A 32-year-old woman comes to the physician complaining of one year of nasal congestion and runny nose. She also feels mucus dripping down her throat that sometimes makes her cough. She has tried over-the-counter saline spray with mild relief. The patient cannot identify any precipitating factors and feels that her nasal passages are constantly blocked. Physical examination shows boggy-appearing nasal turbinates with mild erythema. Which of the following is the best next step in management of this patient?

Question

A 32-year-old woman comes to the physician complaining of one year of nasal congestion and runny nose.  She also feels mucus dripping down her throat that sometimes makes her cough.  She has tried over-the-counter saline spray with mild relief.  The patient cannot identify any precipitating factors and feels that her nasal passages are constantly blocked.  Physical examination shows boggy-appearing nasal turbinates with mild erythema.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bea9_eb85_8f63_0302ddd091e2_MD0005_00 This patient's presentation is consistent with chronic rhinitis, which can be allergic or nonallergic. Allergic rhinitis (AR) typically presents at an earlier age (<20) with predominant eye symptoms (eg, watery eyes), sneezing, nasal congestion, and watery rhinorrhea. Patients usually can identify a trigger (eg, animals, pollen) with seasonal or year-round symptoms. There is also an increased association with other allergic conditions (eg, eczema, asthma). Physical examination can show normal or pale blue nasal mucosa with pallor and occasionally shows polyps. Treatment involves allergen avoidance and topical intranasal glucocorticoids for symptomatic relief. Nonallergic rhinitis (NAR) typically presents after age 20 with nasal blockage, rhinorrhea, and postnasal drip. Patients have limited eye symptoms and are usually unable to identify a clear trigger. Although symptoms may worsen during seasonal changes, they can occur throughout the year. The nasal mucosa can appear normal or boggy and erythematous on examination. NAR is less commonly associated with other allergic conditions. This patient's predominant nasal congestion and postnasal drip without clear triggers are more consistent with NAR. Treatment includes topical intranasal glucocorticoids (eg, fluticasone) or intranasal antihistamine (eg, azelastine). Patients with more severe symptoms may require combination therapy. (Choices A and E) Allergy skin testing is not required for diagnosing AR or differentiating AR from NAR in patients such as this with characteristic clinical findings. Allergen-specific IgE antibodies provide similar information to allergy skin testing but are more expensive and less sensitive for diagnosing inhalant allergies. These tests are generally reserved for differentiating between NAR and AR in patients who do not respond to initial treatment or in those being considered for immunotherapy. (Choice C) Intranasal ipratropium bromide is helpful for patients with rhinorrhea without other symptoms. It is less effective than intranasal glucocorticoids, especially in those with significant nasal congestion or postnasal drip. (Choice D) Chlorpheniramine is a first-generation H1 antihistamine with anticholinergic properties that can relieve postnasal drip and rhinorrhea. However, it is sedating and generally not used as first-line therapy. Educational objective: Nonallergic rhinitis typically presents after age 20 with nasal blockage, rhinorrhea, and postnasal drip. Patients have limited eye symptoms, are unable to identify a clear trigger, and can have symptoms throughout the year. Treatment includes topical intranasal glucocorticoids (eg, fluticasone) or intranasal antihistamines (eg, azelastine). References: Chapter 6: Nonallergic rhinitis. (http://www.ncbi.nlm.nih.gov/pubmed/22794679) Comparison of clinical differences between patients with allergic rhinitis and nonallergic rhinitis. (http://www.ncbi.nlm.nih.gov/pubmed/24057906)

A 32-Year-Old Woman Comes to the Physician Complaining of One