What is the best treatment approach for a patient with intermittent nighttime awakenings due to sinus congestion and a runny nose, which resolve by morning?

Nighttime Allergic Rhinitis with Morning Resolution

Start intranasal corticosteroids (fluticasone propionate 1-2 sprays per nostril) used once daily in the evening before bed, as this pattern strongly suggests nocturnal allergen exposure (dust mites, bedroom allergens) causing intermittent allergic rhinitis. 1

Understanding the Clinical Pattern

This presentation is classic for bedroom allergen exposure causing nocturnal allergic rhinitis that resolves once the patient leaves the allergen-rich environment in the morning. 2

• The intermittent nature with complete morning resolution points to environmental allergen exposure during sleep rather than infectious rhinosinusitis, which would persist throughout the day. 2
• Common culprits include dust mites in bedding, pet dander if animals sleep in the bedroom, or mold in the sleeping environment. 2

First-Line Treatment Approach

Intranasal corticosteroids are the single most effective medication class for controlling all four major symptoms of allergic rhinitis (sneezing, itching, rhinorrhea, and nasal congestion) and should be initiated immediately. 2, 1

• Fluticasone propionate 50 mcg per spray: Use 1-2 sprays per nostril once daily in the evening (before bed for this patient's timing). 3
• Relief may begin within the first day, but maximum effectiveness requires several days of continuous use. 3
• Continue daily use as long as exposure to the bedroom allergens persists. 3
• Direct sprays away from the nasal septum to prevent mucosal erosions and potential septal perforation. 2, 1

Why Not Other Options?

• Oral antihistamines alone are inadequate because they have minimal effect on nasal congestion, which appears to be a primary symptom based on "sinus congestion." 1, 4
• Avoid topical decongestants (oxymetazoline) beyond 3 days maximum, as rhinitis medicamentosa (rebound congestion) can develop, worsening the problem. 2, 1, 4
• Oral decongestants (pseudoephedrine) could help congestion but cause insomnia, which would be counterproductive for nighttime symptoms. 2

Environmental Controls (Concurrent with Medication)

Implement allergen avoidance measures immediately, even while starting intranasal corticosteroids. 1

• Encase mattress and pillows in allergen-impermeable covers for dust mite control. 2
• Wash bedding weekly in hot water (>130°F/54°C). 2
• Remove pets from the bedroom if present. 2
• Use HEPA air filtration in the bedroom. 2
• Check for and remediate any mold or excessive humidity. 2

When to Escalate or Refer

• If symptoms persist after 1 week of intranasal corticosteroids, consider adding an intranasal antihistamine (azelastine) to the regimen, as combination therapy is more effective than either alone. 1
• If no improvement after 1 week, stop and consult a physician to rule out sinus infection or other causes. 3
• Consider allergy testing (skin or specific IgE blood tests) if empiric treatment fails or if identifying specific allergens would help target environmental controls. 2

Critical Pitfalls to Avoid

• Never use topical decongestants regularly - rhinitis medicamentosa can develop in as little as 3 days and will worsen the congestion cycle. 2, 1
• Don't rely on oral antihistamines as monotherapy for congestion-predominant symptoms - they are ineffective for this complaint. 1, 4
• Don't stop intranasal corticosteroids when symptoms improve - continue as long as allergen exposure persists to maintain relief. 3
• Don't add oral antihistamines to intranasal corticosteroids - multiple high-quality trials show no additional benefit. 1

Duration and Monitoring

• Adults can use intranasal corticosteroids for up to 6 months continuously before checking with a doctor. 3
• Children ages 4-11 should use for no more than 2 months per year before medical consultation due to potential growth effects. 3
• Monitor for epistaxis (5-10% incidence) and nasal irritation, which are the most common side effects. 5