Rhinitis medicamentosa

A sleep clinician's guide to runny noses: evaluation and management of chronic rhinosinusitis to improve sleep apnea care in adults

STUDY OBJECTIVES

The treatment of obstructive sleep apnea is often impeded by intolerance of positive airway pressure therapy, which is frequently attributed to the inability to breathe through the nose. Providers caring for patients with sleep apnea need a working knowledge of nasal passage disease and available treatments to better manage this common comorbidity.

METHODS

This review examines the literature connecting rhinosinusitis to adverse sleep and sleep apnea outcomes. It explores the different types of nasal and sinus diseases a sleep apnea provider might encounter, focusing on the medications used to treat them and indications for referral to otolaryngology.

RESULTS

Chronic rhinosinusitis can be either allergic or nonallergic. Both types can interfere with sleep and sleep apnea therapy. The successful management of chronic rhinosinusitis can improve positive airway pressure tolerance and adherence. A wide range of over-the-counter and prescription pharmacotherapy is available, with data supporting intranasal over oral treatment. Surgical treatment for chronic rhinosinusitis in obstructive sleep apnea addresses nasal obstruction, often with inferior turbinate reduction and septoplasty.

CONCLUSIONS

Sleep specialists should have a working knowledge of the available options to treat chronic rhinosinusitis. These options are often safe, effective, and readily accessible. Otolaryngologists and allergists/immunologists provide additional treatment options for more complicated patients. Providing treatment for chronic rhinosinusitis should be included as part of comprehensive sleep apnea care.

CITATION

Ali MM, Ellison M, Iweala OI, Spector AR. A sleep clinician's guide to runny noses: evaluation and management of chronic rhinosinusitis to improve sleep apnea care in adults. J Clin Sleep Med. 2023;19(8):1545-1552.

The Nose as a Route for Therapy: Part 1. Pharmacotherapy

This article reviews nasal structure and function in the light of intranasal pharmacotherapy. The nose provides an accessible, fast route for local treatment of nose and sinus diseases, with lower doses than are necessary systemically and few adverse effects. It can also be used for other medications as it has sufficient surface area protected from local damage by mucociliary clearance, absence of digestive enzymes, responsive blood flow, and provides a rapid route to the central nervous system.

[Rhinitis medicamentosa]

One type of non-allergic non-infectious rhinitis is represented by a heterogeneous group of rhinitis medicamentosa, which can be divided into several pathogenetic types. The most common rebound nasal congestion associated with the use of topical decongestants. Excessive use of intranasal decongestants leads to a decrease in the number of alpha-adrenoreceptors on the surface of cell membranes and uncoupling their connection with the G-protein and the development of tachyphylaxis. To prevent the development of rebound nasal congestion caused by topical decongestants, it is important to limit the frequency of their use. In most cases, the duration of the use of vasoconstrictor drugs should be limited to 5-7 days, according to Patient information leaflets for the drugs. However, in patients who have had a history of episodes of rebound nasal congestion, which develops including the previously indicated periods, the duration of decongestant therapy should be limited to 3 days. Rhinitis associated with local inflammation is caused by the intake of acetylsalicylic acid (ASA) or other non-steroidal anti-inflammatory drugs. Currently, the so-called "aspirin triad" is well known - a combination of bronchial asthma, rhinosinusitis (often polyposis) and intolerance to ASA. Neurogenic rhinitis develops due to the use of drugs that violate vascular tone, for example, antihypertensive drugs or type 5 phosphodiesterase inhibitors. Drug-induced rhinitis has a significant impact on the patient's quality of life: nasal congestion, rhinorrhea, secondary night apnea, insomnia as a result of nasal breathing disturbances, headaches, irritability, weakness after sleepless nights disturb patients to a large extent. Timely diagnosis and withdrawal of a provocative drug, the use of topical corticosteroids in case of severe rhinitis are the basis of the treatment of rhinitis medicamentosa. In severe cases, there is a need, including surgical treatment, such as, for example, submucosal laser destruction of the lower nasal concha.

BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (Revised Edition 2017; First edition 2007)

This is an updated guideline for the diagnosis and management of allergic and non-allergic rhinitis, first published in 2007. It was produced by the Standards of Care Committee of the British Society of Allergy and Clinical Immunology, using accredited methods. Allergic rhinitis is common and affects 10-15% of children and 26% of adults in the UK, it affects quality of life, school and work attendance, and is a risk factor for development of asthma. Allergic rhinitis is diagnosed by history and examination, supported by specific allergy tests. Topical nasal corticosteroids are the treatment of choice for moderate to severe disease. Combination therapy with intranasal corticosteroid plus intranasal antihistamine is more effective than either alone and provides second line treatment for those with rhinitis poorly controlled on monotherapy. Immunotherapy is highly effective when the specific allergen is the responsible driver for the symptoms. Treatment of rhinitis is associated with benefits for asthma. Non-allergic rhinitis also is a risk factor for the development of asthma and may be eosinophilic and steroid-responsive or neurogenic and non- inflammatory. Non-allergic rhinitis may be a presenting complaint for systemic disorders such as granulomatous or eosinophilic polyangiitis, and sarcoidoisis. Infective rhinitis can be caused by viruses, and less commonly by bacteria, fungi and protozoa.

[Medically-induced rhinitis]

This paper summarizes the currently accepted concepts of the pathogenetic mechanisms underlying the morphological and functional changes in intranasal mucosa of the patients having a long history of the application of the long-acting topical vasoconstrictor agents. The author presents the data illustrating the effectiveness of various methods for the pharmacotherapeutic treatment of medically-induced rhinitis.

Correlation Between the Septal Body and the Nasal Turbinates in Patients With Deviated Nasal Septum

OBJECTIVE

The purpose of this study was to evaluate the degree of deviation and the sizes of nasal turbinates and the septal body (SB) on each side separately and to compare the 2 sides, and to evaluate if there is a correlation between SB size and middle and inferior turbinate (IT) sizes on each side.

MATERIAL AND METHODS

A retrospective analysis was made of paranasal computerized tomography scans obtained randomly from the database. Computerized tomography was performed at 120 kVp and 100 mA with 2 mm slice thickness. The study comprised 199 paranasal computerized tomography scans on each of which the width of the SB, the degree of deviation, and the width of the inferior and middle turbinates (MTs) were measured on each side separately.

RESULTS

In cases of moderate and severe deviation, the sizes of the SB, the MT, and IT contralateral to the deviation were statistically significantly larger than those on the ipsilateral side (P < 0.001). There was a negative correlation between SB size and the MT and IT sizes in each nasal cavity.

CONCLUSIONS

The SB is a dynamic structure and may play a role in regulation of nasal airflow.

Nasal septal turbinate: cadaveric study

BACKGROUND

Despite the importance of its location, the functional behavior of the nasal septal turbinate (NST) is still not completely understood. Basic histological knowledge is still lacking. The aim of this study was to describe the histological features of the NST and to compare its morphometric features to those of the adjacent nasal septum and the inferior and middle turbinates.

METHODS

The study included 50 fresh cadavers. Excisional biopsy specimens of the NST with adjacent posterior septum were collected. In addition, mucosal and submucosal biopsy specimens were taken of the inferior and middle turbinates. Morphometric analysis was performed on five different tissue types: glandular elements, connective tissue stroma, arterial structures, and capillary or venous sinusoids.

RESULTS

The mean proportion of venous sinusoids was statistically lower in the nasal septum and NST than in the inferior and middle turbinate. The mean proportion of glandular tissues was higher in the NST than in other regions of the nasal cavity. The mean proportion of arterial tissue was lower in the nasal septum and the NST. Significantly fewer capillary elements were found in the inferior and middle turbinates than in the nasal septum and NST. The mean proportion of connective tissues was lower in the NST than in other regions of the nasal cavity.

CONCLUSION

The similar histopathological cell distribution in the middle and inferior turbinate supported a function as an erectile organ, but the findings for the NST pointed to different functional properties of this region.

Current and future directions in pediatric allergic rhinitis

BACKGROUND

Allergic rhinitis (AR) is a common pediatric problem that significantly affects sleep, learning, performance, and quality of life. In addition, it is associated with significant comorbidities and complications.

