Intranasal corticosteroid failure is usually delivery failure. The patient tilts the head back, aims straight up the nose towards the septum, sniffs hard, and tastes the drug at the back of the throat - which is where most of it has gone. Then the spray is declared ineffective and something else is prescribed.
The technique that works is unintuitive enough that it has to be demonstrated. Head slightly forward, not back. Use the opposite hand, so the right hand sprays the left nostril, which naturally angles the nozzle away from the septum and towards the turbinate. Aim towards the outer corner of the eye on that side. A gentle breath in, not a sniff - the drug is meant to stay on the mucosa, not travel to the pharynx. And no blowing the nose for several minutes afterwards.
Two consequences follow from getting this wrong, and both are worth naming. Epistaxis and septal crusting come almost entirely from repeatedly spraying the septum, and they are the commonest reason patients stop. And a spray that is swallowed does nothing for nasal obstruction, so the next step after a genuine failure - a different drug, imaging, or a surgical opinion - gets taken on false information. Demonstrating this takes under a minute, and asking the patient to show you is the only way to know it has landed.
- Ask the patient to demonstrate the technique rather than asking whether they use it.
- Opposite hand to nostril, head slightly forward, aim at the outer corner of the eye on that side.
- Breathe in gently - a hard sniff sends the drug to the pharynx, where it does nothing useful.
- Attribute epistaxis and crusting to septal aim before blaming the drug.
- Do not escalate to imaging or a surgical opinion until you have watched the technique once.
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