Treatment of Nasal Congestion and Sinus Pain

Initial Management

The American Academy of Otolaryngology-Head and Neck Surgery recommends using acetaminophen or ibuprofen for facial pain and sinus pressure, as these are usually sufficient to relieve pain associated with acute rhinosinusitis 2
Intranasal corticosteroids reduce inflammation, decrease vascular permeability, and inhibit inflammatory mediator release, effectively addressing the underlying cause of congestion, according to the American Academy of Otolaryngology-Head and Neck Surgery 1
Nasal saline irrigation improves quality of life, decreases symptoms, and decreases medication use, particularly in patients with frequent sinusitis, as stated by the American Academy of Otolaryngology-Head and Neck Surgery 2

Topical decongestants (xylometazoline, oxymetazoline) can be used for immediate relief but MUST NOT exceed 3-5 consecutive days to avoid rebound congestion and rhinitis medicamentosa, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery and the Journal of Allergy and Clinical Immunology 2, 3
Pseudoephedrine causes small increases in systolic blood pressure (0.99 mmHg) and heart rate (2.83 beats/min), with no effect on diastolic blood pressure, according to the Journal of Allergy and Clinical Immunology 3

If symptoms persist beyond 10 days without improvement, or if there is worsening after initial improvement ("double sickening"), bacterial sinusitis should be considered, as stated by the American Academy of Otolaryngology-Head and Neck Surgery and Rhinology 5, 6
Amoxicillin with or without clavulanate is first-line therapy for 5-10 days for most adults with bacterial sinusitis, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 6

The American Academy of Otolaryngology-Head and Neck Surgery and Praxis Medical Insights recommend starting immediately with intranasal corticosteroid spray + saline irrigation + acetaminophen/ibuprofen for pain 1, 2
If severe congestion, add topical decongestant for maximum 3-5 days OR oral pseudoephedrine (if no contraindications), as recommended by the American Academy of Otolaryngology-Head and Neck Surgery and the Journal of Allergy and Clinical Immunology 2, 3

Never use topical decongestants beyond 3-5 days, as this causes rebound congestion that worsens the original problem, according to the American Academy of Otolaryngology-Head and Neck Surgery, the Journal of Allergy and Clinical Immunology, and Praxis Medical Insights 1, 2, 3
Do not routinely prescribe antihistamines unless there is clear allergic component with sneezing and itching, as stated by the American Academy of Otolaryngology-Head and Neck Surgery and Praxis Medical Insights 1, 2
Avoid oral steroids unless symptoms are very severe or intractable, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery and the Journal of Allergy and Clinical Immunology 2, 4