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REVIEW ARTICLES Rhinitis Medicamentosa

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REVIEW ARTICLES Rhinitis Medicamentosa n SCIENTIFIC SECTION I "-I I REVIEW ARTICLES Rhinitis medicamentosa MARTIN J. BLACK, MD, FRCS[C]; KENNETH A. REMSEN,* B SC Rhinitis medicamentosa, the syndrome of rebound nasal congestion secondary sal mucosa of rabbits. His work to prolonged topical intranasal use of vasoconstrictors, is reviewed. In this was followed that of Lierle and condition the nasal airway is very obstructed; atrophic rhinitis is the most by serious complication. Management consists of withdrawing the offending Moore,9 Walsh and Cannon,10 nasal spray and alleviating the nasal obstruction by means of any of several Kully,' Lake,2 Ryan'1 and Fabri- treatment modalities. cant."' Despite the early evidence of ill On passe en revue la rhinite medicamenteuse, le syndrome de rebond de la effects of the intranasal use of congestion nasale secondaire a l'usage topique prolongee des vasoconstricteurs vasoconstrictors, advertising con- nasaux. En cette affection l'obstruction des voies aeriennes est prononcee; tinued to illustrate the benefits of la rhinite atrophique s'avere la complication la plus grave. On a effectue this practice without sufficient men- la cure de sevrage en supprimant le vasoconstricteur en cause et en soulageant tion of the deleterious effects asso- l'obstruction nasale par n'importe laquelle de plusieurs modalites du traitement. ciated with prolonged use. Kully' reported in 1945 that no class of Both the otolaryngologist and the soconstrictors. The condition of re- drugs was more widely distributed family practitioner are frequently bound nasal congestion secondary and used than the vasoconstrictors. confronted by the patient troubled to prolonged topical intranasal use At that time there were 240 prod- by a "stuffy" nose. The most com- of vasoconstrictors is appropriately ucts of this kind available. mon causes of this problem are termed rhinitis medicamentosa.' Addiction to nosedrops was well acute viral rhinitis (the common documented in 1946 by Lake,' who cold), allergic rhinitis, anatomic History of the condition described how one patient "had defects and purulent sinusitis.1 Af- become so addicted to the use of ter careful consideration of these Vasoconstrictors have been avail- nosedrops that it was necessary to disorders during history-taking and able for intranasal use since the hospitalize her and then get her out physical examination a different 19th century. The alkaloid ephe- of the room while one of the first condition may reveal itself. The drine was first isolated in 1887 assistants went through her belong- patient tells of the frequent use of from the Chinese herb Ma-huang.' ings and removed numerous bottles nosedrops to gain relief of the nasal Shortly afterwards Oliver and of nosedrops". Following these obstruction, and the physician dis- Schafer4 discovered epinephrine in publications little appeared in the covers a hyperemic, edematous na- the adrenal medulla, and 10 years literature until 20 years later, when sal mucosa that shrinks little after later Stolz' and Dakin' produced Stride" reported that up to 5% the intranasal administration of va- it synthetically. The commonly of outpatient consultations in many used phenylephrine was discovered ear, nose and throat units were for From the department of otolaryngology, 5 years later by Barger and Dale.7 rhinitis medicamentosa "a direct Jewish General Hospital, Montreal The discovery of amphetamine fol- consequence of misguided topical *Fourth-year medical student, McGill lowed in 1930 and that of napha- nasal therapy". Subsequent reports University zoline in 1941.' Early in the 1930s were presented by Blue,'4 May work began in an effort to de- and and Reprint requests to: Dr. Martin J. West1 Baldwin.'" Despite Black, Department of otolaryngology, termine the adverse effects of these the past and recent work describing Jewish General Hospital, 3755 Cote agents in humans. In 1931 Fox8 rhinitis medicamentosa, the intra- St. Catherine Rd., Montreal, PQ described the chronic effect of epi- nasal use of vasoconstrictors is in- H3T 1E2 nephrine and ephedrine on the na- creasing steadily.'" CMA JOURNAL/APRIL 19, 1980/VOL. 122 881 Intranasal use of vasoconstrictors The obvious disparity between are of two main classes: the sym- the therapeutic indications and the pathomimetic amines and the imi- As Kully3 wrote: "The nasal actual use of this class of drug dazole derivatives (incomplete sym- mucosa responds to infection as do evinces the need for better physi- pathomimetics). The latter include other body tissues, with swelling, cian and patient awareness of the naphazoline, xylometazoline and augmented blood supply, increased limitations of nasal vasoconstrictors. oxymetazoline.13" 2 Drugs of either