Rhinitis Medicamentosa: management with buffered saline irrigation
|Paul Schalch, MD.
Board certified Otolaryngologist – Head and Neck Surgeon.
Clinical assistant professor at Southern Illinois University School of Medicine.
About the author: Dr Schalch works at Southern Illinois Healthcare, in Carbondale, Illinois, and has a special interest in rhinology and sleep apnea surgery.
Rhinitis medicamentosa (RM) is a condition characterized by persistent congestion of the nasal passages due to diffuse inflammation of the nasal mucosa and hypertrophy of the inferior turbinates in patients who have abused over-the-counter topical decongestants containing phenylephrine and oxymethazoline, among others.
Typically, patients start using these decongestants to treat nasal congestion that commonly presents during allergy season, during a viral upper respiratory infection, while on continuous positive airway pressure (CPAP) for sleep apnea or to help with nasal congestion that presents at night, during exercise or after any nasal surgical procedure. Patients experience a so called “rebound congestion”, which occurs after using the over the counter decongestant for longer than 4-6 days, and then stopping it, which causes significant nasal obstruction that may be severe and long lasting (hours to days). This, in turn, causes continued use of the topical decongestant, thus creating a vicious cycle leading to dependency. This condition should not be confused with drug-induced rhinitis, which constitutes inflammation of the nose as a side-effect of systemic medications, such as anti-hypertensives, hormones or antidepressants, among others.
The persistent use of topical decongestants may lead to severe inflammation, crusting, hypertrophy of the inferior turbinates, loss of smell and sometimes even perforation of the nasal septum.
The mainstay of treatment of RM includes stopping the topical decongestant and making sure the patient does not restart it due to the severe rebound congestion (withdrawal period). Topical steroids have been proven useful during this transition period, as well as oral steroids for severe cases. An effective adjunct to this therapy is buffered saline solution in the form of nasal irrigation, which not only moisturizes the nasal mucosa, but provides medication-free, non-addicting decongestant relief. Patients can be kept on nasal saline irrigation for long-term periods without any concerns for side effects, and this has proven to be useful when it comes to preventing relapse (repeat use of topical decongestants).