eMedicine Specialties > Allergy and Immunology > Medical Topics

Rhinitis Medicamentosa: Differential Diagnoses & Workup

Author: Natalya M Kushnir, MD, Allergist-Immunologist, Group Private Practice, Allergy and Asthma Medical Group of the Bay Area, Berkeley; Clinical Investigator, Allergy and Asthma Clinical Research Inc, Walnut Creek, California
Contributor Information and Disclosures

Updated: Oct 13, 2009

Differential Diagnoses

Allergic Rhinitis
Continuous Positive Airway Pressure (CPAP) Rhinitis
Nasal Polyps
Rhinitis, Nonallergic
Rhinosinusitis

Other Problems to Be Considered

Deviated nasal septum
Upper respiratory infection
Rhinopathy, nonallergic (formerly known as vasomotor rhinitis)
Cocaine abuse
Pregnancy

Workup

Laboratory Studies

Carefully collected medical history usually determines diagnosis. Laboratory studies such as nasal smear, total IgE, CBC, erythrocyte sedimentation rate (ESR), allergy skin testing, and CT scan of the sinuses may be helpful in identifying underlying conditions.

Imaging Studies

  • Sinus imaging studies may be helpful to rule out rhinosinusitis, nasal polyps, and deviated septum.
  • Rhinosterometry is used more for research purposes.14
    • This direct noninvasive optical surgical microscope angles in a 3-dimensional coordinate system to achieve accurate measurements within 0.2 mm.
    • Researchers use rhinosterometry to estimate nasal mucosal reactivity to histamine provocations and to quantify nasal mucosa swelling.14,20

Other Tests

Rhinitis medicamentosa usually coexists with other medical conditions that originally trigger decongestant use. It is important to identify any condition that can be potentially treated.

  • Skin testing is recommended for patients with history of allergic rhinitis (AR).
  • Patients who are suspected to have ASA triad may be considered for aspirin challenge.
  • Rhinoscopy is useful in identification of nasal septal deviation, other anatomic abnormalities, and nasal polyps.

Histologic Findings

  • Increased vascularity, edema of the mucosa
  • Squamous cell metaplasia; epithelial cells change from ciliated columnar to nonciliated stratified squamous
  • Mononuclear infiltration
  • Glandular and Goblet cell hyperplasia
  • Increased secretory activity
  • Increased phagocytosis
  • Increased epidermal growth factor receptor staining (It appears to increase in the hyperplastic epithelium.)
  • Abnormal cilia structure and function
  • Increase in plasma cells, fibroblasts, and lymphocytes

More on Rhinitis Medicamentosa

Overview: Rhinitis Medicamentosa
Differential Diagnoses & Workup: Rhinitis Medicamentosa
Treatment & Medication: Rhinitis Medicamentosa
Follow-up: Rhinitis Medicamentosa
References
Further Reading
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References

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  3. Doshi J. Rhinitis medicamentosa: what an otolaryngologist needs to know. Eur Arch Otorhinolaryngol. May 2009;266(5):623-5. [Medline].

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  11. Bernstein IL. Is the use of benzalkonium chloride as a preservative for nasal formulations a safety concern? A cautionary note based on compromised mucociliary transport. J Allergy Clin Immunol. Jan 2000;105(1 Pt 1):39-44. [Medline].

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  21. Graf P, Hallen H. One-week use of oxymetazoline nasal spray in patients with rhinitis medicamentosa 1 year after treatment. ORL J Otorhinolaryngol Relat Spec. Jan-Feb 1997;59(1):39-44. [Medline].

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  27. Graf P. Long-term use of oxy- and xylometazoline nasal sprays induces rebound swelling, tolerance, and nasal hyperreactivity. Rhinology. Mar 1996;34(1):9-13. [Medline].

  28. Graf PM, Hallen H. Changes in nasal reactivity in patients with rhinitis medicamentosa after treatment with fluticasone propionate and placebo nasal spray. ORL J Otorhinolaryngol Relat Spec. Nov-Dec 1998;60(6):334-8. [Medline].

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  30. Lasley MK. Rhinitis and sinusitis in children. 1999;19:437-448.

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Keywords

rhinitis medicamentosa, rebound rhinitis, chemical rhinitis, drug-induced rhinitis, vasoconstrictor overuse, decongestant overuse, overuse of intranasal vasoconstrictive medications, topical nasal decongestants, rebound swelling, overuse of nasal spray

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Contributor Information and Disclosures

Author

Natalya M Kushnir, MD, Allergist-Immunologist, Group Private Practice, Allergy and Asthma Medical Group of the Bay Area, Berkeley; Clinical Investigator, Allergy and Asthma Clinical Research Inc, Walnut Creek, California
Disclosure: MEDA Honoraria Speaking and teaching; GSK Honoraria Speaking and teaching; MERCK Honoraria Speaking and teaching

Medical Editor

William F Schoenwetter, MD, Consultant in Allergic Diseases, Brainerd Medical Center, Brainerd, Minnesota
William F Schoenwetter, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, American College of Physicians, American Medical Association, Joint Council of Allergy, Asthma and Immunology, and Minnesota Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

John E McClay, MD, Associate Professor of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Dallas, University of Texas Southwestern Medical School
John E McClay, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and American Medical Association
Disclosure: Nothing to disclose.

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting

Chief Editor

Michael A Kaliner, MD, Clinical Professor of Medicine, George Washington University School of Medicine; Chief, Section of Allergy and Immunology, Washington Hospital Center; Medical Director, Institute for Asthma and Allergy
Michael A Kaliner, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Allergy, Asthma and Immunology, American Society for Clinical Investigation, American Thoracic Society, and Association of American Physicians
Disclosure: Abbott Consulting fee Consulting; Alcon Consulting fee Consulting; Glaxo Consulting fee Consulting; Greer Consulting fee Consulting; Sanofi Consulting fee Consulting; Schering Consulting fee Consulting; Teva  Consulting; Meda Honoraria Speaking and teaching

 
 
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