OBJECTIVE

The aim was to provide an update on the epidemiology, comorbidities, pathophysiology, current treatment, and future direction of pediatric AR.

METHODS

Literature reviews in each of these areas were conducted, and the results were incorporated.

RESULTS

The prevalence of AR is increasing in the pediatric population and is associated with significant morbidity, comorbidities, and complications. The mainstay of current treatment strategies includes allergen avoidance, pharmacotherapy, and allergen specific immunotherapy.

CONCLUSIONS

In the future, diagnosis will be improved by microarrayed recombinant allergen testing and therapy will be expanded to include emerging treatments such as sublingual immunotherapy and combination products.

12 minute consultation: a patient with nasal crusting

BACKGROUND

Nasal crusting is frequently encountered by the otorhinolaryngologist and often requires no specific treatment. It is, however, important to carry out a full history and examination, followed by appropriate investigations, in order to detect the small number of cases in which crusting is caused by systemic or malignant disease.

METHODS

This review was based on a literature search last performed on 30th July 2009. The MEDLINE, EMBASE and Cochrane databases were searched using the subject headings (nasal crusting OR crusts) and in combination with diagnosis, therapy and surgery. Similar searches were performed for relevant diseases, e.g. Wegener's granulomatosis, sarcoidosis. Results were limited to English language articles including clinical trials, meta-analyses, systematic reviews and review articles. Relevant references from selected articles were reviewed.

RESULTS

Knowledge of the causes of nasal crusting will help to target the history, examination and investigation of patients with this condition. Screening tests for systemic conditions can be useful but most have limited sensitivity and must be interpreted cautiously. Nasal septal biopsy is indicated when there is a suspicion of malignancy, or to support a suspected diagnosis of vasculitis. The treatment offered depends upon the cause of crusting and the severity of symptoms.

CONCLUSION

A careful and thorough history and examination, and targeted investigation, of the patient with nasal crusting will ensure correct diagnosis and treatment of patients with this common condition.

The Nasal Decongestant Effect of Xylometazoline in the Common Cold

Background

Xylometazoline is a nasal decongestant spray that constricts nasal blood vessels and increases nasal airflow, enabling patients with a blocked nose to breathe more easily. The purpose of this study was to characterize objectively and subjectively the decongestant and additional effects of xylometazoline in the common cold.

Methods

A double-blind, placebo-controlled, parallel group study was performed. Patients with a common cold (n = 61) were treated with xylometazoline 0.1% (n = 29) or placebo (saline solution; n = 32; 1 spray three times a day for up to 10 days). The primary objective was to determine the decongestant effect (nasal conductance); the secondary objectives were to determine the peak subjective effect (visual analog scale), duration of relief of nasal congestion, total and individual cold symptoms and general well-being (patients’ daily diary), and adverse events (AEs).

Results

The decongestant effect of xylometazoline was significantly greater than placebo, as shown by the nasal conductance at 1 hour (384.23 versus 226.42 cm3/s; p ≤ 0.0001) and peak subjective effect (VAS, 20.7 mm versus 31.5 mm; p = 0.0298). Nasal conductance was significantly superior for up to 10 hours (p = 0.0009) and there was a trend in favor of xylometazoline for up to 12 hours (not statistically significant). Xylometazoline significantly improved total and some individual common cold symptoms scores (p < 0.05), leading to significantly greater patient general evaluation and satisfaction with treatment (p < 0.05). Nineteen AEs were reported: 8 with xylometazoline (all mild-moderate) and 11 with placebo (1 severe).

Conclusion

Xylometazoline is an effective and well-tolerated decongestant nasal spray that significantly relieved nasal congestion compared with placebo in the common cold and provided long-lasting relief with just 1 spray, helping patients to breathe more easily for a longer period of time.