exudation and diapedesis. Shrink- group, when applied intranasally, ing the tissues with medication re- Physiology of the will cause local vasoconstriction. verses this physiologic response. In upper respiratory tract2'19 The imidazoles, however, lack the no other tissue of the body is in- systemic effects on the myocardium fection treated by diminishing the The nose serves as a physiologic and bronchioles associated with the blood supply and shrinking the col- air-conditioner, performing three sympathomimetics.20 For this rea- lateral edema. Such treatment les- main functions: filtering the in- son the use of the imidazoles is sens neither the severity nor the spired air and regulating its tem- preferred. duration of the infection. On the perature and humidity. Anatomic- Sympathomimetics are divided contrary, the typical cause of an ally the nose is well suited to this into two groups on the basis of acute rhinitis may be altered and purpose as the nasal mucous mem- their action on the hypothetical a- prolonged." Boies," in his textbook branes, folded over the turbinates, and a3-receptors in the affected tis- of otolaryngology, stated that de- create a large surface area for im- sues. The a-receptors mediate vaso- congestion is required to promote parting warmth and moisture to the constriction and the ,8-receptors are drainage of the purulent fluid with- inspired air. The nasal mucosa con- responsible for vasodilatation." The in the nasal or sinus cavities asso- sists of mucus-secreting pseudo- decongestion afforded by these ciated with an infectious process in stratified ciliated columnar epi- agents is a direct consequence of the nose or paranasal sinuses. He thelium and a highly specialized their vasoconstrictive action. The claimed that topically administered form of ciliated epithelium in the subepithelial capillaries and arte- vasoconstrictors are useful for this olfactory sensory area. The ciliated rioles, together with the venous purpose but advised that the dura- columnar epithelium is rich in gob- sinuses of the erectile tissue, under- tion of their use be limited to 1 let cells, which secrete approxi- go vasoconstriction. If the vaso- week. Fabricant"8 suggested that, mately 1 litre of mucus per day. constriction is severe or prolonged when judiciously employed, nasal The mucus is transported by the a reversal reaction, secondary vaso- vasoconstrictors aid in promoting cilia as a continuous blanket back- dilatation, occurs and the mucosa adequate drainage from paranasal ward toward the choanae, from becomes increasingly less sensitive sinuses by opening obstructed ostia, where it passes into the naso- to subsequent applications of vaso- and that "a number of sympatho- pharynx. Here it is carried to the constrictors; the result is the drug mimetic amines have come to as- lateral pharyngeal wall and is swal- habituation characteristic of rhinitis sume a legitimate place in the oto- lowed, lubricating the pharyngeal medicamentosa. laryngologist's treatment schedule. and laryngeal mucosal surfaces. The cause of the secondary vaso- They afford symptomatic relief for The cilia beat approximately 200 dilatation is not fully understood, the patient with acute coryza, but times per minute, and the mucus but a number of theories have been probably have no therapeutic value. blanket moves at a rate of about advanced. In 1945 Kully' suggested Intranasal vasoconstrictors should 0.5 cm/min. that it was due to either fatigue be used only temporarily - five The two nasal chambers vary in of the constrictor mechanism or days' use, as stated on prescrip- their activity, with alternating con- the presence of an active vasodila- tions, with no refills." gestion of the inferior turbinate on tor in the drug. He and others"4,",' Nasal vasoconstrictors are used one side and decongestion on the believe that "overconstriction might therapeutically in preparation for opposite side. The change occurs produce local submucosal hypoxia nasal operations, as an adjunct in every 20 to 120 minutes in this and reactive hyperemia manifested treating serous otitis media, and for so-called nasal cycle. The cavern- as vasodilatation. Soon after Kully's acute and chronic sinusitis, and are ous tissue on the medial surfaces report was published Ryan,11 work- used prophylactically to prevent the of the turbinates becomes more or ing with rabbits, demonstrated com- barotrauma associated with air less congested with variations in plete absence of epithelial cell cilia travel and scuba diving. They are the temperature and humidity of following the intranasal administra- also used in nursing infants suf- the inspired air. These changes vary tion of either desoxyephedrine fering from a cold. However, of the effective surface area of the (methamphetamine) or naphazoline 22 patients with rhinitis medica- nasal
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