Courtesy of Karah Nazor, Ph.D. and Dr. Susan Raschal, D.O.. Art Credit: Zina, Level Five Graphics

Biologist and Swim the Suck race director Karah Nazor, Ph.D. and Chandler Nichols, Ph.D. (student), members of the Chattanooga Open Water Swimmers interviewed Dr. Susan Raschal, D.O. about the causes, prevention and treatment of post-swimming congestion.

Dr. Raschal is an allergist with Covenant Allergy and Asthma Care in Chattanooga, Tennessee.

Their questions included:
* What are common irritants found in the water?
* Is post-swimming congestion caused by allergies or allergens in the water, such as pollen?
* What are recommendations on nose sprays?
* To NetiPot or not?
* Should we swim if we are already congested?
* Do allergy shots help prevent post-swimming congestion?
* Are there any other causes of congestion besides allergies and irritants in the water?

Dr. Nazor writes, “We swimmers submerge our faces for hours on end in pools, lakes, rivers, creeks, ponds, and oceans, and as we turn our heads to breathe, with proper head positioning, one of our nostrils lays on the surface of the water in a prime horizontal position for water to flow right on up into the nose. It is inevitable that we have the painful experience of getting water up our nose and accidentally swallow small volumes of water.

Surfers also get a lot of water up their noses. It is of no surprise that, at one point or another, many of us have experienced a stuffy nose after swimming. For some, congestion or fear of becoming congested after swimming in the pool or open water gets to a point where it interferes with their participation in the sport. But what actually causes congestion after swimming and how can we prevent it and treat it should it arise?

To find out, we asked Allergist Dr. Susan Raschal for her answers and advice about post-swimming congestion.
The 30-minute Zoom interview with Dr. Raschal on post-swimming congestion can be watched in two 15-minute videos:

Causes of Post-swimming Congestion

Q: What causes congestion after swimming in the open water and the pool?

A: If you answer “Yes” to any of the following questions, you come into contact with common irritants found in the water which could be causing or exacerbating congestion.
– Do you swim in a pool that is treated with chlorine or one that is chemically “shocked”?
– Have you ever seen a yellow film of pollen floating on the surface of your local outdoor swimming spot?
– Do you swim in a pond, lake or river (or their tributaries) that can be accessed by livestock? Livestock access to water courses not only causes erosion, but also introduces Escherichia coli (E. Coli) into the water.
– Do seals, sea lions, geese and other waterfowl frequent the water where you swim? Again, these animals are a source of (E. Coli) or fecal coliforms in the water.
– Is eutrophication (algae blooms) an issue in the lakes or ocean where you swim?
– Are there any factories that release pollutants (chemical contaminants) into the creeks and rivers (or their tributaries) where you swim?
– Does your city have combined sewers with CSO stations that release primary treated sewage into the waterway after heavy rain events?
– Have you ever emerged from an ocean swim and have friends point out your green “mustache” or “Bay Beard” in which the fine hairs of your face have trapped algae from the water? Though appreciated by South End Rowing Club member Zina Deretsky, algae is a common irritant in open water that can trigger post-swimming congestion.

Q: Is post-swimming congestion caused by allergies or allergens in the water, such as pollen?

A: Dr. Rascal explains that it is a common misconception for people to think that congestion or stuffiness in the nose is always attributable to “allergy.” Oftentimes the trigger of congestion is nonallergic and due to inhalation of “irritants” from the air, and for swimmers, from the water.

An allergy is a reaction by your immune system to a foreign substance or allergen that does not cause an immunological reaction in most people. Allergies are caused by both one’s genetics and the environment. Not everyone who suffers from post-swimming congestion has allergies.

When it comes to open water and pool swimming, the irritants found in the water are slightly different than those in the air, and they are a big part of post-swimming congestion that many people experience. Common irritants for swimmers include chlorine, algae, pollen, bacteria, perfume, lotion and chemicals.

These irritants, unfortunately, can find their way into the upper respiratory system and into the four pairs of sinus cavities, namely the frontal, maxillary, sphenoid, and ethmoid sinuses, through the nose and cause rhinitis. Irritants trigger inflammation of the nasal membranes lining the sinus cavities. When inflamed, the blood vessels in the nose dilate and fill with blood and fluid, and the mucous membranes produce excessive mucus. The tissue swells and constricts the nasal passages, preventing drainage from the sinuses and trapping the mucus. Bacteria accumulates, the pH changes, and infection may result. If we do not learn to prevent or treat this congestion, we can develop chronic sinusitis.