BSACI guidelines for the management of allergic and non-allergic rhinitis

This guidance for the management of patients with allergic and non‐allergic rhinitis has been prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI). The guideline is based on evidence as well as on expert opinion and is for use by both adult physicians and paediatricians practicing in allergy. The recommendations are evidence graded. During the development of these guidelines, all BSACI members were included in the consultation process using a web‐based system. Their comments and suggestions were carefully considered by the SOCC. Where evidence was lacking, consensus was reached by the experts on the committee. Included in this guideline are clinical classification of rhinitis, aetiology, diagnosis, investigations and management including subcutaneous and sublingual immunotherapy. There are also special sections for children, co‐morbid associations and pregnancy. Finally, we have made recommendations for potential areas of future research.

BSACI guidelines for the management of rhinosinusitis and nasal polyposis

This guidance for the management of patients with rhinosinusitis and nasal polyposis has been prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI). The recommendations are based on evidence and expert opinion and are evidence graded. These guidelines are for the benefit of both adult physicians and paediatricians treating allergic conditions. Rhinosinusitis implies inflammation of the nose and sinuses which may or may not have an infective component and includes nasal polyposis. Acute rhinosinusitis lasts up to 12 weeks and resolves completely. Chronic rhinosinusitis persists over 12 weeks and may involve acute exacerbations. Rhinosinusitis is common, affecting around 15% of the population and causes significant reduction in quality of life. The diagnosis is based largely on symptoms with confirmation by nasendoscopy. Computerized tomography scans and magnetic resonance imaging are abnormal in approximately one third of the population so are not recommended for routine diagnosis but should be reserved for those with acute complications, diagnostic uncertainty or failed medical therapy. Underlying conditions such as immune deficiency, Wegener's granulomatosis, Churg-Strauss syndrome, aspirin hypersensitivity and allergic fungal sinusitis may present as rhinosinusitis. There are few good quality trials in this area but the available evidence suggests that treatment is primarily medical, involving douching, corticosteroids, antibiotics, anti-leukotrienes, and anti-histamines. Endoscopic sinus surgery should be considered for complications, anatomical variations causing local obstruction, allergic fungal disease or patients who remain very symptomatic despite medical treatment. Further well conducted trials in clearly defined patient groups are needed to improve management.

Nasal congestion: mechanisms, measurement and medications. Core information for the clinician

The article provides the clinician with core information about the aetiology and treatment of nasal congestion and discusses nasal blood vessels, autonomic nerves, nasal cycle, effects of posture, subjective sensation of congestion, objective assessments of congestion and medical and surgical treatments.

Mucosal changes in rhinitis medicamentosa

To evaluate the nasal mucosal changes in rhinitis medicamentosa (RM), especially those related to goblet cells and subepithelial glands, we studied specimens of the inferior turbinate mucosa from 8 patients with RM, 8 patients with chronic hypertrophic rhinitis (CHR), and 5 patients with normal nasal mucosa. All specimens were assessed by electron microscopy and immunohistochemical study. Under a scanning electron microscope, hyperplasia of goblet cells was most prominent in the RM group, and an increased number of gland openings was evident in the RM and CHR groups. In addition, the immunoreactivity of epidermal growth factor receptor staining was strongest in the hyperplastic epithelium of the RM group. According to our results, it is feasible that the mucosa of patients with RM is in a chronic inflammatory, hypersecretory state. Degenerative changes in the secretory elements may cause impairment of mucociliary transport and may be responsible for the nasal obstruction and posterior nasal drip in RM.

Evidence-based treatment of allergic rhinitis

Allergic rhinitis is an extremely common disease worldwide, affecting 10% to 50% of the population. An increasing prevalence of allergic rhinitis over the past decades and its frequent association with asthma have raised concerns about treating the disease appropriately. New knowledge of the pathophysiologic mechanisms underlying allergic inflammation of the airways has resulted in the development of newer and better therapeutic strategies. This review focuses on evidence-based treatment of allergic rhinitis, highlighting the most recent international consensus and evidence-based guidelines on allergic rhinitis.

