What are the treatment options for postnasal drip?

Treatment Options for Postnasal Drip

First-generation antihistamine/decongestant combinations are the most effective first-line treatment for postnasal drip, particularly for non-allergic causes. 1, 2

Treatment Based on Underlying Cause

Non-Allergic Rhinitis-Related Postnasal Drip

• First-line therapy: First-generation antihistamine plus decongestant combination (e.g., dexbrompheniramine maleate plus sustained-release pseudoephedrine sulfate, or azatadine maleate plus sustained-release pseudoephedrine sulfate) 1, 2
• Treatment duration: Minimum of 3 weeks for chronic cases 1
• Alternative therapy: Ipratropium bromide nasal spray for patients who don't respond to antihistamine/decongestant combinations or have contraindications 1, 2

Allergic Rhinitis-Related Postnasal Drip

• First-line therapy: Nasal corticosteroids, antihistamines, and/or cromolyn 1, 2
• Treatment duration: 1-month trial of intranasal corticosteroids 1, 2
• Additional option: Oral leukotriene inhibitors can decrease symptoms of allergic rhinitis 2

Rhinitis Due to Physical or Chemical Irritants

• Avoidance of exposure, improved ventilation, filters, and personal protective devices 1
• Saline irrigation to improve mucous clearance and enhance ciliary activity 3

Acute Bacterial Sinusitis

• Treatment options: Antibiotics, intranasal corticosteroids, and decongestants 1

Chronic Sinusitis

• Antibiotics (minimum 3 weeks) effective against H. influenzae, mouth anaerobes, and S. pneumoniae 1
• Oral antihistamine/decongestant (3 weeks) 1
• Nasal decongestant (5 days) 1
• Followed by intranasal corticosteroids (3 months) 1

Proper Administration Techniques

For Intranasal Corticosteroids

• Shake bottle well before use 3
• Look down by bending neck toward floor 3
• Use right hand for left nostril and left hand for right nostril 3
• Aim toward outer wall and avoid sniffing hard after application 3

For Saline Irrigation

• Use irrigation rather than spray for more effective expulsion of secretions 3
• Can be used as either sole treatment or adjunctive therapy 3

Monitoring and Expected Response

• Most patients will see improvement in cough within days to 2 weeks of initiating therapy 1, 2
• To minimize sedation from first-generation antihistamines, start with once-daily dosing at bedtime before increasing to twice-daily therapy 1, 2

Side Effects to Monitor

• Common side effects of first-generation antihistamines: dry mouth and transient dizziness 1, 2
• More serious side effects: insomnia, urinary retention, jitteriness, tachycardia, worsening hypertension, and increased intraocular pressure in glaucoma patients 1, 2
• Topical decongestants should not be used for more than 3-5 consecutive days due to risk of rhinitis medicamentosa (rebound congestion) 4, 3

Common Pitfalls and Caveats

• Newer-generation antihistamines are less effective for non-allergic causes of postnasal drip cough 1, 2
• Some patients (approximately 20%) may have "silent" postnasal drip with no obvious symptoms yet still respond to treatment 1, 2
• Failure to consider "silent" postnasal drip as a causative factor for chronic cough can lead to missed diagnoses 1, 2
• Antibiotics should NOT be prescribed unless significant or persistent purulent nasal discharge is present on examination 3
• Postnasal drip can sometimes be confused with other conditions like gastroesophageal reflux disease (GERD) 1, 2
• Endoscopic sinus surgery should be considered only for patients with documented chronic sinus infection refractory to medical therapy and with anatomic obstruction 1

Emerging Treatments

• Posterior nasal nerve ablation has shown efficacy for patients with postnasal drip as their primary complaint who have failed medical therapy, with 72.5% of patients reporting at least 30% improvement in symptoms 5
• Salso-bromo-iodine thermal water containing hyaluronic acid and grapefruit seed extract has shown promise as a non-pharmacological treatment option, particularly in children 6