Nasal congestion: causes and ways to ease breathing

Nasal congestion is not a standalone diagnosis, but a symptom in which a person experiences difficulty breathing through the nose. In practice, this sensation can be caused by four main mechanisms: inflammatory swelling of the mucous membrane, excess secretions, anatomical narrowing of the nasal passages, and dysfunction of the nasal valve. In some patients, these mechanisms combine, so the same complaint can have completely different causes. [1]

From a clinical perspective, nasal congestion is important not only as a local symptom. It impairs sleep, increases mouth breathing, reduces the sense of smell, and can cause fatigue, daytime sleepiness, and a reduced quality of life. In chronic rhinosinusitis, this impact is particularly noticeable: the disease is associated with sleep disturbances, fatigue, and significant daily discomfort. [2]

The most common causes in adults remain allergic rhinitis, viral upper respiratory tract infections, chronic rhinosinusitis, drug-induced rhinitis following vasoconstrictor abuse, and structural abnormalities such as a deviated septum and inferior turbinate hypertrophy. In some cases, nasal polyposis plays a leading role. [3]

In children, the spectrum of causes is different. In addition to allergic and infectious inflammation, adenoid hypertrophy plays a significant role. It can lead not only to persistent nasal obstruction but also to snoring, mouth breathing, impaired middle ear ventilation, recurrent ear infections, and sleep problems. Pathological adenoid enlargement most often occurs between the ages of 1 and 6 years. [4]

That's why the modern approach to nasal congestion isn't based on a universal "cure" for a runny nose, but on identifying the underlying cause. One patient will benefit from saline rinses and an intranasal corticosteroid, another will need to discontinue a decongestant spray, a third will need a nasal endoscopy, and a fourth will need surgery on the septum, polyps, or adenoids. [5]

Table 1. Main causes of nasal congestion

Cause	What's happening	Typical tips
Allergic rhinitis	Inflammation of the mucous membrane after contact with an allergen	itching, sneezing, clear discharge, seasonality or association with a trigger
Viral infection	Acute inflammatory swelling and discharge	acute onset, runny nose, sore throat, general malaise
Acute bacterial rhinosinusitis	More severe inflammation of the sinuses and nasal cavity	symptoms lasting more than 10 days without improvement or a second wave of worsening
Chronic rhinosinusitis	Long-term inflammation for more than 12 weeks	congestion, discharge, decreased sense of smell, pressure in the face
Medicinal rhinitis	Rebound edema after prolonged use of vasoconstrictors	constant need for spray, rapid return of symptoms
Structural reasons	Mechanical narrowing of the lumen	persistent congestion, often without noticeable discharge
Nasal polyps	Overgrowth of inflamed tissue	decreased sense of smell, chronic course, bilateral obstruction
Adenoid hypertrophy in children	Obstruction of the nasopharynx by enlarged lymphoid tissue	mouth breathing, snoring, nasal voice, otitis

The table summary is based on current reviews and guidelines on rhinosinusitis, rhinitis, and pediatric adenoid pathology.[6]

Causes and mechanisms

The most common mechanism is inflammatory swelling of the mucous membrane. In allergic rhinitis, contact with an allergen activates inflammatory mediators, causing the mucous membrane to swell, narrowing the nasal passages, and causing itching, sneezing, and watery discharge. Current guidelines for allergic rhinitis confirm that it is inflammation, not simply "excess mucus," that makes congestion one of the leading symptoms. [7]

With a viral infection, the picture is similar, but the mechanism is associated with acute infectious inflammation. For most patients, this is a self-limited condition that resolves without antibiotics. However, if symptoms persist without improvement for at least 10 days or worsen after a brief improvement, the likelihood of acute bacterial rhinosinusitis increases. [8]

Chronic rhinosinusitis is no longer just a "lingering cold." Modern sources consider it primarily a chronic inflammatory condition of the nose and paranasal sinuses. Diagnosis requires symptoms persisting for more than 12 weeks and objective signs of inflammation. Some patients present with nasal polyps, while others do not. [9]

A separate group of causes includes anatomical and functional disorders. A deviated septum, hypertrophy of the inferior turbinates, and nasal valve collapse can impair airflow even without significant inflammation. Such patients often describe persistent or predominantly unilateral congestion, with drug therapy providing only partial or temporary relief. [10]

Medicinal rhinitis develops after excessive or prolonged use of topical vasoconstrictors. Initially, the spray does ease breathing, but then the swelling returns and becomes even more persistent. This creates a vicious cycle where the patient cannot breathe without another dose of the medication. [11]

