Systematic Review
Otolaryngology–
Management of Rhinitis Medicamentosa:
A Systematic Review
Shana M. Zucker1, Blair M. Barton, MD1, and
Edward D. McCoul, MD, MPH1,2,3
Sponsorships or competing interests that may be relevant to content are dis-
closed at the end of this article.
Abstract
Objective. Rhinitis medicamentosa (RM) is a common condi-
tion resulting from overuse of topical nasal decongestants.
Despite the prevalence in otolaryngologic practice, a clear
treatment protocol has not been established. Our objective
was to review the current published literature pertaining to
the treatment of RM with the possibility of finding data that
support one treatment over another.
Data Sources. PubMed, Embase, Cochrane, and Web of
Science databases were examined for patients diagnosed with
RM resulting from chronic use of topical nasal decongestants.
Review Methods. The PRISMA standard (Preferred Reporting
Items for Systematic Reviews and Meta-analyses) was uti-
lized to identify English-language studies reporting treatment
of patients with the primary diagnosis of RM after chronic
use of a topical decongestant. Outcome measures of inter-
est included patient-reported symptom relief and objective
parameters. MINORS criteria (methodological index for
nonrandomized studies) were used to assess the quality of
articles.
Results. A total of 350 articles were identified, 9 of which
met final inclusion criteria for qualitative analysis. Outcomes
defined in each publication were highly varied and relied on
several unstandardized measures. The most commonly
reported treatment option was topical nasal steroids,
although overall there was limited evidence on which to
base treatment recommendation.
Conclusions. There is not adequate evidence to develop a
standardized treatment protocol for RM. The development
of a uniform questionnaire, standard outcomes to be mea-
sured, and a method of assessing such outcomes is neces-
sary. Prospective randomized controlled studies are
warranted to determine the optimal treatment regimen fol-
lowing diagnosis of RM.
Keywords
rhinitis medicamentosa, chronic rhinitis, nonallergic rhinitis,
nasal decongestants, systematic review, rhinomanometry,
nasal congestion
Head and Neck Surgery
1–10
Ó American Academy of
Otolaryngology–Head and Neck
Surgery Foundation 2018
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0194599818807891
http://otojournal.org
Received July 10, 2018; revised August 29, 2018; accepted September
28, 2018.
R
hinitis medicamentosa (RM), also referred to as
rebound rhinitis, is a type of nonallergic mucosal
inflammation resulting from the overuse of topical
nasal decongestants. RM causes patients to experience nasal
stuffiness, swelling, discomfort, and mucosal hyperreactiv-
ity.1-3 Topical nasal decongestants are indirect sympathomi-
metic drugs that exert action by promoting vesicular release
of norepinephrine from neurons with subsequent stimulation
of alpha-adrenergic receptors.4 Topical nasal decongestants,
such as oxymetazoline and phenylephrine, which are avail-
able over the counter, result in vasoconstriction and hyper-
trophy of the nasal soft tissue.5-7 Despite a relatively high
incidence of RM in up to 9% of patients visiting otolaryn-
gology and allergy clinics, the pathophysiologic mechanism
is not well understood.8 Consequently, management of RM
has not been clearly defined, with most physicians advocat-
ing for the prompt discontinuation of topical decongestants
and application of intranasal steroids and nasal saline.1-3,5,6
Patients who self-medicate with topical nasal deconge-
stants pose a particular challenge to physicians, as these
agents are easily accessible over the counter and characteris-
tically provide rapid relief of nasal congestion. As a result,
physical dependence can occur, which drives the vicious
cycle of continued use of the product in an effort to main-
tain nasal patency. Other sinonasal disorders may underlie
or coexist with RM, which indicates the importance of
obtaining a thorough history to identify overlapping sources
1
Department of Otolaryngology–Head and Neck Surgery, School of
Medicine, Tulane University, New Orleans, Louisiana, USA
2
Department of Otorhinolaryngology, Ochsner Clinic Foundation, New
Orleans, Louisiana, USA
3
Ochsner Clinical School, School of Medicine, University of Queensland,
New Orleans, Louisiana, USA
This article was presented as a poster at the 2018 Triological Combined
Sections Meeting; January 18-20, 2018; Scottsdale, Arizona.
Corresponding Author:
