Rhinitis medicamentosa
Encyclopedia
Rhinitis medicamentosa is a condition of rebound
nasal congestion
brought on by extended use of topical decongestant
s (e.g., oxymetazoline
, phenylephrine
, xylometazoline
, and naphazoline
nasal spray
s) that work by constricting blood vessels in the lining of the nose.
hyperplasia
, which may block nasal breathing until surgically removed.
Sympathomimetic amine
s, such as phenylephrine
and pseudoephedrine
, stimulate both alpha and beta adrenergic receptor
s. At first, the vasoconstrictive effect of alpha-receptors dominates. This effect fades first, allowing the vasodilation
due to beta-receptor stimulation to emerge.
Imidazolamine derivatives, such as oxymetazoline
, may participate in negative feedback
on endogenous
norepinephrine
production. Therefore, after cessation of prolonged use, there will be inadequate sympathetic
vasoconstriction in the nasal mucosa, and domination of parasympathetic activity can result in increased secretions and nasal edema
.
However, if oxymetazoline
is used only nightly for allergic rhinitis
, it can be used longer than one week without risk of rhinitis medicamentosa.
" and a "weaning" approach can be used. Symptoms of congestion and runny nose can often be treated with corticosteroid nasal sprays under the supervision of a physician. For very severe cases, oral steroids may be necessary. Oral decongestant medications like pseudoephedrine
can also help with the transition.
There are anecdotal reports of persons having success withdrawing, by withdrawing treatment from one nostril at a time.
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.
s:
Rebound effect
The rebound effect, or rebound phenomenon, is the tendency of some medications, when discontinued suddenly, to cause a return of the symptoms it relieved, and that, to a degree stronger than they were before treatment first began...
nasal congestion
Nasal congestion
Nasal congestion is the blockage of the nasal passages usually due to membranes lining the nose becoming swollen from inflamed blood vessels. It is also known as nasal blockage, nasal obstruction, blocked nose, stuffy nose, or stuffed up nose.Nasal congestion has many causes and can range from a...
brought on by extended use of topical decongestant
Topical decongestant
Topical decongestants are decongestants applied directly to the nasal cavity. By applying them directly to the site of action, topical decongestants relieve nasal congestion while reducing the side effects associated with systemically-acting decongestants, such as high blood pressure...
s (e.g., oxymetazoline
Oxymetazoline
Oxymetazoline is a selective alpha-1 agonist and partial alpha-2 agonist topical decongestant, used in the form of Oxymetazoline hydrochloride, in products such as Afrin, Dristan, Nasivin, Logicin, Vicks Sinex, Visine L.R., Sudafed OM, and Zicam. It was developed from Xylometazoline at E.Merck...
, phenylephrine
Phenylephrine
Phenylephrine is a selective α1-adrenergic receptor agonist used primarily as a decongestant, as an agent to dilate the pupil, and to increase blood pressure...
, xylometazoline
Xylometazoline
Xylometazoline is a drug which is used as a topical nasal decongestant. It is applied directly into the nose, either as a spray or as drops....
, and naphazoline
Naphazoline
Naphazoline is the common name for 2--2-imidazoline hydrochloride. It is a sympathomimetic agent with marked alpha adrenergic activity. It is a vasoconstrictor with a rapid action in reducing swelling when applied to mucous membrane...
nasal spray
Nasal spray
Nasal sprays come in a variety of forms. Medicated such as Astelin, Afrin and Nasonex and natural such as Sinusoothe and Sterimar. Although delivery methods vary, most nasal sprays function by instilling a fine mist into the nostril by action of a hand-operated pump mechanism.-Antihistamine nasal...
s) that work by constricting blood vessels in the lining of the nose.
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 turbinateTurbinate
In anatomy, a nasal concha is a long, narrow and curled bone shelf that protrudes into the breathing passage of the nose...
hyperplasia
Hyperplasia
Hyperplasia means increase in number of cells/proliferation of cells. It may result in the gross enlargement of an organ and the term is sometimes mixed with benign neoplasia/ benign tumor....
, which may block nasal breathing until surgically removed.
Pathophysiology
While the mechanism of RM is unclear, several theories have been proposed.Sympathomimetic amine
Amine
Amines are organic compounds and functional groups that contain a basic nitrogen atom with a lone pair. Amines are derivatives of ammonia, wherein one or more hydrogen atoms have been replaced by a substituent such as an alkyl or aryl group. Important amines include amino acids, biogenic amines,...
s, such as phenylephrine
Phenylephrine
Phenylephrine is a selective α1-adrenergic receptor agonist used primarily as a decongestant, as an agent to dilate the pupil, and to increase blood pressure...
and pseudoephedrine
Pseudoephedrine
Pseudoephedrine is a sympathomimetic drug of the phenethylamine and amphetamine chemical classes. It is used as a nasal/sinus decongestant and stimulant, or as a wakefulness-promoting agent....
, stimulate both alpha and beta adrenergic receptor
Adrenergic receptor
The adrenergic receptors are a class of metabotropic G protein-coupled receptors that are targets of the catecholamines, especially noradrenaline and adrenaline ....
s. At first, the vasoconstrictive effect of alpha-receptors dominates. This effect fades first, allowing the vasodilation
Vasodilation
Vasodilation refers to the widening of blood vessels resulting from relaxation of smooth muscle cells within the vessel walls, particularly in the large arteries, smaller arterioles and large veins. The process is essentially the opposite of vasoconstriction, or the narrowing of blood vessels. When...
due to beta-receptor stimulation to emerge.
