A 45-year-old woman comes to the physician because of chronic nasal congestion. Her symptoms began years ago, but they have worsened lately. She often has paroxysms of 10-12 sneezes, especially when waking up in the morning. She also complains of chronic rhinorrhea and post-nasal drip, and she occasionally has itchy eyes. She is unsure if there is a seasonal component to her symptoms, but they may be worse in the Spring. She does not use aspirin and has not had any episodes of sinusitis. She has tried chlorpheniramine in the past, but it made her drowsy. She does not smoke tobacco or drink alcohol and she denies cocaine or other illicit drug use. She has mild hypertension but is in good health otherwise.
Her blood pressure is 134/84 mm Hg and pulse is 67/min. Her nares are patent with a clear discharge. There are no nasal polyps or septal deviation. The turbinates are pale and her conjunctivae appear normal. Neck, pulmonary, and cardiovascular examinations are within normal limits.
Which of the following is the best next step in this patient's management?

Question

A 45-year-old woman comes to the physician because of chronic nasal congestion.  Her symptoms began years ago, but they have worsened lately.  She often has paroxysms of 10-12 sneezes, especially when waking up in the morning.  She also complains of chronic rhinorrhea and post-nasal drip, and she occasionally has itchy eyes.  She is unsure if there is a seasonal component to her symptoms, but they may be worse in the Spring.  She does not use aspirin and has not had any episodes of sinusitis.  She has tried chlorpheniramine in the past, but it made her drowsy.  She does not smoke tobacco or drink alcohol and she denies cocaine or other illicit drug use.  She has mild hypertension but is in good health otherwise.
Her blood pressure is 134/84 mm Hg and pulse is 67/min.  Her nares are patent with a clear discharge.  There are no nasal polyps or septal deviation.  The turbinates are pale and her conjunctivae appear normal.  Neck, pulmonary, and cardiovascular examinations are within normal limits.
Which of the following is the best next step in this patient's management?

Quizplus · Accepted Answer

This patient's presentation is consistent with typical allergic rhinitis, which affects a large percentage of the normal population. For many individuals, the symptoms are disturbing; they can lower quality of life and impair sleep. Patients typically present with sneezing, watery nasal discharge, and pale turbinates. Although most patients have seasonal exacerbations, this is not always the case. Clinical history and examination are sufficient to establish a diagnosis, and skin testing or other tests to detect allergens are not necessary at this time. Randomized controlled trials have demonstrated that nasal corticosteroids are superior to all other listed modalities in relieving symptoms and improving quality of life. (Choice A) Leukotriene antagonists may be of some benefit, but they are not as effective as nasal corticosteroids. (Choice C) Nasal decongestants are effective for short-term relief of symptoms but should be avoided due to desensitization and rebound symptoms, which can lead to overuse and rhinitis medicamentosa. (Choice D) Oral decongestants can be effective for short periods to decrease rhinorrhea and nasal congestion, but they have no impact on sneezing and itching eyes. In addition, they can increase blood pressure. (Choice E) Sedating and non-sedating anti-histamines often relieve symptoms and are commonly used in patients with paroxysmal and mild symptoms. However, they are inferior to nasal steroids in patients with persistent, moderate-to-severe symptoms (such as this patient). Educational objective: Nasal corticosteroids are the most effective and best tolerated treatment for typical allergic rhinitis. __________ References: Comparison of nasal glucocorticoid, antileukotriene and a combination antileukotriene and antihistamine in the treatment of seasonal allergic rhinitis. (http://www.ncbi.nlm.nih.gov/pubmed/12063523) Intranasal corticosteroids versus H1 receptor antagonists in allergic rhinitis: systematic review of randomized controlled trials. (http://www.ncbi.nlm.nih.gov/pubmed/9848901)

A 45-Year-Old Woman Comes to the Physician Because of Chronic