Edward D. McCoul, MD, MPH, Department of Otorhinolaryngology,
Ochsner Clinic Foundation, 1514 Jefferson Hwy, CT4, New Orleans, LA
70121, USA.
Email: emccoul@gmail.com
2 Otolaryngology–Head and Neck Surgery
of nasal obstruction or inflammation.3-5,7-9 Patients with
allergic rhinitis, septal deviation, or upper respiratory infec-
tions often elect to use over-the-counter topical nasal decon-
gestants, putting themselves at higher risk for developing
RM.4 Despite the recognition of RM as a clinical entity for
several decades, an widely accepted protocol of treatment
to wean patients off these medications has yet to be
established.10
A variety of medical and surgical treatments are poten-
tially available to treat patients with RM. We aimed to sum-
marize the available evidence in the literature about the
treatment of RM, which might form the basis for a standar-
dized protocol for treatment and a guide for future research.
Outcomes of interest included improved breathing and
reduced decongestant use among patients with RM.
Methods
A comprehensive review of the English-language literature
was performed from the following electronic bibliographic
databases: PubMed, EMBASE, the Cochrane Library, and
Web of Science (science and social science citation index).
Search criteria included all occurrences in the title or
abstract of the following terms: (1) rhinitis medicamentosa,
rebound rhinitis, chronic rhinitis, or atrophic rhinitis and
(2) nasal decongestant and (3) nasal steroids or turbinate
reduction. Inclusion criteria for the literature search were
defined with the PICOS approach (population, intervention,
control, outcome, study design). Search criteria included
adults .18 years of age described as having RM, rebound
rhinitis, chronic rhinitis, or atrophic rhinitis as a result of
the chronic use of topical nasal decongestant medications.
Interventions included, but were not limited to, nasal ster-
oid treatment or turbinate reduction and were compared
with a control. Outcomes measured in our search were
improvement of breathing and related symptoms. Study
designs included case-control, case series with chart review,
prospective cohorts, and randomized controlled trials. A sys-
tematic search was performed and reported in accordance
with the PRISMA standard (Preferred Reporting Items for
Systematic Reviews and Meta-analyses; Figure 1).
Two reviewers (S.M.Z., B.M.B.) performed eligibility
assessment of data in a standardized manner. In the initial
screening, the abstract of every citation was reviewed for
relevance to the treatment of RM in human patients.
Irrelevant citations and case reports were excluded and
duplicate records subsequently removed. The full text of the
remaining citations was obtained and reviewed in full.
Noneligible studies were excluded—specifically, those that
did not provide data on treatments or outcomes and those
that did not distinguish between patients with RM and those
with other forms of rhinitis. One full-text article was
excluded because the authors published 2 articles about the
same patients in a prospective cohort: the original report10
and a 1-year follow-up.11 The 1-year follow-up study was
selected for inclusion in the qualitative synthesis. The other
remaining studies were included for qualitative analysis.
Despite the use of the exclusion criterion of patients .18
years old, 3 of our qualifying studies each included 1 under-
age patient in the study cohort.12-14
The MINORS criteria (methodological index of nonran-
domized studies) were used by 2 independent reviewers
(S.M.Z., B.M.B.) to appraise the quality of the selected arti-
cles (Table 1). The MINORS criteria form a validated test
that was developed as a tool to assess the quality and risk of
bias of observational studies.15 The qualifying articles were
reviewed and scored out of a maximum of 16 (if the study
was nonrandomized) or a maximum of 24 (in the case of
a comparative study). The items are scored as 0 (not
reported), 1 (reported but inadequate), or 2 (reported and
adequate).15
Extracted data from full-text articles included study set-
ting, design, population, participant demographics and base-
line characteristics, criteria for patient collection, details of
the intervention and control conditions, recruitment and
completion rates, and outcomes and times of measurement,
as well as sponsorship by pharmaceutical companies. The
principal summary measures were patient reports of symp-
tom relief, nasal airflow, thickness of nasal mucosa, and
ability to discontinue use of topical vasoconstrictors without
