A 37-year-old woman comes to the physician because of persistent nasal congestion and runny nose. She states that she developed nasal congestion, a productive cough, and myalgias 4 weeks ago. She has been self-medicating with over-the counter nasal decongestant spray and antitussive liquid for the last 2 weeks, with gradual resolution of her cough and myalgias. However, she has developed recurrent nasal congestion and runny nose that is unresponsive to treatment. Her nasal discharge is clear. She has no associated sneezing, facial pain, or ocular itching. Her overall health is good and she denies similar symptoms in the past.
On physical examination, her nasal mucosa appears edematous and red. The remainder of her physical examination is within normal limits.
Which of the following is the best next step in management?

Question

A 37-year-old woman comes to the physician because of persistent nasal congestion and runny nose.  She states that she developed nasal congestion, a productive cough, and myalgias 4 weeks ago.  She has been self-medicating with over-the counter nasal decongestant spray and antitussive liquid for the last 2 weeks, with gradual resolution of her cough and myalgias.  However, she has developed recurrent nasal congestion and runny nose that is unresponsive to treatment.  Her nasal discharge is clear.  She has no associated sneezing, facial pain, or ocular itching.  Her overall health is good and she denies similar symptoms in the past.
On physical examination, her nasal mucosa appears edematous and red.  The remainder of her physical examination is within normal limits.
Which of the following is the best next step in management?

Quizplus · Accepted Answer

This patient's presentation is consistent with rhinitis medicamentosa (RM), which is most commonly due to overuse of over-the-counter nasal decongestant sprays. The spray's vasoconstrictive effect requires increasing amounts of the drug for symptomatic relief due to tachyphylaxis and leads to rebound vasodilation with swelling and rhinorrhea. Patients then use more nasal decongestant spray to relieve their symptoms, which begins a cycle of congestion with temporary relief followed by worsening congestion as the spray wears off. Patients also get an emotional lift from the spray and eventually become dependent on the drug. The nasal irritation may be worsened by the benzalkonium chloride preservative present in many sprays. Diagnosis is made by history and physical examination showing swollen red nasal mucosa. Treatment involves medication cessation, which may be difficult since patients experience worsening rebound symptoms. Some data suggest that intranasal fluticasone use for a few days helps to alleviate the withdrawal nasal congestion. Some patients require oral steroids for more severe withdrawal symptoms. Rhinitis medicamentosa can be prevented by limiting over-the-counter nasal decongestant spray use to < 5 days. < (Choice B) Ipratropium nasal spray is effective for rhinorrhea caused by allergic and non-allergic rhinitis. However, this patient's lack of sneezing or itchy eyes makes these options less likely. Although ipratropium nasal spray may improve some of the patient's symptoms, discontinuing the over-the-counter spray and initiating therapy with fluticasone would be more effective. (Choice C) Nasal endoscopy is usually indicated to evaluate for obstructive lesions in patients with significant sinusitis who fail conservative therapy. (Choice D) Regular nasal saline lavage is usually effective in chronic rhinosinusitis, which is defined as > 12 weeks of sinus congestion refractory to medical therapy. This patient has had only 4 weeks of symptoms and will likely not benefit significantly from nasal saline lavage. (Choice E) Sinus x-ray is usually performed in patients with sinusitis who fail medical therapy. However, this patient's lack of fever or sinus tenderness on palpation makes this diagnosis less likely. Educational objective: Rhinitis medicamentosa usually occurs in patients with chronic use of vasoconstrictor nasal sprays. Symptoms are due to a cycle of rebound exacerbation with worsening nasal congestion and discharge. Treatment involves stopping the decongestant spray and initiating a trial of intranasal steroids (e.g., fluticasone). __________ References: Rhinitis medicamentosa. (http://www.ncbi.nlm.nih.gov/pubmed/16784007) Fluticasone reverses oxymetolazone-induced tachyphylaxis of response and rebound congestion. (http://www.ncbi.nlm.nih.gov/pubmed/20203244)

A 37-Year-Old Woman Comes to the Physician Because of Persistent