Rhinorrhea is the most common complaint in sickcall. Causes may include allergens, infectious agents, chemicals, medications, temperature (especially cold), or foods. If the rhinorrhea does not resolve after the usual course of decongestants, what then?

Allergic Rhinitis: This condition can be seasonal or year-round. Caused by allergens such as pollen, mites, mold, or dander.

• Symptoms: Sneezing, nasal and palatal itching, clear rhinorrhea, nasal congestion, sore throat, ± cough.

• Exam: Pale, boggy nasal mucosa. Clear stringy nasal discharge, postnasal drip.

Vasomotor Rhinitis: Can be paroxysmal or chronic. Exacerbated by odors, alcohol, weather/temperature changes, emotions, bright lights.

• Symptoms: Congestion, watery nasal discharge, obstruction can shift from side to side, ± headache.

• Exam: Nasal mucosa pale or hyperemic, watery secretions, and ± edema.

Rhinitis Medicamentosa: Occurs when over-the-counter nasal sprays are used to excess (for more than five days). Tachyphylaxis to nasal sprays contributes. Also seen with cocaine use.

• Symptoms: Severe nasal congestion, watery discharge

• Exam: Nasal mucosa is beefy red, inflammatory hypertrophy may be present, ± punctate bleeding

Rhinitis Associated with Hormones: With this condition, the vessels in the nasal passages overreact, causing congestion. Seen in hypothyroidism, pregnancy, oral contraceptive use, and menopause.

• Symptoms: Congestion, watery discharge, and ± sneezing

• Exam: Mucosa hyperemic and edematous, clear secretions

Infectious Rhinitis: Usually precipitated by a sinus or related infection, but may be associated with colds and flu.

• Symptoms: Nasal congestion with purulent discharge. Usually with post-nasal drip, sinus pain. ± fever.
  

• Exam: Mucosa hyperemic and edematous. Discharge may be opaque and green/yellow. Sinus tenderness or other signs of concurrent disease.

Cloudy or white nasal mucus indicates a head cold, caused by viruses. Viruses as well as bacterial infections can also cause the mucus to appear green or yellow, "purulent drainage". Nasal mucus typically looks dark when dried or in the first 2 hours of the morning; this alone does not indicate infection. Mucus that changes from clear to discolored and back is most likely a virus.

The following guidelines are recommended after sinusitis is ruled out and over-the-counter decongestant abuse is addressed, despite recurrent or persistent rhinorrhea.

STEP 1

• Beclomethasone nasal inhaler # 1. 2 sprays BID.

• Deconamine SR 1 PO BID or Entex LA 1 PO BID.

• Patient information concerning nasal hygiene and the chronic nature of allergic and non-allergic rhinitis.

• If the patient responds well to the above treatment and has chronic symptoms, they can attempt transition to regular daily use of the Beclomethasone spray only. Deconamine SR or Entex LA is held in reserve for PRN use for breakthrough symptoms. If breakthrough symptoms occur frequently, return to daily Deconamine SR or Entex LA use.

If the patient fails step 1 therapy, the primary reason for treatment failure should be ascertained. Step 2 therapy should be initiated under the relevant corresponding reason (s):

Course of Action for nasal irritation

• Discontinue Beclomethasone aerosol.

• Substitute Beclomethasone aqueous (AQ) DS nasal spray. 2 sprays QD.

• Emphasize good nasal hygiene. Add nasal saline spray with gentle blowing to remove thickened secretions.

Course of Action for secondary bacterial rhinosinusitis

• Add decongestant therapy. Either: pseudoephedrine 60 mg I BID - QID or oxymetazoline nasal spray, 2 sprays BID for 7 days maximum.

• Add antibiotic Septra DS I PO BID x 10 d or Amoxicillin 250 to 500 mg PO TID x 10d for acute sinusitis.

• Consider 21 day course for chronic sinusitis and ENT referral if 4 or more courses of antibiotic therapy required during a year.

Course of Action for excessive sedation

• Discontinue Deconamine SR or Entex LA

• Substitute non-sedating antihistamine

• Claritin (loratadine) 10 mg QD or

• Allegra (fexofenadine) 60 mg BID or

• Hismanal (astemizole)* 10 mg QD.

* Note: Astemizole is contraindicated in patients with hepatic dysfunction (e.g., alcoholic cirrhosis, hepatitis) or who are taking drugs such as ketoconazole, itraconazole, erythromycin, clarithromycin, troleandomycin, mibefradil dihydrochloride, or quinine. Use can lead to elevated astemizole plasma levels associated with QT prolongation and increased risk of ventricular tachyarrhythmias (such as torsades de pointes, ventricular tachycardia, and ventricular fibrillation) at the recommended dose.

Course of Action for incomplete response

• Assess compliance with original medication regimen.

• Assure OTC nasal decongestant sprays are not being used.

• Re-educate if non-compliance.

• If the patient still has primarily nasal congestion symptoms,  add a decongestant pseudoephedrine 60 mg 1 PO BID or TID.

• Substitute Nasacort AQ (triamcinolone) for beclomethasone nasal spray.

Patients who fail steps 1 and 2 should be considered for referral to a specialist. Allergy referral is appropriate for those patients who have allergic triggers by history, recurrent sinus infections, and overuse of topical OTC decongestant nasal sprays. ENT referral is appropriate for those patients who have structural abnormalities on exam (deviated septum. nasal polyps. etc.), difficult recurrent infections, or a history of previous nasal or sinus surgery.