relapse. The risk of bias was assessed at the study level by
examining each study for design, the stated purpose for the
study, and the source of patient data collection. The risk of
bias at the evidence level was determined for each study to
provide an estimate of strength and study design.
Quantitative data were assessed for suitability of pooling
into a meta-analysis.
Results
The initial database query identified 345 articles, which
were screened for relevance to the treatment of RM
(Figure 1). Article reference lists were also screened, yield-
ing an additional 5 relevant articles. Duplicates were
removed, followed by articles meeting exclusion criteria,
then those not adequately fulfilling inclusion criteria. One
additional article10 was excluded because the authors had
published 2 reports, 1 year apart, on the same 10-patient
prospective case cohort; the 1-year follow-up11 was selected
for inclusion, while the original article was deemed ineligi-
ble to avoid data duplication.
A total of 9 articles were included for analysis. Risk of
bias was assessed, and overall study quality was heteroge-
neous, with 4 randomized controlled trials and 5 noncon-
trolled studies (Table 1). MINORS scores ranged from 9 to
12 (out of 16) for the noncontrolled studies and 18 to 20
(out of 24) for the controlled studies (Table 2).
Data from the included studies are summarized in Table
3. The RM treatment regimens included nasal steroids,
nasal steroids with oxymetazoline hydrochloride, oral ATP
(adenosine triphosphate), a laser diode, and a kinetic oscilla-
tor. Outcome data included patient reports of symptom
relief, nasal volume, peak inspiratory flow, nasal flow and
resistance, minimal cross-sectional area, thickness of nasal
mucosa, histamine sensitivity, and ability to discontinue use
of topical vasoconstrictors without relapse. Findings were
Zucker et al
Figure 1. Flow diagram of study screening and selection. RM, rhinitis medicamentosa.
positive across all studies: regardless of the intervention,
patients experienced improvement in each study’s measured
parameters. However, the patient age range, observation
period, and number of patients in the intervention differed
across publications. Furthermore, outcome measures and
treatment protocols were inconsistent across the included
publications. As such, quantitative pooling was unable to be
performed in this review due to heterogeneity of outcome
measures across interventions.
Discussion
RM is a pervasive and frustrating condition for patients and
physicians alike, without a consensus on treatment type or
treatment duration. The lack of standard regimen is directly
linked to the uncertainty, as reflected in the literature, of the
pathophysiologic mechanism underlying RM. One proposal
holds that the chronic vasoconstriction causes hypoxemia
and subsequent ischemia of the nasal mucosa, resulting in
impaired function and congestion.7,9 Alternatively, fatigue
of the overstimulated alpha- and beta-adrenergic vasocon-
strictor mechanisms may occur, resulting in reactive hypere-
mia and edema, as well as tachyphylaxis and decreased
sensitivity to endogenous catecholamines, defined as a
3
decreasing therapeutic response necessitating a higher
dosage of medication to attain the same benefit.4,7,9 A third
proposal is that increased parasympathetic activity intended
to counter the sympathomimetic drugs may alter vasomotor
tone, resulting in increased vascular permeability and
edema.4 Histologic, pharmacokinetic, and pathophysiologic
studies are necessary to better understand the mechanism of
RM, which would lead investigators to more targeted
treatments.
Of the interventions assessed, 1 eligible publication
assessed oral ATP; 1 used a kinetic oscillator device; and 1
utilized a laser diode treatment. The most commonly used
treatment among the included studies was intranasal ster-
oids.12,13,16-22 Whereas the pathophysiology of the condition
of RM is not fully understood, the mechanism of action is
most well understood for nasal steroids. The conclusion of
Vaidyanathan et al may be a good starting point in better
understanding the pathophysiology of the condition, as their
results showed statistical significance in reversal of tachy-
phylaxis in response to fluticasone.19 It has been established
that the use of nasal steroids results in activation of beta-
adrenergic receptors, resulting in a cascade that inhibits
endothelial adherence of leukocytes and the subsequent
4 Otolaryngology–Head and Neck Surgery

