eMedicine Specialties > Allergy and Immunology > Medical Topics

Rhinitis Medicamentosa: Follow-up

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

Follow-up

Further Outpatient Care

  • Follow up in 1-2 weeks to support the patient, assess the status of the residual obstruction in patients with mechanical nasal obstruction, and evaluate the turbinates for possible permanent hyperplasia.

Deterrence/Prevention

  • Avoid topical vasoconstrictors in the future. Studies showed that those with a history of rhinitis medicamentosa who successfully stop using the offending medication have a rapid onset of rebound congestion upon repeat use of topical vasoconstrictor medication, even if used for only a few days.21

Complications

  • Most patients are able to eventually discontinue topical nasal medication with full recovery. In those who are unable, reports exist of permanent hyperplasia requiring intervention varying from submucosal electrocautery or cryotherapy to partial turbinate destruction by laser or surgical resection.
  • Nasal septal perforations
  • Atrophic rhinitis
  • Sinus infection

Prognosis

  • Studies showed that nearly all patients were able to eventually stop using the offending medication.22
  • Those who used topical preparations again, even 1 year later, had rapid rebound congestion within a few days.21

Patient Education

  • The key to treatment and prevention of rhinitis medicamentosa lies in educating the patient about the consequences of using nasal vasoconstrictors for longer than 5-7 days.
  • Once informed that the cause of the chronic congestion is their medication, most patients immediately begin withdrawing.

Miscellaneous

Medicolegal Pitfalls

  • Failure to recognize that a treatable condition, such as deviated septum or allergic rhinitis, may have been the cause for initiating nasal decongestant medication
  • Failure to elicit a history of use of nasal decongestant medication in a patient with chronic stuffy nose

Special Concerns

  • Pregnancy
    • Rhinitis of pregnancy affects as many as 20% of expecting mothers. High estrogen levels, especially during the 3rd trimester of pregnancy, tend to increase acetylcholine levels. The direct cholinergic action leads to swelling and congestion of the nasal mucosa.
    • Therapy for a pregnant patient with rhinitis medicamentosa is the same as outlined above. The patient's obstetrician should be consulted before starting any medications.
  • Neonates
    • One report exists of a healthy neonate prescribed phenylephrine for noisy breathing, sternal retractions, and perioral cyanosis. The parents continued to administer the medication every 3-4 hours for 12 days. By then, the infant had developed rhinitis medicamentosa that resulted in hypoxia, right ventricular hypertrophy (RVH), apnea, and cyanotic spells. This patient required bilateral nasal stents formed from a #4 endotracheal tube (ETT). Irrigation and suctioning were performed prior to each feeding to maintain patency. As a precaution, an apnea monitor was thought to be helpful until the rhinitis medicamentosa resolved. Oral pseudoephedrine was also recommended, with close monitoring of blood pressure for 1 hour after the dose. This patient recovered completely.
    • Careful use of nasal Decadron drops or a nasal steroid spray can help wean these patients as well. Nasal stuffiness in infants may warrant a workup for gastroesophageal reflux.
  • Continuous positive airway pressure (CPAP)-induced rhinitis
    • This therapy, prescribed for sleep apnea, can cause increased flow through the nasal cavity, which, in turn, causes dry mucous membrane, overproduction of the mucus, and congestion.
    • Appropriate use of such machines should be ensured, including evaluation of pressure used, regular maintenance, and humidification of the air delivered. Nasal gel is recommended to prevent drying of the mucous membranes of the nasal cavity.
 


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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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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