — the leading cause in children, causing mouth breathing and snoring
• Turbinate enlargement, often alongside long-standing rhinitis

Causes people do not expect

• Pregnancy rhinitis — hormonal, affects a substantial minority of pregnancies, and resolves within a fortnight of delivery. Decongestant sprays are exactly the wrong answer here
• Medication — some blood pressure drugs, including beta blockers and ACE inhibitors; the combined pill; some antidepressants; and anti-inflammatories in aspirin-sensitive people
• Cocaine use — which causes blockage, crusting and, over time, septal perforation
• An underactive thyroid, which thickens the nasal lining
• A foreign body — in children, and occasionally in adults who have forgotten

Rarer, and the reason one-sided blockage gets looked at

Nasal and sinus tumours are uncommon but present exactly like this — persistent one-sided blockage, blood-stained discharge, facial numbness or eye symptoms. Long-term hardwood dust exposure is a recognised occupational risk. Granulomatous conditions such as GPA can also present in the nose.

Much of this is worked out from the history, and a video consultation covers that well. What we cannot do is look inside your nose, which is why some of this ends in a referral — and we will say so directly rather than treating blind.

The questions that matter

• One side or both, and does it swap? The first and most useful question. Alternating is reassuring; fixed on one side is not
• How long — weeks, months or years
• Is your sense of smell affected? Early loss points strongly at polyps
• Sneezing, itch or clear runny nose — suggesting allergy
• Better on holiday, at weekends, or in a different house
• Any use of an over-the-counter decongestant spray, and for how long — asked in every case, because it is so often the answer
• Full medication list, including the contraceptive pill and blood pressure treatment
• Nasal injury, previous surgery, snoring, and whether anyone has seen you stop breathing at night
• Nosebleeds, facial pain, numbness or visual change

Tests where they help

• Specific IgE allergy testing to named allergens where the trigger is unclear or would change what you do
• Thyroid function where other features fit
• Full blood count and inflammatory markers where the picture is atypical
• Total IgE alone is not a useful allergy test, and we do not recommend it

What needs an ENT examination

Nasendoscopy — a thin camera passed into the nose — is how polyps, septal deviation and anything sinister are identified, and it takes a few minutes in clinic. We refer, urgently where indicated, for:

• Persistent one-sided blockage
• Loss of smell not recovering
• Blood-stained discharge, or recurrent one-sided nosebleeds
• Facial numbness, swelling or eye symptoms — same-day
• Blockage not responding to correctly used treatment after several weeks
• A child with one-sided offensive discharge, which needs the object removing

Saline rinsing — the most underrated thing here

A daily rinse clears mucus and allergen, reduces swelling, and makes a steroid spray work better. Use bought sachets or cooled boiled water with the correct salt and bicarbonate mix.

Never use water straight from the tap. Rare but serious infections have followed rinsing with untreated tap water. Boil and cool it, or use distilled or sterile water — and rinse the device out and let it dry between uses.

At night

• Raise the head of the bed a few inches on blocks — more effective than extra pillows, which bend you at the waist
• Keep the bedroom cool and reasonably humid; central heating dries the lining
• Allergen-proof bedding covers if dust mite is the trigger — and wash bedding weekly at 60°C
• Keep pets out of the bedroom

Day to day

• Steam inhalation — modest evidence, but comfortable and safe. Keep the bowl on a stable surface and mind scald risk, particularly with children
• Stay well hydrated
• Stop smoking, and avoid vaping — both irritate and swell the nasal lining directly
• Reduce alcohol, which dilates nasal blood vessels and blocks the nose within minutes in some people
• Regular exercise, which transiently opens the nose — and helps weight, which helps snoring
• Nasal strips or an internal dilator for snoring — mechanical, harmless, and worth a try

What not to do

• Do not use decongestant sprays for more than five to seven days. The single most important sentence on this page
• Do not use oral decongestants regularly if you have high blood pressure, heart disease, glaucoma or prostate problems
• Do not take repeated antibiotic courses for clear discharge
• Do not blow your nose violently — gently, one side at a time
• Do not ignore blockage on one side that never swaps. That is the one thing on this page worth acting on rather than managing

Babies and small children

Newborns breathe through their noses almost exclusively, so a blocked nose interferes with feeding and is more consequential than it looks. Saline drops before feeds, and a nasal aspirator, are the mainstay. Decongestant sprays and drops are not for young children. Seek advice for difficulty feeding, noisy or laboured breathing, or a blocked nose in a baby under three months.

Why does my nose block more the more spray I use?

Because the spray is now the cause. Over-the-counter decongestants shrink the lining, and used beyond about a week the lining swells harder each time the dose wears off — rhinitis medicamentosa. It is common, it is not your fault, and it is completely reversible. Start a steroid spray first, then stop the decongestant, and expect two to four uncomfortable weeks. Worth doing rather than continuing indefinitely.

Why is it always the same side?

That is the finding worth acting on. A normal nose alternates sides through the day; blockage fixed on one side suggests a deviated septum, a polyp, or occasionally something that needs excluding. It needs a look inside with a camera, which is a quick outpatient procedure — not something to manage with sprays indefinitely.

Why can't I smell anything?

Loss of smell with blockage points strongly at nasal polyps, which are treatable and routinely missed for years. Steroid sprays and drops shrink them, and surgery is available where they do not. Smell can also be lost after a viral infection, which often recovers slowly over months. Either way it is worth getting looked at rather than accepting.

Are steroid nasal sprays safe long term?

Yes. Absorption into the body is very low and they are used for years safely, including in children. The risks people worry about come from steroid tablets, not sprays. Nosebleeds usually mean you are spraying at the septum — aim outwards, towards the ear on that side.

How long before the spray works?

Longer than most people give it. Two weeks of daily use before judging it, and four to six weeks for full effect. It is preventive, so using it only on bad days will not work. And check the technique — aiming outwards, no hard sniffing — because poor technique is the commonest reason it appears to fail.

Would surgery fix it?

If the cause is structural, yes — and that is exactly when medication will not. Septoplasty for a deviated septum, turbinate reduction, or sinus surgery for polyps are all effective in the right person. Fixed, one-sided, long-standing blockage is a referral rather than another prescription, and we would rather send you than keep trying sprays.

My nose blocks when I lie down. Is that normal?

Largely, yes — blood pools in the nasal lining when you lie flat, and the lower nostril blocks when you turn onto your side. It becomes a problem when the airway is already narrowed. Raising the head of the bed on blocks helps more than extra pillows, and treating the underlying inflammation helps more than either.

Could this be why I'm so tired?

Quite possibly. Nasal blockage forces mouth breathing, fragments sleep and worsens snoring, and the resulting tiredness is regularly attributed to everything except the nose. If you snore heavily, wake unrefreshed, or someone has seen you stop breathing at night, that needs assessing for sleep apnoea in its own right.

Is it safe to rinse my nose with tap water?

No — use cooled boiled, distilled or sterile water. Rare but extremely serious infections have followed nasal rinsing with untreated tap water. Rinse the device out afterwards and let it dry. Done properly, saline rinsing is one of the most effective and least appreciated treatments available for a blocked nose.