What's the next step for a patient with a history of Deviated Nasal Septum (DNS) and allergies, who hasn't improved after one week of levofloxacin (levofloxacin) for symptoms of retroorbital pain, nasal congestion, postnasal drip, and cough?

Management of Treatment-Refractory Upper Airway Symptoms in a Patient with DNS and Allergies

This patient likely has upper airway cough syndrome (UACS) secondary to allergic rhinitis and/or chronic rhinosinusitis, not acute bacterial sinusitis, and levofloxacin was an inappropriate initial choice—the next step is to discontinue the fluoroquinolone and initiate a first-generation antihistamine-decongestant combination (such as dexbrompheniramine 6 mg or azatadine 1 mg with sustained-release pseudoephedrine 120 mg, both twice daily) along with intranasal corticosteroids. 1

Why Levofloxacin Failed

The clinical presentation—retroorbital pain, nasal congestion, postnasal drip, and cough without fever, purulent drainage, or acute worsening—does not meet criteria for acute bacterial rhinosinusitis (ABRS). 1 ABRS requires purulent nasal drainage accompanied by nasal obstruction and/or facial pain-pressure-fullness lasting up to 4 weeks. 1 This patient's symptoms are more consistent with UACS from allergic rhinitis or chronic rhinosinusitis, conditions where antibiotics provide no benefit. 1

Reassess the Diagnosis

Before proceeding with treatment, confirm this is not ABRS by verifying the absence of:

• Purulent (not clear) nasal discharge 1
• Worsening symptoms after initial improvement (the "double-sickening" pattern) 1
• Severe symptoms (fever ≥39°C, purulent discharge) for at least 3-4 consecutive days 1

Alternative diagnoses to consider include allergic rhinitis, vasomotor rhinitis, or anatomic obstruction from the deviated septum itself. 1, 2 The history of allergies strongly suggests an allergic component. 1

First-Line Treatment: Antihistamine-Decongestant Combination

Initiate a first-generation antihistamine-decongestant (A/D) preparation immediately. 1 The evidence specifically supports:

• Dexbrompheniramine maleate 6 mg twice daily PLUS pseudoephedrine sulfate 120 mg sustained-release twice daily, OR
• Azatadine maleate 1 mg twice daily PLUS pseudoephedrine sulfate 120 mg sustained-release twice daily 1

These older-generation combinations have proven efficacy in randomized controlled trials for UACS-induced cough, whereas newer non-sedating antihistamines (like loratadine or terfenadine) have failed to show benefit. 1 The anticholinergic effect of first-generation antihistamines is critical for reducing secretions in non-histamine-mediated rhinitis. 1

Expected timeline: Noticeable improvement should occur within days to 1-2 weeks, with marked improvement or resolution taking several weeks to occasionally a few months. 1

Add Intranasal Corticosteroids

Simultaneously start intranasal corticosteroids, which are highly effective for both allergic rhinitis and chronic rhinosinusitis. 1 These address the underlying inflammation that perpetuates symptoms. 1

If Partial Response Occurs

If symptoms improve but don't fully resolve after 1-2 weeks of A/D therapy:

• If nasal symptoms persist: Add ipratropium bromide nasal spray for additional anticholinergic effect, particularly helpful when A/D preparations are contraindicated (glaucoma, benign prostatic hypertrophy). 1

• If UACS symptoms resolve but cough persists: Evaluate for asthma as a second cause, since chronic cough is frequently multifactorial. 1 Consider bronchoprovocation challenge or empiric asthma treatment. 1

Consider Imaging Only If Treatment Fails

If symptoms persist despite 2-3 weeks of appropriate medical therapy, obtain sinus imaging (CT preferred over plain films) to evaluate for chronic sinusitis. 1 Look for:

• Air-fluid levels (indicating acute bacterial infection requiring antibiotics) 1
• Mucosal thickening (may warrant empiric antibiotic trial in context of refractory symptoms) 1

In patients with chronic cough and excess sputum production, sinus radiographs showing abnormalities have an 81% positive predictive value for chronic sinusitis causing UACS. 1

When Antibiotics Are Actually Indicated

Only prescribe antibiotics if imaging confirms sinusitis AND symptoms persist despite optimal medical management. 1 If bacterial sinusitis is confirmed:

• First-line: Amoxicillin or high-dose amoxicillin-clavulanate 1
• For true penicillin allergy: Doxycycline or respiratory fluoroquinolone (levofloxacin/moxifloxacin) 1
• Duration: 10-14 days minimum 1

Note that chronic sinusitis often involves S. aureus, coagulase-negative staphylococci, and anaerobes—not the typical acute pathogens. 1

Address the Deviated Septum

The DNS may be contributing to chronic obstruction and secondary rhinosinusitis. 1 However, septoplasty should only be considered after exhausting medical management, as it takes 24 months to become cost-effective. 3 Refer to ENT if medical therapy fails and imaging shows structural issues perpetuating disease. 1

Common Pitfalls to Avoid

• Don't continue levofloxacin. 4 Fluoroquinolones carry serious risks (tendon rupture, CNS effects, aortic dissection) and are inappropriate for non-bacterial conditions. 4
• Don't use newer non-sedating antihistamines alone for UACS—they lack the anticholinergic effect needed for secretion control. 1
• Don't assume all nasal symptoms require antibiotics. Most chronic rhinitis is non-infectious. 1, 2
• Don't forget this may be multifactorial. Address allergies, consider GERD, and evaluate for asthma if cough persists. 1