A 23-year-old woman comes to the office due to nasal congestion, rhinorrhea, and postnasal drip for more than a year. Symptoms fluctuate in intensity and are worsened by cigarette smoke and strong fragrances. Although symptoms do not change with the season, they worsen when the patient walks from indoors to outdoors on a cold day. She has no eye or ear symptoms, itching, wheezing, or skin rash. The patient has been using over-the-counter oral loratadine and pseudoephedrine without significant improvement. Medical history is unremarkable. On inspection, the nasal mucosae appear boggy and erythematous, and rhinorrhea is clear. The conjunctivae are normal. The lungs are clear to auscultation. Which of the following is the best next step in management of this patient?

Question

A 23-year-old woman comes to the office due to nasal congestion, rhinorrhea, and postnasal drip for more than a year.  Symptoms fluctuate in intensity and are worsened by cigarette smoke and strong fragrances.  Although symptoms do not change with the season, they worsen when the patient walks from indoors to outdoors on a cold day.  She has no eye or ear symptoms, itching, wheezing, or skin rash.  The patient has been using over-the-counter oral loratadine and pseudoephedrine without significant improvement.  Medical history is unremarkable.  On inspection, the nasal mucosae appear boggy and erythematous, and rhinorrhea is clear.  The conjunctivae are normal.  The lungs are clear to auscultation.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d2dd_a277_bc81_c13e2029f439_MD0003_00 This patient has rhinitis triggered by strong smells and sudden exposure to cold air. She lacks eye symptoms or triggers consistent with allergies (eg, seasonal variation), and the symptoms do not improve with oral antihistamines. This presentation is consistent with nonallergic rhinitis (NAR), also known as vasomotor rhinitis. In contrast to patients with allergic rhinitis, patients with NAR usually cannot identify specific allergic triggers (eg, pollen counts), and they typically have negative testing for aeroallergens. However, many have very specific behavioral triggers (eg, walking into cold air, eating). In addition, patients with NAR typically lack the sneezing and allergic conjunctivitis (eg, itchy eyes, injected conjunctivae) that classically accompany allergic rhinitis. First-line treatment for both allergic rhinitis and NAR is intranasal glucocorticoids. Intranasal antihistamines (eg, azelastine, olopatadine) or intranasal ipratropium bromide can also be used. Combination therapy is often required for patients with moderate to severe symptoms. (Choice A) Imaging can be helpful for patients with chronic sinusitis, which can present with nasal congestion. However, patients with chronic sinusitis also typically have mucopurulent drainage, facial pain or pressure, and a decreased sense of smell. (Choice C) Although nasal cytology in patients with NAR usually reveals predominant eosinophils and increased numbers of mast cells, NAR is a clinical diagnosis, so nasal cytology is not required. (Choice D) A serum radioallergosorbent test (RAST) can be helpful for identifying triggers in patients with allergic rhinitis. However, it is not usually helpful in patients with NAR because the results are typically negative; therefore, skin allergy or serum RAST testing is usually considered only if there is inadequate response to empiric treatment. (Choice E) Serum IgE levels are usually elevated in allergic rhinitis but not in NAR. Educational objective: Nonallergic rhinitis usually presents with nasal congestion and rhinorrhea without specific allergic triggers. Patients should be treated with intranasal glucocorticoids; intranasal antihistamines can be added if needed. References: Chapter 6: nonallergic rhinitis. (http://www.ncbi.nlm.nih.gov/pubmed/22794679)

A 23-Year-Old Woman Comes to the Office Due to Nasal