Baseline Adequate
MINORS Stated Consecutive Collection Endpoints Assessment Follow-up Follow-up Calculation Control Contemporary Equivalence Statistical
of Groups Analyses
activation of prostaglandin synthesis, thereby promoting res-

2
2
2
2
—
—
—
—
—
olution of the edematous state of the nasal mucosa.1,23,24 It
is believed that the edema, rather than vasodilation, is the
component of RM that is responsible for the hallmark nasal
obstruction.1,23 Treatment of RM fails because the symptom
0
0
2
2
—
—
—
—
—
of chronic obstruction results in relapse to abuse of decon-
gestants; therefore, subjects whose obstruction is relieved
exhibit lower rates of returning to topical decongestant
use1,23 with nasal mucosa that reverts to normal.24-27
Groups

2
2
2
2
—
—
—
—
—
Clinical trials in the mid-1970s developed the use of dex-
amethasone as an intranasal steroid treatment, with decreas-
ing frequency over 2 to 4 weeks.3,12,28 Since then,
administration of corticosteroids has been established as a
Unbiased Appropriate Loss to Prospective Adequate

Group

first-line therapy for allergic rhinitis,29 but with a more con-

2
2
2
2
—
—
—
—
—

crete understanding of the pathophysiology of RM, a more

appropriate and specific pharmacologic intervention could
of Sample

be developed.1,6,7,9,17 Contrary to previous studies, which

pointed to immediate cessation of topical nasal deconge-
0
0
0
0
0
0
0
0
0

stants,3,21 findings in this review point to the potential for

an alternative management plan.
A further finding of this review, albeit understated, is the
\5%

2
2
1
2
1
1
2
2
0

importance of patient education. Only 2 studies highlighted

the importance of informing patients of the cause of their
rhinitis, which is the overuse of topical nasal decongestants,
Period

and that limiting the frequency and duration of these medi-

2
2
2
1
2
2
2
1
2

cations is central to avoiding development of RM.11,16

Reviews describing RM highlighted the significance of
properly informing patients of the risk of abusing topical
Appropriate of Endpoint

decongestants, emphasizing that this crucial piece of com-

1
2
1
1
1
1
0
1
0

munication could help prevent the development of RM alto-

gether. These reviews further suggested that, given both
patient-reported and objective measures of nasal pressure,
Dashes indicate nonrandomized study (ie, 16 maximum score vs 24 for comparative study).

administration of these medications should be limited to a

controlled medical setting.7,16 Such discussion of patient
2
2
2
2
2
2
2
2
2

education is hardly touched on in the included studies, and

limiting the use of topical decongestants to a medical center
Table 1. MINORS: Methodological Index of Nonrandomized Studies.a
Clearly Inclusion of Prospective

was not suggested.

of Data

The selectivity of the inclusion and exclusion criteria

2
2
2
2
1
2
2
2
2

greatly affects the ability to qualitatively assess the findings

of these publications as a whole. The inclusion of patients
with perennial allergic rhinitis in 1 study weakens the
Patients

broader conclusions that can be drawn.17 Furthermore,

1
2
1
1
1
2
2
1
1

inclusion criteria of daily overuse of topical nasal deconge-

stants ranged from minimum 1 month,12 3 months,18 4
months,21 minimum 1 year,14 and minimum 15 months.20
Aim

2
2
2
1
2
2
2
2
2

One study included patients whose use of topical nasal

decongestants ranged from 3 to 15 years, with dose per day
ranging from daily use to 15 times a day.16 One study
Score

18
20
19
18
10
12
12
11
9

defined overuse as administration 5 times a day, and the

duration of these doses ranged from 2 weeks to .10
years.13 One study included exclusively healthy patients in
Vaidyanathan (2010)19

whom RM was induced with oxymetazoline and treated by

Ferguson (2001)17

Baldwin (1975)12
Caffier (2008)14
Hallén (1997)16

Bende (1996)20

administering nasal steroids 3 times a day for 2 weeks and

Wang (1991)13
Author (Year)