Pollen is a major concern to swimmers and non-swimmers alike. When genetically programmed to have allergies, one reacts inappropriately to an innocuous substance like pollen. The inhaled pollen is an example of an allergen; any substance that causes an allergic reaction. Large pollen grains can be trapped by the hair cells in the nose and prevents an allergic reaction. The yellow pollen seen coating our decks, cars, houses, and plants in the spring is too large to inhale and therefore do not cause symptoms. In the water, some of these pollen grains and other irritants flow past those hair cells, irritate the epithelial tissue, and cause swelling. The pollen on the surface of the water (whether the visible yellow variety or the smaller particles we cannot see) enters the nasal cavity as an irritant and it does not cause a significant amount of allergy. This distinction is important when analyzing what treatment options are best for you.

For those who suffer from congestion after pool swimming, remember that chlorine is not an allergen but IS a significant irritant. The better ventilated the building where the pool is housed, the better the conditions for swimmers. The preventative treatments and suggestions for post-swimming congestion are the same no matter if you are a pool or open water swimmer.

Tip for those with allergies: If you swim while congested caused by untreated allergies, you are more likely to suffer from more severe congestion after swimming. Irritants may also exacerbate the underlying allergic symptoms. Allergies due to inhalation of aerosolized allergens (pollen, dust mites, mold, dogs and cats, etc.) may be effectively treated using evidence-based solutions such as allergy shots, tablets, and drops.

Tip! Prevention is key for irritants. When the irritants in water cannot be avoided, swimmers can exhale out of the nose while swimming (most of us do this) or wear a nose clip (not many prefer this) to help prevent irritants from entering the nose or sinus cavities.

Tip! Irritants accumulate in stagnant areas of open water, so avoid those areas or hold your face up out of the water until you get through it.

Tip! Fortunately, there are both prescription and non-prescription nasal sprays that are effective in preventing congestion caused by the irritants in the water.

Recommendations on Nose Sprays

Q: Many swimmers use nose sprays to keep the nasal passages open so that water does not get trapped in the sinuses. Can you teach us about the different types of nose sprays and what works best?

A: Steroidal nasal sprays. If you have inflammation caused by allergies, irritants in the water can exacerbate the problem. Allergies should be optimally managed before entering the water. The single most effective treatment for allergic rhinitis is steroidal nasal sprays (e.g. Nasacort, Nasarel, Nasonex, X-hance, Flonase, etc.). These need to be taken for a few weeks before they are optimized by the body and able to work to reduce inflammation.

Antihistamine nasal sprays begin working in 15 minutes and are useful for treating allergy associated runny nose rather than congestion (e.g. Azelastine).

Nasal decongestants sprays (e.g. Afrin, Zicam) are over-the-counter medications that temporarily work by constricting the blood vessels in the nose, which reduces swelling and congestion. It is important to be aware of ingredients that may be addictive (such as oxymetazoline or neo-synephrine) and these should not be used for more than 3-5 days in a row but can be applied before entering the water to prevent or reduce congestion.

Oral decongestants (pseudoephedrine) are a good alternative to nasal sprays.

Tip! For those who become congested after open water swimming, Dr. Raschal suggests using a nasal decongestant spray or preferably an oral decongestant immediately before a swim to keep the sinuses open so that the water and irritants do not get trapped in the sinuses.

Tip! When administering any spray, it is important to aim the nasal spray toward the outside of the nose away from the septum.

To NetiPot or not?

Q: Do you recommend nasal irrigation such as the NetiPot to flush out the sinus cavities after swimming? Some swimmers swear by this practice whereas others say it only traps more water in their sinuses further exacerbating their congestion.

A: Dr. Raschal says yes. She recommends using NeilMed sinus rinse rather than NetiPot, however, both work and can be used while the sinuses are congested and to rinse irritants out of the sinuses.

Tip! Dr. Raschal suggests rinsing with NeilMed every time after swimming in a pool or open water to remove the irritants from the sinuses to help prevent congestion and infection. The NeilMed bottle and 50 saline packets cost US$13.99 here on Amazon.

Tip! NetiPot users typically pour water into one nostril and let it flow out the other, but Dr. Raschal explains a different and more effective method:

– Turn your head to the side, and lay your face on a stack of towels
– Seal the NeilMed bottle opening to the inferior nares (nostril)
– Gently squeeze the solution into the sinuses. Then, lift your head and allow the solution to drain out the same side onto the stack of towels.
– Repeat this process until half the 240ml bottle is emptied for each side of the nose.
– You must ensure you use either tap water that has been boiled for 5 minutes (and then cooled) or distilled water and use the saline packets.

