A 35-year-old man comes to the physician because of a 2-week history of nasal congestion. He has used a topical decongestant every few hours since his symptoms began. He experienced relief for almost 1 week, but then his nasal congestion returned. The patient has a history of allergic rhinitis and has had episodes of rhinorrhea in the past, but none of them lasted longer than a few days. He denies fever, throat pain, headaches, cough, and lymph node enlargement. Aside from his allergic rhinitis, the patient has no other medical problems. Physical examination shows nasal mucosa that appears edematous and red with a few areas of punctate bleeding. The remainder of the examination reveals no abnormalities. Which of the following is the most appropriate next step in the management of this patient?

Question

A 35-year-old man comes to the physician because of a 2-week history of nasal congestion.  He has used a topical decongestant every few hours since his symptoms began.  He experienced relief for almost 1 week, but then his nasal congestion returned.  The patient has a history of allergic rhinitis and has had episodes of rhinorrhea in the past, but none of them lasted longer than a few days.  He denies fever, throat pain, headaches, cough, and lymph node enlargement.  Aside from his allergic rhinitis, the patient has no other medical problems.  Physical examination shows nasal mucosa that appears edematous and red with a few areas of punctate bleeding.  The remainder of the examination reveals no abnormalities.  Which of the following is the most appropriate next step in the management of this patient?

Quizplus · Accepted Answer

Vasoconstriction by α-adrenergic agonists is prominent in the vessels of the nasal mucosa, making these medications effective decongestants. Phenylephrine, xylometazoline, and oxymetazoline are used as topical preparations for the treatment of allergic rhinitis and common cold associated congestion and rhinitis. These medications, however, are characterized by rapidly declining effect after a few days of use. This phenomenon is called tachyphylaxis. It occurs because of decreased production of endogenous norepinephrine from the nerve terminals due to a negative feedback mechanism, resulting in relative vasodilation (ie, removal of normal vasoconstrictive tone) and subsequent edema and congestion. This leads to exacerbation of the nasal congestion symptoms. Rebound rhinorrhea (ie, rhinitis medicamentosa) is described as nasal congestion without cough, sneezing, or postnasal drip. Rhinorrhea may or may not be present (note the paradox in naming). Rebound rhinorrhea is associated with the use of topical decongestants for > 3 days. The use of adrenergic agonists should be stopped to allow the restoration of normal norepinephrine feedback pathways. Another medication associated with the phenomenon of tachyphylaxis is nitroglycerine. The decrease in its effect is explained by the diminished release of NO from the target cells. Drug-free intervals of 8-10 hours should be maintained during the use of nitroglycerine to prevent tachyphylaxis. (Choice B) Ephedrine is an indirect-acting adrenergic agonist used as a decongestant. Like the other adrenergic medications, it causes tachyphylaxis after a few days of treatment. A switch to ephedrine would not improve this patient's rebound rhinorrhea. (Choice C) This patient has been excessively using a decongestant; if he discontinues it and experiences excessive withdrawal symptoms, a short-term course of topical corticosteroids can be considered for symptom control. However, oral corticosteroids would not be indicated. (Choice D) Antihistamines are used for the treatment of allergic rhinitis, but they are not effective in treating rebound rhinorrhea. (Choice E) Antibiotics are effective in the treatment of certain bacterial infections. They are not used in the treatment of rebound rhinorrhea. Educational objective: Topical preparations of α-adrenergic agonists cause vasoconstriction of the nasal mucosa vessels and are used as decongestants. Overuse of these drugs causes negative feedback, resulting in decreased norepinephrine synthesis and release from nerve endings, which diminishes their effect (ie, tachyphylaxis). __________ References: Rhinitis medicamentosa. (http://www.ncbi.nlm.nih.gov/pubmed/16784007) Diagnosing rhinitis: allergic vs. nonallergic. (http://www.ncbi.nlm.nih.gov/pubmed/16719251)

A 35-Year-Old Man Comes to the Physician Because of a 2-Week