Graf (1997)11
Juto (2014)18

then 2 times a day for 3 more days.19 The exclusion criteria,

however, were generally comparable.
The outcomes examined included patient reports of
symptom relief, peak nasal inspiratory flow, nasal flow and
a
Zucker et al
Table 2. Itemized Assessment of Risk of Bias for Studies Included in Systematic Review.
Author (Year) Direction of Inquiry Randomization
Hallén (1997)16 Prospective Yes
Ferguson (2001)17 Prospective Yes
Juto (2014)18 Prospective Yes
Vaidyanathan (2010)19 Prospective Yes
Wang (1991)13 Prospective (case series) No
Caffier (2008)14 Prospective (case series) NA
Baldwin (1975)12 Prospective (case series) NA
Graf (1997)11 Prospective (case series) NA
Bende (1996)20 Prospective (case series) NA
Abbreviation: NA, not applicable.
resistance, peak inspiratory flow, minimal cross-sectional
area, thickness of mucosa, histamine sensitivity, patient abil-
ity to discontinue use of topical nasal decongestants without
relapse, and histological examination. The 2 most common
measures were objective patient report of symptom relief
and nasal flow and resistance. Given the complementary
role for subjective and objective measures—specifically,
objective measures that are accurate and replicable—we
propose that the outcomes to be measured would ideally
include (1) a standardized subjective patient symptom score,
(2) nasal flow and resistance, and (3) histological changes.
Simplifying or ensuring that future studies measure these 3
outcomes, with the same indices, would reduce variability
and yield results that could provide standardized practice
recommendations.
The heterogeneity of reporting patient symptom scores
stands out as a key issue from this systematic review. Of
the included studies, 6 incorporated patient reports of symp-
tom relief as 1 of their primary outcomes, yet all 6 utilized
different methods. In 1 study, patients reported their daily
‘‘nasal congestion’’ scores on a visual analog scale of 1 to
10 in both the morning and the evening over the course of
the 6-week trial17; another study used a visual analog scale
of 1 to 100 to estimate ‘‘nasal stuffiness’’ before treatment
and at 6 and 12 months after the treatment period.21 Other
studies reported quotes of patients describing their ‘‘sinuses
opening up,’’12 queried patient ‘‘need’’ for topical deconge-
stants at 2 and 6 months after the treatment period,20 used a
visual analog scale of 1 to 10 to report nasal airflow as well
as patient satisfaction at pre- and posttherapeutic time
points,17 and required patients to keep a diary symptom
score based on summing scales of 0 to 4 in the categories of
stuffiness, itching, and secretion.14 The heterogeneity in
assessments of the hallmark symptom of RM highlights a
deficiency in the current literature. The employment of
common measures and a validated disease-specific tool
would enhance validity and comparability.
A second useful outcome for studying RM is analysis of
nasal flow and resistance. Current evidence suggests that
rhinomanometry would be the most precise, accurate, and
relevant objective test for RM, with high reliability.30-32
5
Blinding Handling of Lost Data Basis for Treatment Allocation
Yes NA Randomized
NA Excluded Randomized
Yes Excluded Randomized
Yes Excluded Randomized
NA NA NA
NA NA Standard protocol
NA NA Standard protocol
NA NA Standard protocol
NA NA Standard protocol
Furthermore, given that RM is a condition in which swelling
and congestion are key physical findings, the ability of rhino-
manometry to measure transnasal flow and pressure make it
an appropriate functional examination.31 Additionally, acoustic
rhinometry, which evaluates changes in airway dimensions
and geometry,31,32 is highly correlated with rhinomanometry
and was found to produce comparable results; as such, these
measures could be used complementarily,30,32 which would
facilitate standardization of objective outcomes.
Finally, further examination of histologic changes was
one of the least common outcomes assessed, yet it has the
potential to deepen the understanding of the pathophysiol-
ogy of RM.8,33 Recent findings suggest that patients with
RM have alterations including, but not limited to, reduced
cilia cell counts, changes in cilia ultrastructure, and rupture
of the basal layer, each of which predisposes a patient to
interstitial edema.9,30,31 Additionally, ultrastructural changes
to the endothelial cells of capillaries of the submucosal sinu-
soid venous plexuses suggestive of increased permeability is
indicative of edema.20,30 Using these 3 ideal outcomes and
common methods would allow for better comparison and
potential pooling of results.
It is important to note that the strength of the conclusions
drawn from this systematic review depends on the quality
of the evidence of the studies, as reflected in the assessment
with MINORS criteria. Notably, while the loss to follow-up
was predominately reported and adequate, the majority of
the studies had inadequate reporting of patient selection,
and none of the included studies prospectively calculated a
sample size. Further significant limitations include that 3 of
the 4 randomized studies were subject to potential conflict
of interest, as they were supported by pharmaceutical and
pharmaceutical device companies.16-18 Additionally, 2 stud-
ies combined information in such a way that only vague
inferences can be made about their findings. Specifically, 1
article included patients with either RM or perennial allergic
rhinitis but did not distinguish their outcomes in the presen-
tation of the data,17 whereas the second article administered
2 different treatments and likewise presented all patients as
1 group.13 Another publication experienced patient dropout
but made assumptions about the data.19 This limits the
 Table 3. Study Data Available for Qualitative Analysis.