Imidazolamine derivatives, such as oxymetazoline
Oxymetazoline
Oxymetazoline is a selective alpha-1 agonist and partial alpha-2 agonist topical decongestant, used in the form of Oxymetazoline hydrochloride, in products such as Afrin, Dristan, Nasivin, Logicin, Vicks Sinex, Visine L.R., Sudafed OM, and Zicam. It was developed from Xylometazoline at E.Merck...
, may participate in negative feedback
Negative feedback
Negative feedback occurs when the output of a system acts to oppose changes to the input of the system, with the result that the changes are attenuated. If the overall feedback of the system is negative, then the system will tend to be stable.- Overview :...
on endogenous
Endogenous
Endogenous substances are those that originate from within an organism, tissue, or cell. Endogenous retroviruses are caused by ancient infections of germ cells in humans, mammals and other vertebrates...
norepinephrine
Norepinephrine
Norepinephrine is the US name for noradrenaline , a catecholamine with multiple roles including as a hormone and a neurotransmitter...
production. Therefore, after cessation of prolonged use, there will be inadequate sympathetic
Sympathetic nervous system
The sympathetic nervous system is one of the three parts of the autonomic nervous system, along with the enteric and parasympathetic systems. Its general action is to mobilize the body's nervous system fight-or-flight response...
vasoconstriction in the nasal mucosa, and domination of parasympathetic activity can result in increased secretions and nasal edema
Edema
Edema or oedema ; both words from the Greek , oídēma "swelling"), formerly known as dropsy or hydropsy, is an abnormal accumulation of fluid beneath the skin or in one or more cavities of the body that produces swelling...
.
However, if oxymetazoline
Oxymetazoline
Oxymetazoline is a selective alpha-1 agonist and partial alpha-2 agonist topical decongestant, used in the form of Oxymetazoline hydrochloride, in products such as Afrin, Dristan, Nasivin, Logicin, Vicks Sinex, Visine L.R., Sudafed OM, and Zicam. It was developed from Xylometazoline at E.Merck...
is used only nightly for allergic rhinitis
Allergic rhinitis
Allergic rhinitis, also known as pollenosis or hay fever, is an allergic inflammation of the nasal airways.It occurs when an allergen, such as pollen, dust or animal dander is inhaled by an individual with a sensitized immune system...
, it can be used longer than one week without risk of rhinitis medicamentosa.
Treatment
The treatment of RM involves withdrawal of the offending nasal spray. Both a "cold turkeyCold turkey
"Cold turkey" describes the actions of a person who abruptly gives up a habit or addiction rather than gradually easing the process through gradual reduction or by using replacement medication....
" and a "weaning" approach can be used. Symptoms of congestion and runny nose can often be treated with corticosteroid nasal sprays under the supervision of a physician. For very severe cases, oral steroids may be necessary. Oral decongestant medications like pseudoephedrine
Pseudoephedrine
Pseudoephedrine is a sympathomimetic drug of the phenethylamine and amphetamine chemical classes. It is used as a nasal/sinus decongestant and stimulant, or as a wakefulness-promoting agent....
can also help with the transition.
There are anecdotal reports of persons having success withdrawing, by withdrawing treatment from one nostril at a time.
A study has shown that the anti-infective agent benzalkonium chloride
Benzalkonium chloride
Benzalkonium chloride, also known as alkyldimethylbenzylammonium chloride and ADBAC, is a mixture of alkylbenzyldimethylammonium chlorides of various even-numbered alkyl chain lengths. This product is a nitrogenous cationic surface-acting agent belonging to the quaternary ammonium group...
, which is frequently added to topical nasal sprays, aggravates the condition by further increasing the rebound swelling.
Causes
Common issues that lead to overuse of topical decongestantTopical decongestant
Topical decongestants are decongestants applied directly to the nasal cavity. By applying them directly to the site of action, topical decongestants relieve nasal congestion while reducing the side effects associated with systemically-acting decongestants, such as high blood pressure...
s:
- Deviated septumDeviated septumNasal septum deviation is a common physical disorder of the nose, involving a displacement of the nasal septum.-Causes:It is most frequently caused by impact trauma, such as by a blow to the face. It can also be a congenital disorder, caused by compression of the nose during childbirth...
- Upper respiratory tract infectionUpper respiratory tract infectionUpper respiratory tract infections are the illnesses caused by an acute infection which involves the upper respiratory tract: nose, sinuses, pharynx or larynx...
- Vasomotor rhinitis
- CocaineCocaineCocaine is a crystalline tropane alkaloid that is obtained from the leaves of the coca plant. The name comes from "coca" in addition to the alkaloid suffix -ine, forming cocaine. It is a stimulant of the central nervous system, an appetite suppressant, and a topical anesthetic...
use - PregnancyPregnancyPregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...
(these products are not considered safe for pregnancy) - Chronic rhinosinusitis
- Hypertrophy of the Inferior Turbinates
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.