What is the best next step for a 36-year-old woman with allergic rhinitis symptoms, including sneezing, rhinorrhea, nasal congestion, and post-nasal drip, with nasal congestion being the most bothersome symptom?

Management of Allergic Rhinitis with Nasal Congestion as Primary Symptom

A glucocorticoid nasal spray is the most appropriate next step for this patient with allergic rhinitis whose most bothersome symptom is nasal congestion. 1

Diagnostic Assessment

This 36-year-old woman presents with classic symptoms of allergic rhinitis:

• Sneezing, rhinorrhea, nasal congestion, and post-nasal drip
• Symptoms occurring at least three days weekly for years
• Worsening of symptoms in spring (seasonal pattern)
• Worsening since moving into an old farmhouse (environmental trigger)
• Nasal congestion identified as most bothersome symptom
• Physical exam showing pale nasal mucosa, enlarged turbinates, clear rhinorrhea, and cobblestone appearance of posterior pharynx

These findings are consistent with the diagnostic criteria for allergic rhinitis according to the American Academy of Otolaryngology-Head and Neck Surgery guidelines 1.

Treatment Selection Algorithm

1. Identify most bothersome symptom: Nasal congestion
2. Determine severity: Symptoms affect daily functioning and quality of life
3. Select appropriate first-line therapy based on predominant symptom:
   • For nasal congestion: Intranasal corticosteroid
   • For sneezing/itching: Second-generation antihistamine

Rationale for Intranasal Corticosteroid Recommendation

Intranasal corticosteroids are strongly recommended as first-line therapy for allergic rhinitis when:

• Nasal congestion is the predominant symptom 1
• Symptoms affect quality of life 1
• Symptoms are persistent or frequent 1

The American Academy of Otolaryngology-Head and Neck Surgery guidelines specifically state: "Clinicians should recommend intranasal steroids for patients with a clinical diagnosis of allergic rhinitis whose symptoms affect their quality of life" (Strong Recommendation) 1.

Intranasal corticosteroids:

• Are the most potent long-term pharmacologic treatment for congestion associated with allergic rhinitis 2
• Have broad anti-inflammatory activities that target multiple inflammatory mediators 3
• Provide superior relief of nasal congestion compared to oral antihistamines 4

Why Other Options Are Less Appropriate

1. Oral second-generation antihistamine (option C):

   • While appropriate for allergic rhinitis, these are more effective for sneezing and itching than for nasal congestion 1
   • The patient already uses nonprescription antihistamines with only "some relief"
   • Guidelines recommend oral antihistamines primarily for patients with "primary complaints of sneezing and itching" 1

2. Skin testing for allergens (option A):

   • Not indicated as first-line approach when diagnosis is clear
   • Guidelines recommend allergy testing only when "patients do not respond to empiric treatment, or when the diagnosis is uncertain, or when knowledge of the specific causative allergen is needed to target therapy" 1

3. CT of the sinuses (option B):

   • Guidelines explicitly recommend against routine sinonasal imaging in patients with symptoms consistent with allergic rhinitis 1
   • No symptoms suggestive of bacterial sinusitis that would warrant imaging

4. Nonprescription nasal decongestant spray (option E):

   • Not recommended for long-term use due to risk of rhinitis medicamentosa 2
   • Not appropriate for chronic symptoms as described in this case

Implementation Considerations

• Fluticasone propionate nasal spray works by blocking multiple inflammatory substances involved in allergic reactions 3
• Patient should be advised that:
  • It may take several days to reach maximum effect 3
  • Regular, consistent use is important for optimal benefit 3
  • The medication should be continued as long as exposure to allergens persists 3

Common Pitfalls to Avoid

1. Misdiagnosing allergic vs. non-allergic rhinitis:

   • This patient's history of seasonal pattern, clear rhinorrhea, and pale nasal mucosa strongly supports allergic etiology 5

2. Inadequate treatment of nasal congestion:

   • Nasal congestion is consistently identified as the most bothersome symptom of allergic rhinitis 6
   • Inadequately treated congestion can significantly impair quality of life and function 4

3. Overreliance on antihistamines alone:

   • While helpful for some symptoms, antihistamines have modest decongestant action 2
   • For patients with prominent congestion, intranasal corticosteroids are superior 4, 6

4. Failure to address environmental factors:

   • Environmental control measures may be considered as adjunctive therapy, especially given worsening symptoms after moving to an old farmhouse 1

In conclusion, based on the clinical presentation with nasal congestion as the most bothersome symptom and the strong recommendations from clinical guidelines, a glucocorticoid nasal spray is the most appropriate next step in management.