A recent question from a reader about the effects of one particular nasal spray made me realize that we have never talked about the great variety of sprays available to keep your nose clean, clear, and functional. Here, then, is a brief but hopefully complete overview of what you can, should, and should not put in your nose.
The nose is the primary gateway to the airway. When air enters the nostrils, it is drawn quickly through the pharynx, larynx, trachea, and bronchi to the end of the road—the alveoli of the lung. It then returns up and out the nose again, usually 12–16 times a minute. The main role of the nose is to allow for the free passage of air into the body. But the nose does many more things—it also warms and humidifies the air, so that by the time the inhalation reaches the nasopharynx, the air is body temperature and fully moistened. While for quick inhalations of air (and for singing), the mouth works well, the nose has evolved as the preferable breathing passage.
For the nose to do its job, it needs to be open, clean, and moist. By open, I mean no mechanical obstruction that prevents inhalation, such as a deviated septum or significantly enlarged turbinates. Clean refers to the need to clear the membranes of mucus and dry crusts that may develop for a variety of reasons. And moisture is required for the nasal lining to trap and clear inhaled debris, such as dust or pollen, and allow it to moisten the inhaled air.
While we can introduce a variety of materials through the nose, for the purposes of nasal health there are only four main groups of medications to consider.
First and foremost is saline. Salt water is gentle and acts to lubricate and clean the lining of the nose. I remember attending a medical meeting some 25 years ago where, for comic relief, one of the doctors held up a neti pot brought in by an Indian patient. It was met by general laughter and ridicule. What next?! Well . . . the neti pot has certainly come of age and, with the aid of Oprah and Dr. Oz, it is now generally accepted, especially in the singing community. I recommend the neti pot (or other saline flushes, like NeilMed) as a routine part of your daily toilet. It moistens in the winter; reduces allergens in spring, summer, and fall; and generally keeps your nose functioning optimally. You can also carry saline sprays in your pocket, but these are not as effective as a full-out saline wash.
Saline—whether flushed, irrigated, or sprayed—is usually isotonic. This means that it has the same concentration of sodium as nasal tissues. It doesn’t exert any osmotic force on the nasal lining and is perceived as a gentle sensation. If hypertonic solutions are used, either saline or other types, they will pull fluid from the tissues and reduce swelling in the nasal lining. You can make this yourself simply by adding a little (not too much!) extra salt to your neti pot. It will burn a bit, but the extra salt will pull some of the fluid out of swollen tissues.
The second group of sprays is the decongestant. These include Afrin, Neo-Synephrine, and other products containing oxymetazoline or phenylephrine. Decongestant sprays work by constricting the blood vessels in the nasal lining, especially the turbinates. You will get quick relief of congestion as the tissues shrink—especially helpful during a severe cold or allergy attack.
Decongestant sprays are useful, but with some caveats. If used for more than a week, you will get less and less relief—the blood vessels just get tired of constricting and stop responding. This condition, called “rhinitis medicamentosa,” is sometimes referred to as an addiction and is difficult to reverse. If overused, decongestant sprays can also raise your blood pressure and constrict vessels elsewhere in the body—a potential issue if you’re pregnant or already suffer from hypertension.
The third group is the steroid (cortisone) sprays. These are most commonly prescribed for nasal allergies and include fluticasone (Flonase), Nasacort, Nasonex, and QNASL. Steroid sprays are specifically used to reduce inflammation associated with allergies. They are sometimes also prescribed for other causes of nasal swelling but, since cortisone inhibits the body’s microbe-fighting mechanism, I personally avoid its use for nasal infections, even if only viral.
The differences between steroid sprays are not so much in the medication as in the delivery system and the vehicle (water, gel, or powder) that carries the steroid into the nose. For example, fluticasone can be drying, especially in the winter, and cause nose bleeds. For this reason, not all steroid sprays are the same, and if you are getting side effects from one, consider trying another version. Also consider that while most of the medication stays in the nose, some can drip down into the throat and cause vocal side effects. A small amount is absorbed into the body, which may be of concern if you are pregnant or have a medical condition such as glaucoma.
The final and newest group is the antihistamine sprays, which include Patanase, Astelin, and Astepro. These are specific for allergic rhinitis and carry none of the side effects of steroid sprays. I recommend antihistamine sprays specifically for allergic rhinitis, especially if it’s seasonal or temporary (such as may occur if you are cat-sitting or visiting an allergenic part of the country). These are a bit drying but generally useful. One product, Dymista, combines a steroid (fluticasone) with an antihistamine in a single spray—potentially effective, but more expensive.
Before using nasal sprays, consider what you are treating. Not all sprays are equal, so try to use the right spray for the right condition. Medicated sprays are useful for temporary conditions and may be a good option for nasal allergies in a singer who finds oral antihistamines too drying. On the other hand, if you are treating nighttime nasal congestion, also consider nonspray options, such as mentholated vapors, Breathe Right nasal strips, or simply elevating the head of the bed. Unless you have a significant nasal problem, such as allergic polyps, I am generally leery of long-term and routine nasal steroids. Desensitization and modification of the environment (including diet) also need to be addressed.
