What is Rhinitis Medicamentosa (Rebound Congestion)?
Rhinitis medicamentosa (RM), also known as ‘rebound congestion’, is when the inside of the nose becomes swollen due to the excessive use of nasal decongestant sprays. It’s a type of condition sparked by certain drugs.
People often use nasal decongestant sprays to relieve a blocked nose caused by allergies, sinus infections, polyps (small growths) in the nose, or infections in the upper respiratory tract where we breathe. The earliest versions of these sprays were based on a substance called ephedrine, but it was noticed that using them for a long time could actually make nasal congestion worse. This could happen as quickly as 3 days, and after 4 to 6 weeks of use.
However, thanks to the development of modern decongestant medications, such as the imidazoline derivatives, the chances of developing rebound congestion is now thought to be small or even nonexistent.
What Causes Rhinitis Medicamentosa (Rebound Congestion)?
This condition usually results from the prolonged use of nasal decongestant sprays. If you use these sprays for more than 7 to 10 days, you can develop this condition. It’s also been reported that the use of cocaine through the nose can cause a similar issue.
Let’s discussing how congestion in your nose works.
The lining of your nose has a system of blood vessels. Some of these vessels, called arterioles, are mostly controlled by things called alpha-2 adrenoreceptors. Other blood vessels, the venous plexus, are controlled by both alpha-1 and alpha-2 adrenoreceptors. When these receptors get stimulated, they cause a decongestant effect. This means they make the large blood vessels in your nose contract, which decreases blood flow and reduces swelling and runny nose.
Many factors can contribute to nasal congestion. One of these is stimulation of the parasympathetic nervous system. That’s the part of your nervous system that, among other things, helps your body rest and digest food. Another factor is the release of local mediators – these are cells like mast cells, eosinophils, and basophils. These cells stimulate the release of things like histamine, tryptase, kinins, prostaglandins, and leukotrienes, which cause changes in your nose’s blood vessels and increase fluid leakage through your nose’s capillaries and an increase mucus production.
Nasal decongestants sprays can be divided into two groups: beta-phenylethylamine derivatives and imidazoline derivatives. The first group works by mimicking the effects of the part of your nervous system that readies your body for action. These drugs cause your blood vessels to contract by activating alpha-1 adrenoreceptors. However, they might sometimes cause these blood vessels to dilate again because they weakly activate beta-adrenoreceptors. The second group of nasal decongestants works mainly through alpha-2 adrenoreceptors. They cause blood vessels in your nose to contract, which is especially effective at decreasing the blood flow in your nose’s lining.
The imidazoline group usually has a stronger and longer-lasting effect than the beta-phenylethylamine group. For instance, 0.1% xylometazoline hydrochloride, which belongs to the imidazoline group, starts working within a few minutes and lasts up to 10 hours. On the other hand, 1% phenylephrine, which belongs to the beta-phenylethylamine group, start working within 15 to 20 minutes and lasts 2 to 4 hours.
Examples of beta-phenylethylamine nasal decongestants include ephedrine HCl and phenylephrine HCl. Imidazoline nasal decongestants include naphazoline HCl, oxymetazoline HCl, and xylometazoline HCl.
A common preservative in nasal sprays, benzalkonium chloride, has been linked to worsening of the condition because it might cause the lining of your nose to swell. But this is still a topic of debate, as there’s no evidence that nasal sprays with corticosteroids and benzalkonium chloride worsen nasal congestion.
Risk Factors and Frequency for Rhinitis Medicamentosa (Rebound Congestion)
This condition commonly happens in young and middle-aged adults. It affects men and women at similar rates. It’s reported that it represents 1% to 9% of visits to ear, nose, and throat doctors. However, these numbers may not provide the full picture as many people can get over-the-counter medications for this condition.
Signs and Symptoms of Rhinitis Medicamentosa (Rebound Congestion)
If you’ve been using a nasal decongestant for a long time and you’re still experiencing symptoms like a stuffy nose without any runny discharge, you might have a condition that causes your nasal passages to swell. It can result in uncomfortable symptoms like having to breathe through your mouth, experiencing a dry mouth, or even snoring. If you visit a doctor, they may observe that the inside of your nostrils, called the nasal mucosa, has a swollen, reddish, and rough-looking appearance. In some cases, it might also appear pale and bloated. As this condition worsens, the inside of your nostrils could start to thin out and become crusty.
Testing for Rhinitis Medicamentosa (Rebound Congestion)
Diagnosing Rhinitis Medicamentosa (RM), or inflammation of the nose due to medication use, is heavily based on clinical observations as there are no specific lab tests or imaging scans that can confirm it. Therefore, paying close attention to symptoms, past health information, and physical evaluations is extremely important in making a correct diagnosis. It’s also crucial to recognize that other nose and sinus conditions may exist alongside RM.
Treatment Options for Rhinitis Medicamentosa (Rebound Congestion)
For treating RM, or rebound nasal congestion, the first step is to stop using nasal decongestants. It’s important to know that when you stop using these, your nasal congestion might feel like it’s getting worse for a short time. This doesn’t mean the treatment isn’t working – it’s actually a normal part of the process.
There’s scientific evidence, from both animal studies and small trials with people, that using a nasal spray with corticosteroids can help lessen this rebound congestion. Corticosteroids are medicines that can reduce inflammation.
Additional treatments that might be used during this withdrawal process include short courses of oral corticosteroids (prednisone), nasal steroid injections, and oral antihistamines. Antihistamines are a type of medication that can help reduce symptoms like sneezing, itching, runny nose, and watery eyes. Other types of medications, like adenosine and mast cell stabilizing agents, may also be used. However, such treatments are largely based on limited case reports – meaning the full scope of their effectiveness isn’t yet known.
What else can Rhinitis Medicamentosa (Rebound Congestion) be?
The following are different types of conditions related to inflammation or irritation of the nose:
- Allergic Rhinitis: This is triggered by allergens like pollen, dust or animal dander.
- Non-Allergic Rhinitis: This isn’t caused by allergens, but other forms of irritants or changes in the environment.
- CPAP-Related Rhinitis: This often happens to people using Continuous Positive Airway Pressure (CPAP) machines for their sleep apnea.
- Rhinosinusitis: This is a condition where both the nose and sinuses get inflamed or swollen.
What to expect with Rhinitis Medicamentosa (Rebound Congestion)
In cases of long-term overuse, it usually takes about one year for a person to fully recover.
Possible Complications When Diagnosed with Rhinitis Medicamentosa (Rebound Congestion)
- Long-term inflammation of ethmoid sinuses
- Atrophic rhinitis (a dry condition of the nose’s inner lining)
- Septal perforation (hole in the nose’s wall divider)
- Chronic rhinosinusitis (ongoing sinus inflammation)
- Enlarged nasal structures (turbinate hyperplasia)
Preventing Rhinitis Medicamentosa (Rebound Congestion)
Before doctors recommend the use of a nasal decongestant spray, they often educate the patients about the potential side effects of using this medicine too much. This could be a difficult task, given that these sprays are usually easy to buy without a prescription at a drugstore.
Patients should also be informed that frequent, short-term use of these nasal sprays, even after stopping for a year, can lead to a recurrence of Rhinitis Medicamentosa (RM) – a condition of rebound nasal congestion caused by overuse of nasal decongestants.
