What is the best treatment for chronic severe post nasal drip?

Best Treatment for Chronic Severe Post Nasal Drip

Intranasal corticosteroids are the cornerstone of treatment for chronic severe post nasal drip, with fluticasone propionate being particularly effective for long-term management. 1, 2

Understanding Post Nasal Drip

• Post nasal drip (PND) is now preferably termed Upper Airway Cough Syndrome (UACS) and is characterized by drainage of secretions from the nose or paranasal sinuses into the pharynx 2
• Common symptoms include sensation of drainage in the throat, throat clearing, nasal discharge, and cobblestone appearance of the oropharyngeal mucosa 2
• Some patients may have "silent" PND with no obvious symptoms yet still respond to treatment 2

First-Line Treatment Options

Intranasal Corticosteroids

• Intranasal corticosteroids are the most effective monotherapy for chronic post nasal drip, particularly when related to allergic or inflammatory causes 1, 2
• Fluticasone propionate nasal spray has been shown to significantly reduce nasal symptoms including post nasal drip 3
• Recommended dosing for adults is 200 mcg once daily (two 50-mcg sprays in each nostril) or 100 mcg twice daily (one 50-mcg spray in each nostril twice daily) 3
• Maximum benefit may take several days to achieve, though some patients notice improvement within 12 hours 3
• For severe cases, fluticasone propionate nasal drops may be more effective than sprays as they better reach the middle meatus 4

Antihistamine-Decongestant Combinations

• First-generation antihistamine plus decongestant combinations are recommended for non-allergic rhinitis-related post nasal drip 2
• Effective combinations include dexbrompheniramine maleate plus sustained-release pseudoephedrine sulfate, and azatadine maleate plus sustained-release pseudoephedrine sulfate 2
• A minimum of 3 weeks of treatment is recommended for chronic cases 2
• Second-generation antihistamines are less effective for non-allergic causes of post nasal drip 2

Treatment Based on Underlying Cause

For Allergic Rhinitis-Related Post Nasal Drip

• Intranasal corticosteroids are the first choice, with a recommended 1-month trial 2
• Oral antihistamines may be added, though second-generation agents are generally preferred over first-generation to avoid sedation 1
• Leukotriene receptor antagonists (e.g., montelukast) can be considered, especially for patients with concurrent asthma 1

For Chronic Rhinosinusitis-Related Post Nasal Drip

• A combination approach is recommended: 2
  • Intranasal corticosteroids for at least 3 months
  • Antibiotics for a minimum of 3 weeks if bacterial infection is suspected
  • Saline nasal irrigation to prevent crusting and facilitate mechanical removal of mucus 5

For Non-Allergic Rhinitis-Related Post Nasal Drip

• Ipratropium bromide nasal spray is effective for reducing rhinorrhea 2
• First-generation antihistamine/decongestant combinations are more effective than newer-generation antihistamines 2

Special Considerations

Duration of Treatment

• For allergic rhinitis with post nasal drip, a 1-month trial of intranasal corticosteroids is recommended 2
• For chronic rhinosinusitis, longer treatment courses (3+ months) with intranasal corticosteroids are often necessary 2
• Regular use of intranasal corticosteroids is more effective than as-needed use for persistent symptoms 3

Side Effects to Monitor

• Intranasal corticosteroids: nasal dryness, epistaxis, and rarely, nasal septal perforation 3
• First-generation antihistamines: dry mouth, sedation, dizziness, and in some cases insomnia, urinary retention, or increased intraocular pressure 2
• Decongestants: insomnia, irritability, palpitations, and hypertension 1

Common Pitfalls and Caveats

• Failure to consider "silent" UACS as a causative factor for chronic cough can lead to missed diagnoses 2
• Long-term use of topical decongestants (>3-5 days) should be avoided as they can cause rhinitis medicamentosa 1
• Newer-generation antihistamines are less effective for non-allergic causes of post nasal drip 2
• Endoscopic sinus surgery should only be considered for patients with documented chronic sinus infection refractory to medical therapy 2
• Post nasal drip can sometimes be confused with other conditions like gastroesophageal reflux disease (GERD) 2

When to Consider Specialist Referral

• For symptoms refractory to standard treatment after 3 months of appropriate therapy 5
• For recurrent episodes (more than 3-4 per year) 5
• When complications or anatomical abnormalities are suspected 5