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Rhinitis medicamentosa
	Classification and external resources
ICD-9	472.0
DiseasesDB	11545
eMedicine	article/995056

Rhinitis medicamentosa (or RM) is a condition of rebound nasal congestion brought on by extended use of topical decongestants (e.g., oxymetazoline, phenylephrine, xylometazoline, and naphazoline nasal sprays) that work by constricting blood vessels in the lining of the nose.

[edit] Presentation

This condition typically occurs after 5 to 7 days of use of such medications. Patients often try increasing both the dose and the frequency of nasal sprays upon the onset of RM, worsening the condition. The swelling of the nasal passages caused by rebound congestion may eventually result in permanent turbinate hyperplasia which may block nasal breathing until surgically removed.^[1]

[edit] Pathophysiology

Topical nasal sprays act as an agonist to sympathetic α1 receptors in the blood vessels of the nose, signaling those vessels to contract. By decreasing blood flow to the lining of the nose, the tissue becomes less congested and mucous production is slowed. However, after several days' use of these products these receptors become downregulated, requiring more frequent and higher doses to prevent the rebound congestion that results when the medicine wears off.

[edit] Treatment

The treatment of RM involves withdrawal of the offending nasal spray. Both a "cold turkey" and a "weaning" approach can be used. Symptoms of congestion and runny nose can often be temporized or neutralised with anti-inflammatories by using prescription nasal steroid sprays 1 to 2 times daily for a few weeks. For very severe cases oral steroids may be necessary, such as Prednisolone (e.g. 30mg od, 5/7). Oral decongestant medications like pseudoephedrine can also help with the transition.

Other commercially available products such as Rhinostat may help ease withdrawal from physiological tolerance to the nasal decongestant by providing an easy means to dilute the spray gradually.^{[citation needed]} There are anecdotal reports of persons having success withdrawing, by withdrawing treatment from one nostril at a time.^[2]

A study has shown that the anti-infective agent benzalkonium chloride, which is frequently added to topical nasal sprays, aggravates the condition by further increasing the rebound swelling. ^[3]

[edit] Causes

Common issues that lead to overuse of topical decongestants:

Deviated septum
Upper respiratory tract infection
Vasomotor rhinitis
Cocaine use
Pregnancy (these products are not considered safe for pregnancy)
Chronic rhinosinusitis
Hypertrophy of the Inferior Turbinates

[edit] See also

Topical decongestant

[edit] References

^ Rhinitis Medicamentosa, morbidity
^ Saltus, Richard (March 14, 2006), "Nasal Sprays Can Bring on Vicious Cycle", New York Times, http://www.nytimes.com/2006/03/14/health/14spra.html
^ Benzalkonium chloride in a decongestant nasal spray aggravates rhinitis medicamentosa in healthy volunteers Graf P., Hallen H., Juto JE., Clin Exp Allergy, 1995; 25 (5):395-400.

[edit] Further reading

Bernstein IL: Is the use of benzalkonium chloride as a preservative for nasal formulations a safety concern? 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.
Elwany SS, Stephanos WM: Rhinitis medicamentosa. An experimental histopathological and 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.
Graf P: Adverse effects of benzalkonium chloride on the nasal mucosa: allergic rhinitis and rhinitis medicamentosa. Clin Ther 1999 Oct; 21(10): 1749-55.
Graf P, Hallen H, Juto JE: Benzalkonium chloride in a decongestant nasal spray aggravates rhinitis medicamentosa in healthy volunteers. Clin Exp Allergy 1995 May; 25(5): 395-400.
Lin CY, Cheng PH, Fang SY: Mucosal changes in rhinitis medicamentosa. Ann Otol Rhinol Laryngol 2004 Feb; 113(2): 147-51.
Mabry RL: Rhinitis medicamentosa: the forgotten factor in nasal obstruction. South Med J 1982 Jul; 75(7): 817-9.
Wang JQ, Bu GX: Studies of rhinitis medicamentosa. Chin Med J (Engl) 1991 Jan; 104(1): 60-3.

[0] Rhinitis Medicamentosa, morbidity

[1] Saltus, Richard (March 14, 2006), "Nasal Sprays Can Bring on Vicious Cycle", New York Times, http://www.nytimes.com/2006/03/14/health/14spra.html

[2] Benzalkonium chloride in a decongestant nasal spray aggravates rhinitis medicamentosa in healthy volunteers Graf P., Hallen H., Juto JE., Clin Exp Allergy, 1995; 25 (5):395-400.

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