In children, adenoid hypertrophy remains a significant cause. An enlarged pharyngeal tonsil mechanically obstructs the nasopharynx, impairing airflow and drainage of secretions, and can also impair the function of the auditory tube. Therefore, chronic nasal congestion in children often requires not only a nasal examination but also an assessment of sleep, hearing, speech, and ear health. [12]

Table 2. How the mechanism affects symptoms

Mechanism	How does it feel?	What often accompanies
Edema of the mucous membrane	a feeling of fullness and difficulty breathing through the nose	sneezing, itching, rhinorrhea
Excessive secretion	the nose is clogged with mucus	discharge forward or along the back wall of the pharynx
Mechanical narrowing	more constant congestion	weak effect of drops, asymmetry of symptoms
Polyposis	blunt bilateral obstruction	decreased sense of smell
Drug dependence on spray	short-term relief and quick return of congestion	frequent use of vasoconstrictor
Adenoids in children	persistent mouth breathing	snoring, nasal voice, otitis

The table summary is based on data on the pathophysiology of nasal obstruction, chronic rhinosinusitis, rhinitis medicamentosa, and adenoid hypertrophy.[13]

How does nasal congestion manifest itself and when should you be concerned?

The classic complaint is the inability to breathe freely through one or both halves of the nose. However, clinically, it is important to clarify whether the obstruction is constant, whether it changes throughout the day, and whether it is related to the season, household dust, animals, cold air, odors, physical activity, or body position. Such details often allow one to differentiate allergic inflammation from non-allergic and anatomical variants at an early stage. [14]

If itching, sneezing, and clear discharge are predominant, allergic rhinitis is more likely. If congestion develops acutely due to an infection and is accompanied by a sore throat, fever, and general malaise, a viral infection is more likely. If symptoms persist for more than 10 days or worsen after a brief improvement, acute bacterial rhinosinusitis should be considered. [15]

Chronic rhinosinusitis often includes congestion, a backflow of mucus, a feeling of pressure in the face, and a decreased sense of smell, lasting more than 12 weeks. This condition is characterized not so much by the sudden severity of symptoms as by their persistence. Particularly concerning is the combination with loss of smell and frequent relapses. [16]

Unilateral congestion is a distinct clinical sign. Chronic rhinosinusitis is usually bilateral, so persistent unilateral symptoms should prompt referral to an otolaryngologist. This is especially important if there is concurrent recurrent bleeding, salty or metallic discharge, severe pain, bulging of the eye, double vision, or facial paresthesia. [17]

In children, persistent mouth breathing, snoring, restless sleep, a nasal voice, hearing loss, and recurrent ear infections are cause for concern. This is typical of adenoid obstruction and requires not just the selection of nasal drops, but a full assessment of the nasopharynx and ears. In adults, dependence on a vasoconstrictor spray, when nasal congestion is practically impossible without it, requires special attention. [18]

Table 3. Red flags for nasal congestion

Sign	Why is it important?
Unilateral persistent nasal congestion	requires exclusion of a tumor, foreign body, or a significant anatomical cause
Repeated or persistent nosebleeds	dryness, irritation, but also more serious pathology are possible
Double vision, bulging of the eye, deterioration of vision	possible spread of the process into orbit
Severe pain in the face, high fever	a complicated infectious process is possible
Salty or metallic discharge on one side	a cerebrospinal fluid leak is possible
The child has snoring, apnea, mouth breathing, and ear infections.	significant adenoid obstruction is possible

The table summary is based on current literature on chronic rhinosinusitis and signs requiring expedited referral to a specialist.[19]

Diagnostics

The first stage of diagnosis is a detailed interview. It is important to determine the duration of symptoms, whether they are bilateral or unilateral, seasonality, the presence of discharge, itching, decreased sense of smell, facial pain, dependence on vasoconstrictors, occupational hazards, and underlying medical conditions, including asthma. This medical history allows for the proper planning of further examinations. [20]

Routine imaging is generally unnecessary for acute rhinosinusitis. Current guidelines explicitly state that imaging is not indicated for the typical presentation of acute rhinosinusitis unless a complication or alternative diagnosis is suspected. This helps avoid unnecessary testing and avoid substituting unindicated CT scans for clinical decision-making. [21]

If symptoms persist for more than 12 weeks, chronic inflammation and structural pathology are considered. To confirm chronic rhinosinusitis, objective signs are needed: polyps, swelling, mucopurulent discharge during examination, endoscopy, or changes on CT scan. Simple complaints alone are not sufficient for a definitive diagnosis. [22]

If an allergic origin of congestion is suspected, allergy testing is useful if the results will significantly change the treatment plan. With typical allergic rhinitis symptoms, this can help identify the causative allergens and strengthen environmental control measures. However, routine, unnecessary testing without impacting treatment is unnecessary. [23]

