A 48-year-old man comes to the office due to nasal congestion and rhinorrhea. Three months ago, the patient developed symptoms of nasal congestion, rhinorrhea, cough, fatigue, and fever. He began using over-the-counter acetaminophen and nasal decongestant spray. The fever resolved and symptoms initially improved, but since then, the patient has had worsening nasal congestion and a decreased sense of smell despite continued medication use. He has no other chronic medical problems. He works at a print shop. He does not use tobacco or illicit drugs. Vital signs are within normal limits. The tympanic membranes are clear with no middle ear effusion. Nasal examination shows swollen, beefy-red nasal turbinates obstructing the nasal airway. The oral cavity is clear; the tonsils are small and not inflamed. There is no cervical adenopathy. Which of the following is the most appropriate next step in management of this patient's current condition?

Question

A 48-year-old man comes to the office due to nasal congestion and rhinorrhea.  Three months ago, the patient developed symptoms of nasal congestion, rhinorrhea, cough, fatigue, and fever.  He began using over-the-counter acetaminophen and nasal decongestant spray.  The fever resolved and symptoms initially improved, but since then, the patient has had worsening nasal congestion and a decreased sense of smell despite continued medication use.  He has no other chronic medical problems.  He works at a print shop.  He does not use tobacco or illicit drugs.  Vital signs are within normal limits.  The tympanic membranes are clear with no middle ear effusion.  Nasal examination shows swollen, beefy-red nasal turbinates obstructing the nasal airway.  The oral cavity is clear; the tonsils are small and not inflamed.  There is no cervical adenopathy.  Which of the following is the most appropriate next step in management of this patient's current condition?

Quizplus · Accepted Answer

11ec25c8_d21d_fbed_bc81_713e75680332_MD0003_00 This patient has rhinitis medicamentosa, nasal congestion that occurs after prolonged use of nasal decongestant sprays. Oxymetazoline, the most commonly used over-the-counter nasal decongestant spray, leads to rapid relief of nasal congestion by causing profound vasoconstriction. However, with continued use, it can injure the vascular endothelium, leading to rebound congestion; patients then use it more frequently, setting up a vicious cycle. This can occur in as few as 3-5 days. Physical examination often shows beefy-red nasal mucosa as opposed to the edematous, pale mucosa often seen in allergic rhinitis. Because they sometimes consider over-the-counter medications inconsequential, patients may not volunteer information about the use of nasal decongestant sprays. The most important step in management is cessation of the nasal decongestant spray, which is typically very uncomfortable for patients because of rebound nasal congestion; significant counseling is required. Nasal glucocorticoids are often prescribed to aid cessation. A short course of oral glucocorticoids can be added in severe cases. (Choices A and C) Avoidance of allergens or measurement of serum IgE concentration is often recommended for patients with allergic rhinitis, which can present with nasal congestion. However, it is typically associated with sneezing and itching of the eyes. Physical examination would show edematous, pale nasal mucosa rather than the beefy red mucosa that is classically associated with rhinitis medicamentosa. (Choice B) CT scan of the paranasal sinuses can be used to evaluate for chronic rhinosinusitis, which can cause nasal congestion and develop after upper respiratory symptoms. However, in addition to nasal congestion and a loss of smell, patients with chronic sinusitis typically have mucopurulent drainage and facial pain or pressure. In addition, this patient's continued use of nasal decongestant makes rhinitis medicamentosa much more likely. (Choice D) Serum antineutrophil cytoplasmic autoantibody assay can be used to assess for some systemic diseases that can sometimes present with nasal symptoms (eg, granulomatosis with polyangiitis). However, there are clinical manifestations in other organ systems (eg, lower respiratory tract, kidneys), and this patient's history of nasal decongestant spray use makes rhinitis medicamentosa much more likely. Educational objective: Over-the-counter decongestant sprays can cause rhinitis medicamentosa after only a few days. Cessation of the medication is the most important step in management. References: Management of rhinitis medicamentosa: a systemic review. (http://www.ncbi.nlm.nih.gov/pubmed/30325708) Rhinitis medicamentosa as a cause of increased intraoperative bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/20824778) Rhinitis medicamentosa: electron microscopic changes of human nasal mucosa. (http://www.ncbi.nlm.nih.gov/pubmed/17210334)

A 48-Year-Old Man Comes to the Office Due to Nasal