Background:Correct nasal spray techniqueand patient compliance are the two mostimportant factors in the use of steroid nose spray.

Objectives:To find out if patientsuse steroid nasal spray with a correctspray technique and if they are compliant in using the spray.

Design: Patient-reported survey

Participants: 100 participants (1 excluded)

Main outcome measures 1) Nasal spray technique 2) Patient compliance

Results: Out of 99 participants included in this study only one patient used steroid nose spray with a completely correct spray technique. 40% of patients received guidance instructions from the prescriber about the spray technique. 70% of patients reported using their spray regularly and 53% of patients were found using the correct dosage of the spray.

Conclusions: Wrong spray technique and patient noncompliance is common and can be corrected. This survey emphasizes the importance of giving written and verbal instructions about the use of spray to the patients.

Key Points:

• Only 1 patient out of 99, used steroid nasal spray with a completely correct spray technique.
• Nasal spray technique was taught only to 40% of thepatients
• 70% of the patientsreported regular use of the steroid nose spray and 53% of patients were found to use correct spray dosage.
• Wrong spray technique and non-compliance can be the reason behind the treatment failure with steroid nasal spray.
• We recommend following “British Society for Allergy and Clinical Immunology-how to apply a nasal spray” and/or video instruction from “asthma.org.uk- how to use nasal spray” for the correct spray technique.

Background: Various studies conducted in the past have proven the efficacy of steroid nasal spray in the treatment of inflammatory nasal conditions. [1],[2] Currently, topical steroid nasal sprays are considered as the first-line treatment for the management of allergic rhinitis (hayfever) and chronic rhinosinusitis.[1],[3],[4],[5] Intranasal steroids work locally inside the nose and are found to be more effective than systemic steroids [2]. Local application of steroids in the nose reduces systemic absorption, hence reducing systemic side effects [6]. Various steroid- based nasal sprays are available i.e. Beconase, Nasonex, Avamys,Flixonase [7]. Combination nasal spray is also available which contains topical antihistamine and topical steroid i.e. Dymista [8].

Previous studies have investigated the correlation between the spray technique and the distribution of drug inside the nose [9],[10],[11],[12]. Correct spray technique and patient compliance are the two important factors for the nasal spray to work. Furthermore, incorrect spray technique can be associated with side effectsi.e. irritation and epistaxis [6]. Current guidance on the management of chronic rhinosinusitis, allergic and non- allergic rhinitis strongly recommends clinicians to check nasal spray technique and compliance [3], [5].

Significant material is available on the internet to educate people about nasal spray use, however, some of them are inaccurate [7, 13-16]. Therefore, after extensive research, we recommend following the written instructions for the use of steroid nasal spray from “British Societyfor Allergy and Clinical Immunology” or/and video tutorial from “ asthma.org.uk- how to use nasal spray” [7],[13] (See below). We recommend following these steps when using steroid nose spray:

• Clear the nose.
• Slightly bend headforward.
• Use opposite hand when holding spray (Right hand for left nostril and left hand for right nostril).
• Direct spray inside the nose away from nasal septum (towards turbinate) towards ipsilateral ear oreye.
• Administer spray- avoid hard sniffing.
• Repeat the same for the other nostril.

The main objectives of this survey were:

1. To investigate if patients use a correct spray technique while administering steroid nose spray.
2. To investigate the patient's compliance in using the steroid nose spra

Study design and Setting: This survey was conducted at Queen Elizabeth Hospital in Birmingham, UK. Initially, a written paper survey form (see figure 1) was distributed among the patients who were using steroid nasal spray and who came to attend rhinology and immunology outpatient clinics. But, shortly after this survey started, face to face patient consultations were stopped due to COVID-19outbreak. Hence, a telephonic patient-reported survey was undertaken for the remaining patients. During the telephonic survey, we made a minor change in the question 3 of the survey (see figure 1)

1.Participants: Total100 patients took part in this survey. 15 patients filled in paper survey proforma before COVID-19 outbreak and the remaining 85 responded to the telephonic survey. Mean age of the participated patients in this survey was 49 years old, ranging from 18 to 77 years. There were 53 males and 46 females and the male: female ratio was 1.15:1.

1. When analysing the patient’s responses, one respondent was using otrovine instead of steroid spray. Hence, we excluded this patient from the study, which dropped the total number of participants included in the study to 99.
   1. Patient responses: Patient responses to the survey questions are as below:
      1. Who prescribed this nose spray?
         1. ENT 53% (53 patients).
         2. GP 42% (42 patients).
         3. Over the counter 3% (3 patients).
         4. 1 % (1 patient) cannot remember who prescribed the spray
         5. No spray was prescribed by the immunologist.
         6. Were you shown how to use nose spray?
            1. 40% (40 patients) responded yes
            2. 60% (59 patients) responded No

Further breakdown of the taught spray technique in those 40?ses was:

1. 24% of cases (24 patients) by the ENT team.
2. 15% of cases (15 patients) by GP.
3. 1% of cases (1 case) by an asthma nurse.
   1. Outcome Data:
      1. Spray technique: Majority of the patients were using steroid nose spray with an incorrectspray technique. Only 1 patientout of 99 used steroid nose spray in a completely correct manner i.e. followed each step correctly. Different steps in using nose spray were all analysed separately i.e. head position, the direction of spray inside the nose, hand preference for holding spray bottle, sniffing, tasting spray in the mouth (See figure 2).
      2. Patient compliance: Compliance issues were also identified in the use of steroid nose spray. Majorityof the patients revealed “regular” use of the spray 70% (69 patients). However,some patients reported using their spray “most of the times” 14% (14 patients) and “sometimes” 16% (16 patients) respectively. 53% of patients were found using correct spray dose but 34% (34 patients) were using the incorrect dose of the prescribed spray; either underdosing or overdosing. 13% (13 patients) were unable to recall the spray name, neither we were able to find the spray name in our documentation. Hence, we can not comment whetherthey used correctspray dosage (See figure 3).

1. Nasal sprays: Below is the list of nasal spraysand the percentage of patients using these sprays:

• Dymista 33 patients(34%)
• Nasonex 21 patients(21%)
• Avamys 23 patients(23%)
• Flixonase 4 patients (4%)
• Beconase 4 patients(4%)
• Budenasoide 1 patient (1%)
• 13 patients cannotremember the name of the spray (13%).

Wrong spray technique is extremely common among patients using the steroid nose spray. This seems to be overlooked by many clinicians, which is easily correctable. Moreover, patient compliance can be further improved. We emphasize the importance of giving verbal as well as written instructions to the patients when prescribing steroid nose spray.

1. Ethical considerations: This survey was registered with clinical audit registration and management system CARMS- 15756 in Queen Elizabeth Hospital Birmingham, UK.
2. Conflicts of Interest: None declared
3. Data availability statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.4.
4. Funding: No funding