In children with suspected adenoids, a nasopharyngeal examination, endoscopic if possible, is essential, as is an assessment of hearing and the condition of the middle ear. In adults with suspected anatomical obstruction, the examination should include an assessment of the septum, turbinates, nasal valve area, and possible polyps. Diagnosis should always be tailored to the suspected cause, rather than a "template-based" approach. [24]

Table 4. What examinations are really needed and when

Method	When is it useful?	What can it show?
Examination and anterior rhinoscopy	all patients at the first stage	swelling, discharge, dryness, polyps, deviated septum
Endoscopy of the nasal cavity and nasopharynx	for chronic symptoms, polyps, unilateral obstruction, in children with suspected adenoids	objective signs of inflammation, polyps, adenoids, source of obstruction
Allergy testing	in case of probable allergic rhinitis, if the result changes the treatment	causally significant allergens
Computed tomography	in case of confirmation of chronic rhinosinusitis, unclear picture, complications, planning of surgery	sinusitis, polyposis, anatomical features
Hearing examination and tympanometry in children	for adenoids and otitis	impaired ventilation of the middle ear

The table summary is based on the guidelines for rhinosinusitis and adenoid hypertrophy.[25]

Treatment

Treatment always depends on the underlying cause. Regarding basic symptomatic care, current guidelines recognize the benefits of saline irrigation and intranasal anti-inflammatory therapy for a number of conditions. For viral and bacterial rhinosinusitis, saline solutions and topical steroids can be used to relieve symptoms, and for chronic rhinosinusitis, they are considered first-line therapy. [26]

For persistent allergic rhinitis, intranasal corticosteroids remain the preferred monotherapy. The updated 2024-2025 guidelines also support the use of a combination of an intranasal antihistamine and an intranasal corticosteroid when more pronounced symptom control is needed. This is especially important for patients for whom nasal congestion is the main and most persistent symptom. [27]

If watery rhinorrhea is the predominant symptom of non-allergic rhinitis, intranasal ipratropium may be considered. However, it is not a universal solution for obstruction. Therefore, it is important for the patient to understand that if the complaint is "stuffy nose," the medication is selected based on the underlying mechanism, not the actual runny nose itself. [28]

Decongestant sprays are only acceptable as a short-term measure. The drug labeling and instructions clearly state the duration limit, usually no more than 3 days, as more frequent and prolonged use can itself cause or worsen congestion. If medicamentous rhinitis has already developed, the key to treatment is discontinuing the offending medication and switching to anti-inflammatory topical therapy under medical supervision. [29]

Antibiotics are not indicated for all cases of acute bacterial rhinosinusitis. Current guidelines allow for a watchful waiting approach in adults with uncomplicated cases, with reliable monitoring. If the decision to prescribe an antibiotic is made, the first-line drug for most adults remains amoxicillin with or without clavulanic acid for 5-7 days, depending on the clinical situation. [30]

For chronic rhinosinusitis with and without polyps, the mainstay of treatment remains long-term local anti-inflammatory therapy and saline irrigation. Routine administration of antifungal agents is not recommended, and systemic antibiotics should not be automatically prescribed for chronic rhinosinusitis without acute exacerbation. In patients with severe polyposis, in whom conventional therapy and surgical treatment have failed to provide the necessary control or surgery is not possible, biological agents may be used after a specialized evaluation. [31]

If the cause of the obstruction is anatomical, drug therapy alone may not be sufficient. In cases of clinically significant septal deviation, turbinate hypertrophy, nasal valve collapse, severe polyposis, or severe adenoid hypertrophy, surgical options are considered. The decision is made after confirming the source of the obstruction and assessing the extent to which the symptoms are truly related to the identified anomaly. [32]

Table 5. Treatment by underlying cause

Cause	Basic tactics	What not to do
Allergic rhinitis	intranasal corticosteroid, trigger control, if necessary, in combination with an intranasal antihistamine	use vasoconstrictors without control
Viral rhinosinusitis	symptomatic treatment, saline solutions, observation	demand antibiotics from the first days
Acute bacterial rhinosinusitis	observation or antibiotics as indicated, local symptomatic therapy	do CT scans on everyone
Chronic rhinosinusitis	prolonged saline irrigation and intranasal corticosteroid	routinely prescribe antifungal drugs
Medicinal rhinitis	discontinuation of vasoconstrictor, local anti-inflammatory therapy	continue the spray "little by little" for months
Structural obstruction	evaluation by an otolaryngologist, surgery if necessary	trying to endlessly treat an anatomical problem with drops alone
Adenoids in children	observation, local therapy as indicated, evaluation of ears and sleep, surgery in severe cases	consider constant mouth breathing to be normal

