Am Fam Physician. 2016;94(3):185
Original Article: Treatment of Allergic Rhinitis
Issue Date: December 1, 2015
See additional reader comments at: https://www.aafp.org/afp/2015/1201/p985.html
to the editor: I would like to point out an error implied by the cover art in the December 1, 2015, issue. The illustration demonstrates occlusion of the opposite nostril and implies a strong sniffing of the nasal corticosteroid spray. Because deposition of medication in the throat is ineffective and increases systemic absorption, strong sniffing with nasal occlusion is likely less effective than application to the turbinates without sniffing or with gentle sniffing, avoiding occlusion.1
Also, a common recommendation is to use the hand opposite the nostril being treated to aim the spray up and outward, away from the septum, in the direction of the tear duct or medial canthus.2 This effectively applies spray to the more reactive surface of the turbinates and avoids the highly vascular septum, a source of first-pass absorption and a major site of epistaxis.
The best recommendations for corticosteroid nasal spray application are: (1) gently blow nose, (2) lean forward with the nasal spray aiming nearly vertical, (3) using the hand opposite the nostril being treated, aim the nozzle slightly up and outward (lateral and cephalad) toward the tear duct or medial canthus, (4) spray without sniffing or while sniffing very gently, (5) gargle and rinse the mouth and throat.
in reply: All of the studies we could find concerning this issue concluded that there is no optimal technique for administering intranasal sprays given individual anatomical differences and differences in devices. They agree that air movement helps improve medication distribution (sniffing vs. not sniffing) but cannot agree on an optimal head position, although it seems that head position may make a difference if there is no airflow present.
editor's note: Although Dr. Kelleher endorses a recommended technique, the one illustrated on the cover of the December 1, 2015, issue is the one generally illustrated in patient instructions by the manufacturers of intranasal corticosteroids: https://www.flonase.com/about/how-to-use-flonase/, http://nasacort.com/how-to-use.aspx?, and https://www.merck.com/product/usa/pi_circulars/n/nasonex/nasonex_ppi.pdf.—jay siwek, md, editor