WBR1085

Author	PageAuthor::Chetan Lokhande
Exam Type	ExamType::USMLE Step 2 CK
Main Category	MainCategory::Internal medicine
Sub Category	SubCategory::Allergy/Immunology, SubCategory::Head and Neck, SubCategory::Respiratory
Prompt	[[Prompt::A 26-year-old male who works in a college library comes to you with a complaint of running nose. He says that this is not the first time he had this symptoms. He sometimes also presents with a cough, nasal congestion and sneezing. He claims that his jobs requires cleaning the library shelf which usually has a lost of dust on it. On inquiry he said that the physician who saw him last time prescribed him with a medication, which after a few days made his running nose worse. What medication could it be?]]
Answer A	AnswerA::Topical steroids
Answer A Explanation	AnswerAExp::Topical steroids do not cause rebound congestion and are not used as a first line in allergic rhinitis.
Answer B	AnswerB::Topical decongestants
Answer B Explanation	AnswerBExp::Topical decongestants are the right choice since they cause rebound congestion after a few days of treatment . Prevention is by stopping the drug after 3 days.
Answer C	AnswerC::Topical antihistaminic
Answer C Explanation	AnswerCExp::Antihistaminics cause drying of the mucosa due to decreased histaminic secretion. They also do not cause rebound congestion after few days.
Answer D	AnswerD::Topical bronchodilators
Answer D Explanation	AnswerDExp::There are no indications to use topical bronchodilators in a case of allergic rhinitis.Topical bronchodilators should be used when the patients starts showing symptoms of asthma.
Answer E	AnswerE::Oral antibiotic
Answer E Explanation	AnswerEExp::Antibiotics are not routinely used in allergic rhinitis. They might be used only to prevent secondary bacterial infections in non responding cases.
Right Answer	RightAnswer::B
Explanation	[[Explanation::This is a clear case of 'Rhinitis medicamentosa'. The patient classically presents with a running nose which first improves after using topical decongestants but worsens aftera few days due to rebound congestion. This is a very common side-effect of topical decongestants. Rhinitis medicamentosa (or RM) is a condition of rebound nasal congestion brought on by extended use of topical decongestants (e.g. oxymetazoline, phenylephrine, and xylometazoline nasal sprays) that work by constricting blood vessels in the lining of the nose. 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 polyps that block nasal breathing until surgically removed. 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. 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 by using prescription nasal steroid sprays 1 to 2 times daily for a few weeks. For very severe cases oral steroids may be necessary. 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. 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. Common issues that lead to overuse of topical decongestants: 1.Deviated septum 2.Upper respiratory tract infection 3.Vasomotor rhinitis 4.Cocaine abuse 5.Pregnancy (these products are not considered safe for pregnancy, however) 6.Chronic rhinosinusitis 7.Hypertrophy of the Inferior Turbinates Eductional Objective Rhinitis medicamentosa (or RM) is a condition of rebound nasal congestion brought on by extended use of topical decongestants (e.g. oxymetazoline, phenylephrine, and xylometazoline nasal sprays) that work by constricting blood vessels in the lining of the nose. This condition typically occurs after 5 to 7 days of use of such medications. Prevention is by stopping the drug after 3 days. Educational Objective: References: ]]
Approved	Approved::Yes
Keyword	WBRKeyword::Decongestants, WBRKeyword::Rhinitis medicamentosa, WBRKeyword::Rebound congestion
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