The table summary is based on current recommendations for allergic rhinitis, sinusitis, drug-induced rhinitis and adenoid pathology. [33]

Special situations, prevention and prognosis

In children, chronic nasal congestion requires special attention because it affects not only comfort but also development. Enlarged adenoids can lead to mouth breathing, snoring, sleep disturbances, hearing problems, and even changes in the bite and facial skeleton if prolonged. Therefore, severe nasal obstruction in children cannot be considered a harmless habit. [34]

During pregnancy, nasal congestion also requires a cautious approach. Oral decongestants are not recommended in the first trimester, and topical agents are evaluated based on their safety profile. For intranasal corticosteroids, the data are generally favorable, with budesonide having the most extensive safety profile. Treatment decisions should be based on the cause of the symptoms and the need for effective disease control. [35]

Prevention begins not with medications, but with eliminating triggers. For allergic rhinitis, this means controlling allergens and air pollutants; for non-allergic rhinitis, minimizing irritants; and for those prone to drug-induced rhinitis, avoiding long-term use of vasoconstrictor sprays. For chronic rhinosinusitis and chronic inflammation, regular topical therapy and proper technique for applying sprays and rinses are especially important. [36]

Saline rinses may reduce the severity of symptoms and are well tolerated in some patients, although the quality of evidence for some scenarios remains low. They are not a miracle cure or a replacement for primary treatment, but they are a useful adjunct, especially when combined with intranasal anti-inflammatory therapy. [37]

The prognosis depends on the cause. Viral congestion usually resolves on its own. Allergic rhinitis is well controlled in many patients with appropriate topical therapy. Drug-induced rhinitis is reversible but requires discontinuing the offending medication. With chronic rhinosinusitis and anatomical obstruction, the path to lasting improvement is often longer and sometimes involves endoscopic monitoring or surgery. The key is not to treat all types of nasal congestion the same way. [38]

Table 6. The most common mistakes made by patients

Error	What is dangerous?
Use a vasoconstrictor spray for weeks	drug-induced rhinitis develops
Starting an antibiotic without criteria for a bacterial process	extra burden and risk of ineffective treatment
Do a CT scan for a common cold	unnecessary examination without benefit
Ignore one-sided congestion and nosebleeds	it is possible to miss a serious pathology
Considering chronic mouth breathing in a child as a “peculiarity”	adenoids and sleep disorders may be missed
Stop using topical steroids after 2-3 days.	with chronic inflammation, the effect often takes time and regularity

The table summary is based on current guidelines for sinusitis, rhinitis, and drug-induced nasal congestion.[39]

Frequently asked questions

Is it always a runny nose or a cold?

No. Nasal congestion can be associated with allergic inflammation, chronic rhinosinusitis, polyps, a deviated septum, turbinate hypertrophy, nasal valve collapse, rhinitis medicamentosa, and adenoids in children. The symptom itself is the same, but the causes and treatments are very different. [40]

When can bacterial rhinosinusitis be suspected?

The most typical criteria are symptoms lasting more than 10 days without improvement or a recurrence of worsening symptoms after an initial improvement. This dynamic is more important than the simple fact of thick discharge, which in itself does not prove the bacterial nature of the process. [41]

Is it possible to use vasoconstrictor drops for a long time?

No. Over-the-counter topical decongestants are usually specifically limited to no more than 3 days, as frequent or prolonged use can cause rebound congestion. The longer this cycle continues, the more difficult it is to restore normal breathing without the spray. [42]

Is a CT scan necessary immediately?

In a typical acute infection, this is usually not the case. In chronic symptoms, suspected polyps, complications, a significant anatomical cause, or when planning surgery, CT scanning becomes an important part of the evaluation. [43]

What is the best thing for allergic nasal congestion?

For persistent symptoms, an intranasal corticosteroid is usually the mainstay of therapy. If control is inadequate, a combination of an intranasal antihistamine and an intranasal corticosteroid may be more effective in some patients. The choice depends on the severity of symptoms and the clinical situation. [44]

When should a child be shown to an otolaryngologist?

If there is persistent mouth breathing, snoring, nocturnal apnea, frequent ear infections, hearing loss, a nasal voice, or persistent nasal congestion without obvious infection, the child should be examined for adenoid obstruction and other causes. It is especially important not to delay if symptoms are affecting sleep and behavior. [45]

When is urgent help needed?

The urgency increases with severe facial pain, high fever, visual impairment, double vision, bulging of the eye, severe unilateral bleeding, persistent unilateral obstruction, or suspected complications. These symptoms are not typical of a runny nose and require a more rapid in-person examination. [46]