Toxicity of drugs used for treatment of rhinitis: a reminder to the otorhinolaryngologist

We retrospectively studied files on toxicity of drugs used for treatment of rhinitis (nasal antihistamines, oral antihistamines, nasal vasoconstrictors, oral decongestants, nasal corticosteroids, nasal anticholinergic agent, nasal mast cell stabilizer, and respiratory antigen preparations for oral use) that occurred in São Paulo, Brazil, from 1 July 1996 to 30 June 1998. There were 823 cases of toxicity by these agents, with a predominance of oral decongestants (in combination with antihistamines) (53.4%). There was a significant incidence of toxicity within children aged 1 to 4 years (P < 0.05) and a preponderance among males aged 5-9 years and females aged 10-39 years. Accidental intake of medicines accounted for the majority of toxicity cases (57.2%).

Diagnosis and management of rhinitis: complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology. American Academy of Allergy, Asthma, and Immunology

This document contains complete guidelines for diagnosis and management of rhinitis developed by the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology, representing the American Academy of Allergy, Asthma and Immunology, the American College of Allergy, Asthma and Immunology and the Joint Council on Allergy, Asthma and Immunology. The guidelines are comprehensive and begin with statements on clinical characteristics and diagnosis of different forms of rhinitis (allergic, non-allergic, occupational rhinitis, hormonal rhinitis [pregnancy and hypothyroidism], drug-induced rhinitis, rhinitis from food ingestion), and other conditions that may be confused with rhinitis. Recommendations on patient evaluation discuss appropriate use of history, physical examination, and diagnostic testing, as well as unproven or inappropriate techniques that should not be used. Parameters on management include use of environmental control measures, pharmacologic therapy including recently introduced therapies and allergen immunotherapy. Because of the risks to patients and society from sedation and performance impairment caused by first generation antihistamines, second generation antihistamines that reduce or eliminate these side effects should usually be considered before first generation antihistamines for the treatment of allergic rhinitis. The document emphasizes the importance of rhinitis management for comorbid conditions (asthma, sinusitis, otitis media). Guidelines are also presented on special considerations in patients subsets (children, the elderly, pregnancy, athletes and patients with rhinitis medicamentosa); and when consultation with an allergist-immunologist should be considered.

Nasal mucociliary clearance as a factor in nasal drug delivery

The nasal mucociliary clearance system transports the mucus layer that covers the nasal epithelium towards the nasopharynx by ciliary beating. Its function is to protect the respiratory system from damage by inhaled substances. Impairment of nasal mucociliary clearance can result in diseases of the upper airways. Therefore, it is important to study the effects of drugs and drug excipients on nasal mucociliary clearance. A large number of methods are used to assess mucociliary clearance. These methods study the effects of drug and excipients on the mucociliary system in vitro or in vivo in animals and humans. In some cases, the results of different in vitro and in vivo measurements do not correlate well. In vitro methods, especially ciliary beat frequency measurements, have been demonstrated to be valuable tools for toxicity screening. However, in vivo studies are essential to confirm the safety of nasal drug formulations. Nasal mucociliary clearance also has implications for nasal drug absorption. Drugs are cleared rapidly from the nasal cavity after intranasal administration, resulting in fast systemic drug absorption. Several approaches are discussed to increase the residence time of drug formulations in the nasal cavity, resulting in improved nasal drug absorption. However, more experimental evidence is needed to support the conclusion that this improved absorption is caused by a longer residence time of the nasal drug formulation.

One year follow-up of patients with rhinitis medicamentosa after vasoconstrictor withdrawal

The aim of the study was to systematically follow-up 10 patients with rhinitis medicamentosa for at least 1 year after vasoconstrictor withdrawal. During withdrawal of the decongestants the patients used budesonide nasal spray, 400 micrograms/day, for 6 weeks. The thickness of the nasal mucosa, the decongestive effect of oxymetazoline, and the histamine sensitivity were measured with rhinostereometry during the period. The thickness of the nasal mucosa and the symptom scores of nasal stuffiness were reduced considerably 6 and 12 months after vasoconstrictor withdrawal. The histamine sensitivity reflecting nasal hyperreactivity was still increased after 6 months, but not after 1 year. The decongestive effect of oxymetazoline increased after 6 months, indicating reversible tolerance. We conclude that when given adequate treatment and information about nose-drop overuse, all patients were able to stop using the vasoconstrictors and no one relapsed into a daily long-term overuse of vasoconstrictors during the 1-year follow-up period.