What is the next treatment step for a patient with chronic allergic rhinitis?

Treatment of Chronic Allergic Rhinitis with Cobblestone Appearance

Intranasal corticosteroids should be the first-line treatment for this patient with chronic allergic rhinitis presenting with sneezing, congestion, and postnasal drip with cobblestone appearance of the posterior pharynx. 1, 2

Clinical Assessment

The patient presents with:

• Allergic symptoms including sneezing and congestion
• Postnasal drip occurring at least three days weekly for years
• Cobblestone appearance of the posterior pharynx (indicating chronic inflammation)
• Enlarged turbinates with clear linear secretions
• Non-tender sinuses
• Symptoms occurring in a rainy area (potential environmental trigger)

Treatment Algorithm

First-Line Therapy

• Intranasal corticosteroids (INS) - Most effective for controlling all symptoms of allergic rhinitis, particularly nasal congestion 1, 2
  • Options include fluticasone propionate, mometasone furoate, budesonide, or triamcinolone acetonide
  • Administer once or twice daily depending on the specific medication
  • Onset of action usually within 12 hours, with full effect taking several days 2, 3

If Inadequate Response to INS After 2-4 Weeks

1. Add intranasal antihistamine (most effective combination) 1, 2

   • Options include azelastine or olopatadine
   • This combination provides greater symptom reduction than either agent alone

2. Alternative combination options (if intranasal antihistamine not tolerated):

   • Short-term (≤3 days) intranasal oxymetazoline + INS for severe nasal congestion 1
     • Caution: Limit use to avoid rhinitis medicamentosa
   • Oral antihistamine + oral decongestant combination 1
     • Second-generation antihistamines preferred (less sedation)

For Persistent Postnasal Drip

• Add saline nasal irrigation as adjunctive therapy 2
• Consider adding intranasal ipratropium bromide specifically for rhinorrhea 1

Special Considerations

Cobblestone Appearance

The cobblestone appearance of the posterior pharynx indicates chronic postnasal drip and inflammation, supporting the need for anti-inflammatory therapy with INS 1.

Environmental Control

• Advise staying in air-conditioned environments when possible 1
• Identify and avoid specific allergen triggers
• Consider HEPA air filtration in the home

When to Consider Immunotherapy

If symptoms remain inadequately controlled after 4-6 weeks of optimal pharmacotherapy, consider referral for allergen immunotherapy (sublingual or subcutaneous) 1, 2.

When to Consider Leukotriene Receptor Antagonists

• Consider montelukast only if the patient has comorbid asthma 1, 4
• Montelukast is less effective than INS for nasal symptoms but may provide additional benefit for patients with both conditions 4

Treatment Pitfalls to Avoid

1. Avoid long-term oral decongestants - Risk of side effects including hypertension and tachycardia 2

2. Avoid prolonged use of intranasal decongestants - Risk of rhinitis medicamentosa (rebound congestion) if used >3-5 days 1, 2

3. Avoid systemic corticosteroids for chronic management - Single short courses may be appropriate for very severe symptoms or significant nasal polyposis, but recurrent administration is contraindicated due to potential for serious side effects 1

4. Don't rely on oral antihistamines alone for congestion - They are less effective for nasal congestion than INS 5

5. Don't delay escalation of therapy if symptoms persist - Chronic inflammation can lead to complications including sinusitis, otitis media, and sleep disturbance 1

The evidence strongly supports intranasal corticosteroids as the most effective first-line therapy for this patient's chronic allergic rhinitis with prominent congestion and postnasal drip, with additional therapies added in a stepwise fashion if symptoms persist.