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Rhinitis Medicamentosa Treatment & Management

  • Author: Natalya M Kushnir, MD, FAAAAI; Chief Editor: Michael A Kaliner, MD  more...
 
Updated: Nov 17, 2015
 

Medical Care

Once rhinitis medicamentosa is identified, topical decongestant use must be discouraged and discontinued as soon as possible. Patients need to be educated on their condition and offered other methods of treatment that will help them with the medical conditions that originally triggered the decongestant use. For those patients unable or unwilling to immediately stop, several methods may ease the withdrawal process.

The first week is often the most difficult for weaning or withdrawal. Several studies confirm efficacy of nasal corticosteroids in the treatment and prevention of rhinitis medicamentosa. Patients can be offered introduction of nasal corticosteroids while being weaned off decongestants. Oral steroids may be necessary. Buffered or concentrated salt solutions can be also offered with nasal irrigation devices such as NeilMed to provide moisturizing and nonaddicting decongestant relief.

Nasal decongestants can be weaned gradually, allowing patients to use sprays at night in one nostril only and alternating the left and right nostril until congestion is decreased.

Pain relief should be provided to patients who don't have ASA sensitivity but are experiencing headache.

Patients should be offered frequent office visits in the first few weeks of treatment to encourage withdrawal and provide emotional support.

Systemic decongestants: These are particularly helpful in patients who began using vasoconstrictive nasal medications to help with allergic rhinitis. As the symptoms associated with allergic rhinitis are relieved, the intranasal medication can be discontinued.

Oral corticosteroids: Although not always necessary, short-course oral corticosteroids, as described below, are the most effective way to break the cyclic use of topical vasoconstrictors. The oral corticosteroids are often used for 5-10 days, with nasal corticosteroids started at the same time and continued until the process is corrected.

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.

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Surgical Care

Surgical treatment is not recommended unless polyps or deviated septum are present. Reduction of nasal turbinates is not indicated in simple cases; if performed, this reduction results in short-lived effect with return of congestion if nasal decongestants are not discontinued. With discontinuation of decongestants, the condition is usually self-resolving. In cases refractory to the withdrawal treatment, outpatient diode laser inferior turbinate reduction of hyperplastic inferior turbinate represents a highly effective, safe, and well-tolerated treatment option that provides long-lasting recovery by markedly improving nasal airflow thus and stopping addiction to nasal decongestants.[10]

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Consultations

Consult an allergist or otorhinolaryngologist if a patient's case is complicated and refractory to treatment or if the primary care physician is unsure of diagnosis.

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Contributor Information and Disclosures
Author

Natalya M Kushnir, MD, FAAAAI Director, Allergy and Immunology Clinic of the East Bay; Clinical Co-Director, Breathmobile Clinic of Northern California

Natalya M Kushnir, MD, FAAAAI is a member of the following medical societies: American Academy of Allergy Asthma and Immunology

Disclosure: Received honoraria from MEDA for speaking and teaching; Received honoraria from GSK for speaking and teaching; Received honoraria from MERCK-Sherring for speaking and teaching; Received honoraria from Alcon for speaking and teaching.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

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 Center

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, American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Michael A Kaliner, MD Clinical Professor of Medicine, George Washington University School of Medicine; 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, Association of American Physicians

Disclosure: Nothing to disclose.

Additional Contributors

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, Minnesota Medical Association

Disclosure: Nothing to disclose.

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