6
Age, Mean Control: Outcomes Methods of Outcome
Author (Year) Design (Range), y Treatment, n Control Treatment Reviewed Analysis Findings

Hallén (1997)16 RCT 33 10:10 Placebo nasal Fluticasone Patient reports of Nasal mucosal swelling  Mean reduction with
spray qd propionate nasal symptom relief, and MCA recorded rhinostereometry: –
for 14 d spray, 200 mg qd nasal volume, with rhinostereometry, 1.2 mm
for 14 d PNIF, MCA, acoustic rhinometry,  Mean increase in
thickness of nasal and peak inspiratory MCA: 0.27 cm2
mucosa flow meter; nasal  PNIF mean
stuffiness (estimated on improvement: 121 L/
VAS twice daily) min
 Morning symptom
scores: reduced by 45
 Evening symptom
scores: reduced by 37
 Improvement
statistically significant
vs placebo after 1 and
2 wk
Ferguson (2001)17 RCT 37.2 10:9 Placebo nasal BANS, 32 mg/spray Patient reports of Subjective: patients  Significantly less
spray symptom relief, recorded nasal congested and
nasal volume, congestion scores on subjective symptom
MCA 10-point VAS AM and PM improvement vs
(mean used for placebo
statistical analysis);  Nasal airway
objective: nasal volume objectively was
and minimal cross- improved vs placebo
sectional area by but not to statistical
acoustic rhinometry significance
 MCA significantly
decreased
Juto (2014)18 RCT 40 35:36 Device Kinetic oscillation Patient reports of RQSS, diary symptom  Median RQSS
maintained stimulation: symptom relief, score, PNIF stuffiness measure fell
stable mechanical PNIF from 2 to 1 (on scale
pressure vibrations at 50 of 0 to 3)
without Hz
oscillation
Vaidyanathan (2010)19 RCT 33 19:19 Fluticasone, 200 mg Fluticasone, 200 mg PNIF, NAR PNIF, NAR,  Significant decrease in
BID for 3 d; BID for 3 d; oral oxymetazoline dose- PNIF after day 1
placebo at days 1, prazosin, 1 mg, at response curve  Significant increase in
14, 17 days 1, 14, 17 NAR after days 1,
14, 17

(continued)
 Table 3. (continued)
Age, Mean Control: Outcomes Methods of Outcome
Author (Year) Design (Range), y Treatment, n Control Treatment Reviewed Analysis Findings

