Rhinitis medicamentosa

Rhinitis medicamentosa


A condition of rebound nasal congestion brought on by extended use of topical decongestants such as oxymetazoline, phenylephrine, xylometazoline, and naphazoline nasal sprays and certain oral medications, including sympathomimetic amines and various 2-imidazolines that may constrict blood vessels in the lining of the nose.

Presents as nasal congestion without rhinorrhea, postnasal drip, or sneezing following several days of decongestant use.

Typically occurs after 5–7 days of use of topical decongestants.

Often in an attempt to improve symptoms,an increase in both the dose and the frequency of nasal sprays worsens the condition.

The swelling of the nasal passages may result in permanent turbinate hypertrophy, which may block nasal breathing until surgically removed.

The overuse of topical decongestants is related to:

Deviated septum

Upper respiratory tract infection

Vasomotor rhinitis

Cocaine use and other stimulant abuse

Chronic rhinosinusitis

Hypertrophy of the inferior turbinates

It is associated with histological changes that include: an increase in the number of lymphocytes, fibroblasts, epithelial cell denudation, epithelial edema, goblet cell hyperplasia, increased expression of the epidermal growth factor receptor, increased mucus production, nasociliary loss, inflammatory cell infiltration, and squamous cell metaplasia.

Phenylephrine, a direct acting sympathomimetic amine stimulates alpha adrenergic receptors, while mixed-acting agents, such as pseudoephedrine can stimulate both alpha and beta adrenergic receptors directly and indirectly by releasing norepinephrine from sympathetic nerve terminals in the nasal mucosa.

Initially the vasoconstrictive effect of alpha-receptors dominate, but with continued use of an alpha agonist, vasodilation due to beta-receptor stimulation emerges.

Imidazoline derivatives, such as oxymetazoline, may provide a negative feedback on endogenous norepinephrine production.

Following cessation of prolonged use, there is inadequate sympathetic vasoconstriction and predominance of parasympathetic activity that can result in increased secretions and nasal edema.

Treatment of rhinitis medicamentosa involves withdrawal of the offending nasal spray or oral medication.

Immediate withdrawal is the most effective treatment method, but the relief of symptoms may be too long for some.

Gradual weaning preserves normal nasal airflow during the withdrawal process.

An apparatus is available to facilitate the precise titration and gradual withdrawal of decongestant nasal sprays containing physical dependence causing compounds: Rhinostat.

The use of over-the-counter (OTC) saline nasal sprays may help open the nose without causing RM if the spray does not contain a decongestant.

Symptoms of congestion and runny nose can often be treated with corticosteroid nasal sprays, and for very severe cases, oral steroids or nasal surgery may be necessary.

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