What is the likely diagnosis for a patient using ephedrine (ephedrine) nasal spray three times a day (tid) for nasal congestion?

Rhinitis Medicamentosa (Rebound Congestion)

The most likely diagnosis for a patient using ephedrine nasal spray three times daily is rhinitis medicamentosa (rebound congestion), a syndrome of paradoxical worsening nasal obstruction caused by overuse of topical α-adrenergic decongestants. 1, 2

Pathophysiology and Timeline

• Rebound congestion develops from prolonged use of topical decongestants through tachyphylaxis to vasoconstrictive effects and reduced mucociliary clearance due to loss of ciliated epithelial cells 3
• The onset can occur as early as the third or fourth day of continuous topical decongestant use, though some patients may not develop symptoms until 4-6 weeks 2, 3
• Ephedrine acts as both a direct α-adrenergic agonist and indirect sympathomimetic that releases norepinephrine, causing nasal vasoconstriction 4, 5
• With continued use, the decongestive action lessens while the sense of nasal obstruction paradoxically increases, leading to a cycle of increasing frequency and dose 3

Clinical Manifestations

• Patients experience worsening nasal congestion between doses of decongestant spray, creating dependency on the medication 3
• Persistent nasal obstruction despite continued decongestant use is characteristic 3
• Nasal mucosal damage can occur in severe cases 3
• Rarely, nasal septal perforation may develop in extreme cases 3
• Benzalkonium chloride preservative in many nasal sprays may augment local pathologic effects when used for 30 days or more 3

Management Algorithm

Step 1: Immediate Discontinuation

• Stop all topical nasal decongestants immediately 3
• Do not restart ephedrine or any other topical decongestant during the withdrawal period 3

Step 2: Initiate Intranasal Corticosteroids

• Start intranasal corticosteroid (fluticasone, mometasone, or equivalent) at 2 sprays per nostril once daily 3
• These medications do not cause rebound congestion and are the most effective medication class for controlling all major nasal symptoms 1, 3
• Direct sprays away from the nasal septum to minimize irritation and bleeding 3
• Continue for several weeks as the nasal mucosa recovers 3

Step 3: Adjunctive Symptomatic Relief

• Use hypertonic saline nasal irrigation to help clear mucus and improve symptoms during withdrawal 3
• Saline provides symptomatic relief without any risk of dependency 3

Step 4: Consider Oral Corticosteroids for Severe Cases

• For very severe or intractable symptoms, add a short 5-7 day course of oral corticosteroids to hasten recovery and improve patient tolerance during withdrawal 3
• This is reserved for patients who cannot tolerate the withdrawal period with intranasal corticosteroids alone 3

Step 5: Evaluate for Underlying Conditions

• After resolution of rhinitis medicamentosa, evaluate for underlying conditions such as allergic rhinitis or chronic rhinosinusitis that may have led to initial decongestant use 3
• Patients with allergic rhinitis may need to continue intranasal corticosteroids long-term 3

Critical Prevention Points

• Never use topical decongestants for more than 3 consecutive days to prevent rhinitis medicamentosa 1, 2, 3
• For acute congestion episodes lasting only a few days, topical decongestants can be used safely for up to 3-5 days maximum 3
• When rapid relief is needed for severe congestion with underlying rhinitis, combining oxymetazoline with intranasal corticosteroid from the outset (applying decongestant first, waiting 5 minutes, then applying corticosteroid) can be safely used for 2-4 weeks without causing rebound congestion 3

Common Pitfalls to Avoid

• Do not use oral antihistamines or oral decongestants as the primary strategy for managing rebound congestion—they are less effective than intranasal corticosteroids 3
• Avoid gradual tapering of the topical decongestant in most cases; abrupt discontinuation with intranasal corticosteroid support is preferred 3
• Do not underestimate the addictive potential of these medications—patients often develop psychological and physiological dependency 3