Nasal Congestion: Recumbency Rhinitis and the Nasal Cycle


“Why does my nose plug up when I lie down?” you ask your pals while relaxing pool-side, who respond with, “get a life!” between sips of pina colada.  Or you notice one side of your is plugged and the other side is open, and the next day you find things are reversed.  Or perhaps you lead a more interesting life than me and these trivial questions never cross your mind.

ENT docs see tons of patients complaining of a “congested nose.“  Congestion is medical lingo for an abnormal amount of fluid in a body-part or organ, due to more blood flow going into the tissue relative to the outflow of blood.  This causes swelling and enlargement of that tissue.  Imagine a balloon with a small hole being filled with water from your faucet (if you haven’t experienced water-balloon fights as a kid or during your drunken college days, go out and partake in this irresistible activity; you’ll be the better for it, with or without the beer).  Though water exits from the hole, the balloon will continue to expand if the water flowing into the balloon is greater.  Reduce the inflow or pop another hole or two where Inflow = Outflow, and the balloon remains the same size.  Increase outflow so that it’s greater than inflow, and the balloon shrinks.  This in a nutshell is how tissues, including that found inside of your nose, respond to various degrees of blood inflow and outflow.

Other synonyms are plugged, stuffy or blocked.  I’ve seen a few patients where “congestion” meant “fogginess” in the head or an inability to concentrate.   That’s an entirely different problem altogether, perhaps from too much alcohol during the water-ballooning festivities or they’re just…crazy, and best served by another specialist.   You can see it’s important to understand precisely what the patient means by the term “congestion.”  We’ll narrow the definition to a restriction of nasal breathing due to the process already described above.

Nasal congestion is worse during viral illnesses such as colds, nasal/sinus infections or allergies, to name a few causes.

Many people are not aware of this, but there’s a natural cycle of congestion and decongestion within the nose.  Perhaps you’ve noticed this yourself.  If you occlude one nostril, breathe in through your nose, and repeat this on the opposite side, you may notice one side is slightly more restricted (or one side is slightly more open) than the other.  In about 8-12 hours, this will switch.  For instance, your left side may feel more restricted, and 8-12 hours you’ll notice it switched to where your right side feel more restricted.  Most of us don’t routinely finger-close our nostrils, unless you have a weird fascination with your nose. 

Another interesting phenomenon is recumbency rhinitis.   This is nasal congestion when lying down.  People would notice difficulty with nasal breathing when lying flat, or wake up with a plugged nose, only to find it improves after they’re up and about.  This is due to dependent flow of blood.  Dependent flow means gravity-related flow to the lower aspect of a body part.  This is especially true if the nasal vessels are not well regulated, so when an individual lies down, there is increased blood flow to the nose since it is in a more gravity-dependent position.  Usually, the flow of blood is controlled by blood vessels constricting and reducing flow when one is lying down.  But for reasons not entirely clear (this often occurs as one ages) the vessels may not constrict to reduce flow and the nasal tissues become more congested when lying down.  Some folks also notice alternating left-and-right nasal congestion depending on which side they lie; where one side plugs while the other side opens, and vice versa when they switch to lying on the opposite side.

The sense of nasal congestion is accentuated with other conditions inside the nose, such as a deviated nasal septum.  Since air flow is already affected by such an abnormality, the effects of congestion are enhanced by the nasal cycle, laying down, or when the nose is congested from a cold or allergy.

There is treatment for this.  There are a variety of nasal sprays, available both over-the-counter (OTC) and by prescription.  These work directly on the tissue without having to travel through your entire body to get to the target, such as an oral decongestant pill.  In addition, oral decongestants have potential side effects of elevated blood pressure, increased heartrate and insomnia, unpleasantries most of us want to avoid during bedtime.

Another effective treatment I’ll mention, but with a huge note of caution, is low dose Oxymetazalone (i.e., Afrin) spray.  This spray can be used daily at bedtime to help with nasal stuffiness.  Use ONLY one spray each nostril ONLY at bedtime, but not more often.  Notice the emphasis on “ONLY.”  Overuse of this type of spray can result in Rhinitis Medicamentosa, which is something you clearly must avoid. 

And so there you have it.   Carry on with your pool-side pals or better yet, have a water-balloon fight.


©Randall S. Fong, M.D.

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