Know your nasal sprays!
Nasal sprays are a topic that come up over and over, and I can’t stress enough how important it is to know what you are using and how to use it correctly. I’ve spoken to lots of ENTs over the years and this article summarises all that with a look at some important topics: What’s safe to use in the nose? Are all nasal sprays more or less similar? How can we use them effectively? Can they do harm?
Let’s start with something really basic. What is safe to put into my nose?
I would never use anything that is not specifically designed for use in the nose, and you shouldn’t either. For me that means buying products in pharmacies. Over the years I have heard of people squirting all kinds of stuff into their noses on the advice of people who are not medically trained. Please don’t do this. Your nose is as delicate and sensitive as your eyes. The olfactory epithelium, a small patch of tissue high up inside your nose, is actually brain tissue. It’s brain tissue that is out there, exposed to the world, and so easily damaged. That makes it very very special, and for some of you reading this, it’s been attacked by a virus so it needs extra love.
Are all nasal sprays more or less similar? No! There are a couple of categories.
Steroid sprays. This kind of spray reduces inflammation and can also calm certain kinds of activity within the immune system, which is why they can be helpful for people with polyps. Steroid sprays can be either over the counter (OTC) or on prescription–what’s available OTC will depend on what country you live in. Some of the older formulas, available OTC here in the UK (Beconase), are quite effective, but the steroid sprays given on prescription are sometimes newer formulations that may work better for you.
Some people are unsure about steroids and their side effects. For topical application (sprays) they are very well tolerated if used correctly, and this doesn’t lead to much in the way of side effects as the steroid spray does not get into the system. Steroid sprays are commonly used for chronic rhinosinusitis, but are also given sometimes after Covid where there is residual inflammation.
Decongestant sprays. These are available OTC everywhere. Some common brands are Otrivine (UK) and Afrin (US). These sprays shrink the delicate tissues inside the nose and this can provide very swift relief from congestion. But they come with a very important warning: they are quickly addictive. The reason for this has to do with the effect they have on the tissues inside the nose. They shrink, squeezing out the blood supply and nutrients–great for you as suddenly you can breathe easier. But your body is fighting against this, wanting to get blood and nutrients back where they are needed. As the effect wears off, extra blood goes to these areas and now you have a rebound effect that might even be worse than the original congestion. If used to too great an extent, the tissues eventually become damaged.
If you absolutely must use these sprays, try spraying only one nostril at a time, and leave the other nostril 24 hours to recover. Using every couple of hours is a no no!
Saline “moisurising” sprays
These can also be found at the pharmacy, and just provide a bit of relief from the sensation of dryness. Yes, they are made of a salt solution, but it matches the saltiness of your own body fluids, and is therefore comfortable to use, and is not drying.
First Defense sprays and other similar products
These sprays are meant to shorten an infection by coming into contact with the virus as it settles in your nose and at the top of the throat. To be effective, it needs to be used within 36 hours of the first sign of a virus. Another spray, Coldzyme, works on a similar principle but is meant to be sprayed in the mouth. These sprays won’t help your sense of smell, but may help you recover more quickly from a new infection.
How can sprays be used effectively?
Using sprays effectively is key to making them work for you. Let me quote here from a recent article on the subject
When delivering medications topically for olfactory dysfunction, the medications need to reach the olfactory epithelium in the olfactory cleft. This is challenging, as the olfactory epithelium is only a few millimetres wide and approximately 7 cm away from the nasal vestibule (the inside of the nostril)... Along the pathway from the vestibule to the olfactory epithelium lie several intranasal structures that can obstruct medication delivery. To treat olfactory loss in CRS, topical medications applied need to directly target the olfactory cleft, thus improving intrinsic olfactory function. The medications also need to reduce sinonasal tissue inflammation, thus alleviating obstructive olfactory dysfunction and increasing the delivery of other medications directly to the olfactory cleft. Thus, the main challenge is ensuring that the delivery method can deliver medication to this small area to maximise its therapeutic effect.
In other words, reaching the right place with your spray is like aiming your arrow at a target on the other side of a tight clump of trees. To continue:
Nasal sprays have been used for many decades and are the most common way of administering drugs to the olfactory epithelium. They function by aerosolising the drug and transporting it to the nasal epithelium…The characteristics of a device/spray that contains the drug have significant implications in terms of effects, as droplet size and spray angle play a significant role in effective delivery. For example, larger droplet size and a wider spray angle increase the deposition in the nasal vestibule. Current data on the effect of positioning, sniffing, inhaling, or blowing prior to drug administration on the olfactory cleft are not conclusive. Benninger et al. conducted a systematic review to create guidance for patients to optimise drug delivery of intranasal corticosteroid sprays for allergic and nonallergic rhinitis. These guidelines include holding the head in the neutral position, clearing the nose of any mucus, inserting the nozzle into the nostril, and spraying laterally—away from the septum to avoid the potential for epistaxis [nosebleeds]. Following application, the authors recommend gently inhaling and breathing out through the nose to maximise delivery.
However, no such guidance exists for the use of intranasal sprays for olfactory dysfunction. Previous studies demonstrated that most of the liquid delivered using intranasal sprays only reaches the ventral part of the nasal cavity, the largest portion being deposited on the anterior surface of the inferior turbinate, limiting its therapeutic effect.
Hmm. Doesn’t sound that reliable. The efficacy of the nasal spray depends on the effectiveness of the delivery. Nosebleeds? Steroid sprays, if they can’t be aerosolised properly, can land with a splat on the septum, the bone that divides the nose. Over time, that tissue thins and can easily bleed.
So what can be done? The direction of the spray is very important. You should aim once directly back, and another spray should go outwards. Once the nostril is inserted, aim toward the ear on that side. You can watch a video on that here. For anatomy nerds: the tragus is that little flap you press on when you want to plug your ears!
Can sprays do harm?
When used incorrectly, yes, as mentioned above in reference to decongestants, and if aimed at the septum, steroid sprays can encourage nosebleeds. People have often asked in the forum whether steroid sprays in themselves damage the sense of smell. I asked this question of ENT Simon Gane, formerly an AbScent trustee. His feeling is that the tendency to experience loss of smell can be related to many factors, and for some of these steroids are prescribed. He suspects that reduction in smell that might be experienced over time is a result of underlying conditions, rather than the therapeutic substance itself–in this case the spray.
Anything else?
Yup. Remember, I’m not a doctor, and if you’ve got nose trouble, you should consider consulting one.
