Rhinitis medicamentosa (or RM ) is the condition of a nasal congestion caused by extensive use of topical decongestants (eg, oxymetazoline, phenylephrine, xylometazoline, and naphazoline nose spray) certain oral agents (eg, sympathomimetic amines and various 2-imidazolines) that constrict blood vessels in the lining of the nose.
Video Rhinitis medicamentosa
Presentations
The typical presentation of RM involves nasal congestion without rhinorrhea, postnasal drip, or sneezing following a few days of decongestant use. This condition usually occurs after 5-7 days of use of topical decongestants. Patients often try to improve both the dose and frequency of the nasal spray at the beginning of RM, aggravating the condition. Swelling of the nasal passages caused by a rebounding congestion may eventually lead to permanent konka hyperplasia, which can block nasal breathing until surgery.
Maps Rhinitis medicamentosa
Pathophysiology
The pathophysiology of RM is not clear, although several mechanisms involving norepinephrine signaling have been proposed. RM is associated with histologic changes that include: increased number of lymphocytes and fibroblasts, epithelial cell sequencing, epithelial edema, goblet cell hyperplasia, increased expression of epidermal growth factor receptor, increased mucus production, nasociliary loss, inflammatory cell infiltration, and squamous cell metaplasia.
Direct acting sympathomimetic amines, such as phenylephrine, stimulate alpha adrenergic receptors, while mixed-agent agents, such as pseudoephedrine, can stimulate alpha and beta adrenergic receptors directly and indirectly by releasing norepinephrine from the sympathetic nerve terminals. Initially, the vasoconstriction effect of the alpha receptor dominates, but by continuing to use alpha agonists, this effect fades first, allowing vasodilation because beta-receptor stimuli arise.
2-Imidazoline derivatives, such as oxymetazoline, may participate in negative feedback on endogenous norepinephrine production. Therefore, after termination of long-term use, there will be inadequate sympathetic vasoconstriction in the nasal mucosa, and the dominance of parasympathetic activity may result in increased nasal secretion and edema. Evidence suggests that if oxymetazoline is used only every night for allergic rhinitis (not more frequent doses because it can be directed to product labels), it may be used for more than a week without the high risk of medicamentous rhinitis especially with the use of intranasal steroids such as fluticasone furoate..
Treatment
RM treatment involves withdrawal of nasal sprays or offensive oral medications. Both the "cold turkey" and the "weaning" approach can be used. Cold turkey is the most effective treatment method, since it directly eliminates the cause of the condition, but the time period between drug withdrawal and symptom relief may be too long and uncomfortable for some individuals (especially when trying to go to sleep when they can not breathe through their nose).
The benefit of the gradual "weaning" approach is to help maintain normal nasal flow during the withdrawal process. US Pat. No. 5,988,870 is issued for methods and equipment used to facilitate appropriate titrations and the gradual withdrawal of a decongestant nasal spray containing an addictive compound. The system is sold under the Rhinostat trademark
The use of over-the-counter saline nose spray (OTC) may help open the nose without causing RM if the spray does not contain decongestants. <8> Symptoms of stuffed and runny nose can often be treated with corticosteroid nasal spray under the supervision of a physician. For very severe cases, oral steroids or nasal surgery may be necessary.
For RM caused by topical decongestants, there are reports of anecdotes of people who experience success by pulling care from one nostril at a time. [1] [9]
A study has shown that the anti-infective agent benzalkonium chloride, which is often added to topical nasal sprays as a preservative, aggravates the condition by increasing the swelling of the rebound. [10]
Cause
Common problems that cause overuse of topical decongestants:
- Deviated septum
- Upper respiratory tract infection
- Vasomotor rhinitis
- Cocaine use and other stimulant abuse
- Pregnancy (this product is not considered safe for pregnancy)
- Chronic rhinosinusitis
- Hypertrophy of inferior turbine
See also
- Topical decongestants
References
Further reading
- Bernstein IL: Is using benzalkonium chloride as a preservative for nasal formulation a security issue? J Allergy Clin Immunol 2000 Jan; 105 (1 Pt 1): 39-44.
- Black MJ, Remsen KA: Rhinitis medicamentosa. Can Med Assoc J 1980 Apr 19; 122 (8): 881-4.
- Brunton L, Parker K, Blumenthal D, Buxton I (2008) Goodman & amp; Manuel Manuel Pharmacology and Therapeutic Gilman, Chapter 10, Adrenergic Agencies and Antagonists, McGraw-Hill, New York.
- Elwany SS, Stephanos WM: Rhinitis medicamentosa. A histopathological and experimental histochemical study. ORL J Otorhinolaryngol Relat Spec 1983; 45 (4): 187-94.
- Fleece L, Mizes JS, Jolly PA, Baldwin RL: Rhinitis medicamentosa. Conceptualization, incidence, and treatment. Ala J Med Sci 1984 Apr; DA - 19840716 (2): 205-8.
- Graph P: Adverse effects of benzalkonium chloride on the nasal mucosa: allergic rhinitis and medicamentous rhinitis. Clin Ther October 1999; 21 (10): 1749-55.
- Graf P, Hallen H, Juto JE: Benzalkonium chloride in decongestant nasal sprays aggravates medicamentous rhinitis in healthy volunteers. Clin Exp Allergy 1995 May; 25 (5): 395-400.
- Lin CY, Cheng PH, Fang SY: Mucosal changes in medicamentous rhinitis. Ann Otol Rhinol Laryngol 2004 Feb; 113 (2): 147-51.
- Mabry RL: Rhinitis medicamentosa: a forgotten factor in nasal congestion. South Med J 1982 July; 75 (7): 817-9.
- Wang JQ, Bu GX: Study of rhinitis medicamentosa. Chin Med J (Engl) 1991 Jan; 104 (1): 60-3.
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