What are the assessment and treatment options for a patient presenting with nasal congestion, considering potential underlying conditions such as allergic rhinitis or viral upper respiratory infection, and possible comorbidities like hypertension, diabetes, or glaucoma?

Assessment and Treatment of Nasal Congestion

Initial Clinical Assessment

Begin by determining whether symptoms suggest allergic rhinitis, viral upper respiratory infection, or nonallergic rhinitis through specific historical features and physical examination findings, as this distinction fundamentally alters treatment approach. 1

Key Historical Features to Elicit

• Temporal pattern: Seasonal symptoms (outdoor allergens like pollen), perennial symptoms (indoor allergens like dust mites, animal dander), or episodic exposure-related symptoms point toward allergic rhinitis 1
• Associated symptoms distinguishing allergic from nonallergic causes:
  • Nasal and ocular itching, sneezing, and clear rhinorrhea strongly suggest allergic rhinitis 1, 2
  • Isolated nasal congestion with postnasal drainage without itching or sneezing suggests nonallergic rhinitis 3
  • Symptoms lasting 3-4 days with throat pain and fever suggest viral rhinosinusitis 4
• Duration: Viral infections typically peak within 3 days and resolve within 10-14 days 4
• Medication history: ACE inhibitors, alpha-blockers, phosphodiesterase-5 inhibitors, and overuse of topical decongestants (>5 days) can cause drug-induced rhinitis or rhinitis medicamentosa 1
• Comorbidities: Family history of atopy, personal history of asthma or eczema strengthen allergic rhinitis diagnosis 1

Physical Examination Findings

• Allergic rhinitis: Pale or bluish edematous nasal mucosa, clear rhinorrhea, allergic shiners, nasal crease 1, 3
• Nonallergic rhinitis: Erythematous inflamed turbinates with serous secretions 3
• Red flags requiring further investigation: Unilateral symptoms, epistaxis, severe headache, anosmia, or purulent discharge suggest alternative diagnoses (tumors, CSF leak, bacterial sinusitis) 1

Diagnostic Testing

Perform specific IgE testing (skin testing preferred, or serum IgE) only when the diagnosis is uncertain, empiric treatment fails, or when identifying specific allergens is needed for targeted avoidance or immunotherapy. 1, 2

• Skin testing is the preferred diagnostic method with higher sensitivity than serum IgE testing (which has approximately 70-75% sensitivity compared to skin tests) 1, 2
• Testing should be reserved for patients who do not respond to empiric treatment or when the diagnosis remains unclear after history and examination 1

Treatment Approach by Diagnosis

For Acute Viral Rhinosinusitis (Symptoms <10 Days)

Use topical nasal decongestants (oxymetazoline or xylometazoline) for rapid relief, strictly limited to 3-5 days maximum to prevent rhinitis medicamentosa. 4, 5

• Topical decongestants provide superior congestion relief compared to oral pseudoephedrine and are appropriate for short-term use in acute viral infections 5
• Critical caveat: Never exceed 5 consecutive days of use to avoid rebound congestion 4, 5
• Supportive measures include:
  • Nasal saline irrigation (isotonic or hypertonic) for symptomatic relief 4, 5
  • Acetaminophen or NSAIDs for facial pain and inflammation 4, 5
  • Oral decongestants (pseudoephedrine) for 3-5 days maximum, but use cautiously in patients with hypertension, diabetes, or glaucoma 4
• Avoid antihistamines in viral rhinosinusitis as they are ineffective and may worsen symptoms by drying nasal mucosa 4
• Avoid antibiotics unless symptoms persist >10 days without improvement, worsen after initial improvement, or present with severe symptoms (high fever with purulent discharge for ≥3 consecutive days) 4, 5

For Allergic Rhinitis

Treat mild intermittent or mild persistent allergic rhinitis with second-generation oral antihistamines (cetirizine, fexofenadine, loratadine, desloratadine) or intranasal antihistamines (azelastine, olopatadine). 3

Treat moderate-to-severe or persistent allergic rhinitis with intranasal corticosteroids (fluticasone, mometasone, triamcinolone, budesonide) as first-line therapy, either alone or combined with intranasal antihistamines. 3

• Intranasal corticosteroids are the most effective single agent for allergic rhinitis with nasal congestion 1, 6
• Fluticasone propionate dosing: Adults start with 200 mcg once daily (two 50-mcg sprays per nostril); children ≥4 years start with 100 mcg once daily 6
• Symptom improvement may begin within 12 hours but maximum effect requires several days of regular use 6
• After 4-7 days of response, maintenance dose can be reduced to 100 mcg daily 6
• Combination therapy (intranasal corticosteroid plus intranasal antihistamine) provides greater efficacy than either agent alone without increased adverse effects 1
• Allergen avoidance measures should be implemented concurrently 1

For Nonallergic Rhinitis

Treat nonallergic rhinitis with intranasal antihistamines (azelastine, olopatadine) as first-line monotherapy or combined with intranasal corticosteroids. 1, 3

• Oral antihistamines are ineffective for nonallergic rhinitis and should not be used 1
• Intranasal anticholinergics (ipratropium) are useful when rhinorrhea predominates (e.g., gustatory rhinitis) 1
• Intranasal corticosteroids may provide benefit for congestion in nonallergic rhinitis 1

Special Considerations for Comorbidities

Hypertension

• Use oral decongestants (pseudoephedrine) with extreme caution or avoid entirely, as they can elevate blood pressure 4
• Topical decongestants are safer but still limited to 3-5 days 4, 5
• Intranasal corticosteroids and antihistamines have no cardiovascular effects and are preferred 1, 3

Diabetes

• Oral and topical decongestants can be used but monitor for potential effects on glucose control 4
• Intranasal corticosteroids at recommended doses have minimal systemic absorption 6

Glaucoma

• Avoid anticholinergic agents (ipratropium) in narrow-angle glaucoma 1
• Decongestants and intranasal corticosteroids are generally safe 4, 6

When to Refer to Allergist/Immunologist

Refer patients when symptoms persist despite appropriate treatment, complications develop (sinusitis, nasal polyps, otitis media), systemic corticosteroids are required, or symptoms significantly impair quality of life or function. 1, 2

Additional referral criteria include: 1

• Comorbid asthma requiring optimization
• Need for allergen immunotherapy consideration
• Rhinitis medicamentosa
• Diagnostic uncertainty after initial evaluation
• Multiple costly medications required over prolonged periods