Should we swim if we are already congested?

Q: Should we swim if we are already congested? Does frequency affect allergies, as in, the more frequently we swim the worse they get? (Question submitted by Jenny DiSanto)

A: If you swim while congested caused by untreated allergies, you are more likely to suffer from more severe congestion after swimming. Irritants in the water may exacerbate the underlying allergic symptoms. Allergies due to inhalation of aerosolized allergens (pollen, dust mites, mold, dogs and cats, etc.) may be effectively treated using evidence-based solutions such as allergy shots, tablets, and drops.

For those with allergies, more frequent exposure to the allergen worsens symptoms. Exposure to a lower amount of an allergen may cause severe symptoms upon re-exposure to the allergen. This is known as the priming effect. However, this is not true for irritants. Increased exposure to irritants does not potentiate the priming effect but increased exposure to irritants will cause symptoms commensurate to the irritant.

Do allergy shots help prevent post-swimming congestion?

Q: Since starting immunotherapy (allergy shots), I have noticed substantial improvement in congestion after river swimming. Is the congestion/sinus blockage experienced after open water swimming merely due to high exposure to our normal allergens that have accumulated on the water surface? (Question submitted by Andy Sweet)

A: Pollen on the water’s surface acts as an irritant rather than causing an allergic reaction. However, immunotherapy can help the body better control inflammation and be less affected by irritants in the water. An evaluation for allergies, entails skin testing to a variety of allergens via pricks or small skin injections followed by intradermal tests if needed. Typically, allergies are diagnosed more often in children than adults, but anyone of any age can have allergies. A history suggestive of allergic rhinitis and positive skin tests are warranted to determine if allergy shots are indicated. Although some people may have positive reactivity to their skin tests, their symptoms are not suggestive of allergies and do not need to be on allergy shots.

Those treated with allergy shots whose symptoms are not responding as expected, may have Irritant Rhinitis or Vasomotor Rhinitis and not Allergic Rhinitis, which does not respond to allergy shots, drops, or tablets. Another explanation for the lack of significant improvement with allergy shots, is the strength of the allergy vaccine. The vaccine consists of those allergens which were positive upon skin testing. The allergens in the vaccine are expensive and many providers do not use adequate amounts of the allergens. The vaccine may be subtherapeutic and therefore not as effective. Dr. Raschal says to be sure you seek the expertise of a board certified allergist who is more concerned about your health and improvement and not their 401k.

Q: Are there any other causes of congestion besides allergies and irritants in the water?

A: Vaso-motor rhinitis is another condition that causes swelling of nasal passages and is caused not by allergies, but by weather, weather changes, barometric pressure, and irritants. Such fluctuations due to changing seasons cause this condition, and can not be cured like allergies, therefore allergy drops, shots and sublingual tablets are not indicated for Vasomotor rhinitis.

Interestingly, gastroesophageal reflux disease (GERD) can cause gastric contents to migrate into the esophagus, denude the epithelial tissue, expose nerve endings which then cause a neurologic reflex, resulting in upper respiratory swelling and subsequent ear infections, sinus infections, drainage in the back of the throat, and nasal congestion. Rather than ranitidine, which was recently taken off of the market, another option is famotidine (i.e. Pepcid), which treats GERD and thus can help with related congestion.

Food Allergies: Unless you are allergic to dairy, you will not experience an allergic reaction when consuming dairy products. However, some people can develop lactose intolerance (a non-allergic reaction to dairy products) which results in gastrointestinal symptoms such as abdominal distention, gas, diarrhea, and general malaise until defecation. Lactose intolerance is due to a missing enzyme “lactase” in some people’s digestive system. Some studies show that milk is mucous-producing, thus resulting in post nasal drip and congestion.

Concluding Remarks

Swimmers come in contact with a wide variety of irritants when swimming, whether in open water or the pool. Depending on whether a swimmer’s congestion is due to underlying and untreated allergies, is solely non-allergic, or both, there are treatments and prevention methods that can help alleviate symptoms.

Contact Information for Dr. Susan Raschal

Dr. Raschal has treated many swimmers during her career. To schedule an appointment, visit here or call +1-423-468-3267.

Thank you to those who submitted questions: Kimberly Kae Archbold, Rick Balfour, Suzanne Bennett, Emily Collins, Heather Elizabeth Whisnant Cross, Jenny DiSanto, Hallie Hochman McFadden, Victoria Rian, John Spider Sillery, Andy Sweet, Melea Langley Wade, Allison Ware, and Jennifer Whitlock.

Copyright © 2020 by Karah Nazor, Ph.D.