What is the treatment for postnasal drainage?

Treatment of Postnasal Drainage

For postnasal drainage, first-generation antihistamine/decongestant combinations (such as dexbrompheniramine plus pseudoephedrine) are the most effective first-line treatment for non-allergic causes, while intranasal corticosteroids are preferred for allergic rhinitis-related postnasal drainage, with both requiring a minimum 3-week trial for chronic cases. 1, 2

Treatment Algorithm Based on Underlying Cause

For Allergic Rhinitis-Related Postnasal Drainage

• Intranasal corticosteroids are the first-line treatment, requiring a 1-month trial for optimal effect 1, 2
• Fluticasone propionate 200 mcg daily (two 50-mcg sprays per nostril once daily) or 100 mcg twice daily are equally effective regimens 3
• Maximum symptom relief may take several days, though improvement can begin as early as 12 hours after the first dose 3
• Alternative options include oral antihistamines (second-generation preferred to avoid sedation) and/or cromolyn 1, 2
• Oral leukotriene inhibitors can decrease symptoms of allergic rhinitis 1, 2

For Non-Allergic Rhinitis-Related Postnasal Drainage

• First-generation antihistamine plus decongestant combinations are superior to newer non-sedating antihistamines due to their anticholinergic properties 1, 2
• Specific effective combinations include:
  • Dexbrompheniramine maleate plus sustained-release pseudoephedrine sulfate 1, 2
  • Azatadine maleate plus sustained-release pseudoephedrine sulfate 1, 2
• Minimum treatment duration is 3 weeks for chronic cases 1
• Ipratropium bromide nasal spray is an effective alternative for patients who don't respond to antihistamine/decongestant combinations or have contraindications 1, 2

For Chronic Sinusitis with Postnasal Drainage

• Minimum 3 weeks of antibiotics effective against H. influenzae, mouth anaerobes, and S. pneumoniae 1
• 3 weeks of oral antihistamine/decongestant therapy 1
• 5 days of nasal decongestant (not to exceed this duration to avoid rhinitis medicamentosa) 1
• Followed by 3 months of intranasal corticosteroids 1

For Acute Bacterial Sinusitis

• Treatment options include antibiotics, intranasal corticosteroids, and decongestants 1
• Saline nasal irrigation may provide adjuvant benefit, though evidence is mixed in acute settings 4

Adjuvant Therapy: Saline Nasal Irrigation

Evidence for Efficacy

• Saline irrigation may improve patient-reported disease severity with large effect sizes (SMD -1.32 at up to 4 weeks; SMD -1.44 at 4 weeks to 3 months) compared to no saline 5
• The European Position Paper on Rhinosinusitis considers nasal saline irrigation an important aspect of CRS management through mechanical removal of mucus, improvement in mucociliary clearance, and disruption of inflammatory mediators 4
• Two recent studies (2016) showed significant positive effects of isotonic saline irrigation versus no irrigation, particularly with longer treatment duration (mean 7.5 months) 4
• Benefits include improvement in symptoms of thickened mucus and postnasal drainage specifically 6

Optimal Method and Volume

• Nasal douches (high-volume irrigation) are more effective than nasal sprays or nebulization in distributing solution to the maxillary sinus and frontal recess 4
• Volumes ranging from 120-250 mL per irrigation session have been studied 4
• Both isotonic and hypertonic saline can be effective, though one study found isotonic more effective than hypertonic 4
• Frequency: twice daily irrigation is the most commonly studied regimen 4

Clinical Implementation and Monitoring

Expected Timeline for Response

• Most patients will see improvement in cough within days to 2 weeks of initiating therapy 1, 2
• For intranasal corticosteroids, symptom improvement may begin as early as 12 hours, but maximum effect requires several days 3
• A minimum 3-week trial is recommended for chronic rhinitis conditions before determining treatment failure 1

Dosing Strategy to Minimize Side Effects

• To minimize sedation from first-generation antihistamines, start with once-daily dosing at bedtime for a few days before increasing to twice-daily therapy 1, 2
• Common side effects include dry mouth and transient dizziness 1, 2
• More serious side effects to monitor: insomnia, urinary retention, jitteriness, tachycardia, worsening hypertension, and increased intraocular pressure in glaucoma patients 1, 2

Maintenance Therapy

• For allergic rhinitis on intranasal corticosteroids: after 4-7 days of response to 200 mcg daily, patients may be maintained on 100 mcg daily (1 spray per nostril once daily) 3
• For chronic sinusitis: 3 months of intranasal corticosteroids following initial antibiotic therapy 1

Critical Pitfalls and Caveats

Common Diagnostic Errors

• Approximately 20% of patients with postnasal drainage-induced cough have "silent" postnasal drainage with no obvious symptoms, yet still respond to treatment 1, 2
• Failure to consider "silent" upper airway cough syndrome as a causative factor can lead to missed diagnoses 1, 2
• Symptoms and clinical findings are not reliable discriminators for postnasal drainage syndrome, making diagnosis challenging 1, 2
• Postnasal drainage can be confused with gastroesophageal reflux disease (GERD), and in fact, proton pump inhibitor therapy improved symptoms in 75 patients with chronic postnasal drainage without sinusitis or allergies 1, 7

Medication-Specific Warnings

• Newer-generation antihistamines are less effective for non-allergic causes of postnasal drainage cough 1, 2
• Topical decongestants should NEVER be used for more than 3-5 consecutive days due to risk of rhinitis medicamentosa (rebound congestion) 1
• Antihistamines have no role in symptomatic relief for non-atopic patients and may worsen congestion by drying nasal mucosa 1
• Long-term use of topical decongestants can cause rhinitis medicamentosa 1
• Decongestants can cause insomnia, irritability, palpitations, and hypertension 1

When to Consider Alternative Diagnoses

• If no response after 3 weeks of appropriate therapy, consider alternative diagnoses including GERD, which may present with identical symptoms 1, 7
• Endoscopic sinus surgery should only be considered for patients with documented chronic sinus infection refractory to medical therapy and with anatomic obstruction 1
• Not all mucosal thickening on imaging indicates bacterial infection; <8mm of mucosal thickening was associated with sterile nasal puncture in 100% of cases 2

Special Populations

• In pregnancy, caution is recommended with decongestants during the first trimester due to potential fetal heart rate changes 1
• For pediatric patients (4 years and older), start with 100 mcg intranasal corticosteroids (1 spray per nostril once daily), reserving 200 mcg for inadequate responders 3