Wang (1991)13 Prospective 17-50 NA: 22 NA (1) Topical PNIF, NAR Nasal mucus clearance  Nasal mucus
clinical (1), 8 (2) dexamethasone time measurement, clearance time
investigation or triamcinolone gross appearance of shortened in varying
in normal saline nasal mucous degrees throughout
for 1-2 wk, membrane, optical cohort
followed by microscopy appearance
normal saline as of sample taken from
regular nasal junction of anterior and
drops; (2) oral middle thirds of inferior
ATP, 20 mg, 3 turbinate, and
times daily rhinomanometry
Caffier (2008)14 Prospective 44 (15-72) NA:42 NA Video-endoscopic Patient reports of Short term: NAR, patient  NAR: significant
clinical inferior turbinate symptom relief, satisfaction rating on improvement
investigation reduction with a PNIF, NAR, VAS; long term: inferior  Subjective VAS:
diode laser ability to turbinate significant
discontinue photodocumentation, improvement
vasoconstrictors recurrent need for  88% patients
without relapse decongestants successfully stopped
decongestant abuse
after 6 mo, 74% after
1y
Baldwin (1975)12 Case series report 14-60 NA:22 NA Dexamethasone Patient reports of Complete cessation of  All patients
administered by symptom relief, topical vasoconstrictors discontinued use of
Decadron MCA, patient in any form, relief of topical
Turbinaire ability to symptoms, return of vasoconstrictors
apparatus: 0.084 discontinue appearance of nasal within 2 wk of
mgm, with vasoconstrictors mucosa to ‘‘normal’’ treatment regimen
diminishing without relapse without relapse at 6-
frequency over 4 mo follow-up
wk

(continued)

7
8
Table 3. (continued)
Age, Mean Control: Outcomes Methods of Outcome
Author (Year) Design (Range), y Treatment, n Control Treatment Reviewed Analysis Findings

Graf (1997)11 1-y follow-up of 30.3 (18-42) NA:10 NA Budesonide spray, Patient reports of MCA, decongestive effect  Histamine sensitivity:
prospective 400 mg/d, for 6 symptom relief, of oxymetazoline, still increased after 6
clinical wk during MCA histamine sensitivity mo but not after 1 y
investigation decongestant measured with  Decongestive effect of
withdrawal rhinostereometry; oxymetazoline:
symptom score for increased after 6 mo
nasal stuffiness (indicative of
reversible tolerance)
 No relapse to long-
term use during 1-y
follow-up
Bende (1996)20 Case cohort 30 NA:11 NA BANS, 8000 mg/d, Patient reports of NAR at rest and after  Statistically significant
for 2 mo symptom relief, exercise, before and difference in total
NAR after treatment; need NAR at rest before
for topical nasal and after treatment
decongestants 2 and 6 (38.0 6 4.3)
mo after treatment  No statistically
period significant difference
in total NAR after
exercise before and
after treatment
Abbreviations: ATP, adenosine triphosphate; BANS, budesonide aqueous nasal spray; BID, twice per day; MCA, minimal cross-sectional area; NA, not applicable; NAR, nasal airway resistance; PNIF, peak nasal inspira-
tory flow; qd, daily; RCT, randomized controlled trial; RQSS, Rhinitis Questionnaire Symptom Score; VAS, visual analog scale.
Zucker et al
conclusions that can be drawn about the effectiveness of the
findings.
Although the results from these publications cannot be
quantitatively pooled, the reported subjective patient experi-
ence, as well as objective examination of nasal function,
suggests that further investigation of RM is needed. Doing
so with consistently selected and evaluated outcomes and
performing prospective randomized controlled trials would
be a significant contribution to the understanding of the con-
dition, as well as its diagnosis and optimal treatment. The
findings of this study conclude that there is no consensus on
the best medical therapy for the treatment of RM. Despite
this finding, the most common medication used today to
treat RM continues to be intranasal corticosteroids.
Conclusion
There is not adequate evidence to conclusively suggest a
standardized treatment protocol for RM. Given the signifi-
cant variability in study design and outcomes reported
across the relevant publications, it is recommended that uni-
form objective and patient-centered outcome measures be
adopted for future study. Additional high-level evidence is
needed to determine the optimal management strategy for
patients diagnosed with RM.
Acknowledgments
Laura Wright, MLIS, MPH, research support librarian.
Author Contributions
Shana M. Zucker, acquisition and analysis of data, drafting of
manuscript, final approval, accountable for all aspects; Blair M.
Barton, acquisition and analysis of data, drafting of manuscript,
final approval, accountable for all aspects; Edward D. McCoul,
conception and design, interpretation of results, revision of manu-
script, final approval, accountable for all aspects.
Disclosures
Competing interests: None.
Sponsorships: None.
Funding source: American Academy of Otolaryngology—Head
and Neck Surgery Foundation Cochrane Scholars Grant.
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