In a 40-year-old adult with a 2-week history of nasal congestion, increased use of a topical decongestant spray, frontal sinus pressure, hyposmia, chronic nasal erythema with crusting, long-standing tinnitus, and exam findings of frontal and maxillary sinus tenderness and an erythematous crusted nasal septum (no fever or cough), what is the most likely diagnosis and appropriate management?

Diagnosis: Rhinitis Medicamentosa with Possible Underlying Chronic Rhinosinusitis

This patient has rhinitis medicamentosa from prolonged topical decongestant overuse, evidenced by increased nasal spray use, erythematous crusted nasal mucosa, rebound congestion, and 2-week symptom duration. 1

Primary Diagnosis: Rhinitis Medicamentosa

The clinical presentation is classic for rhinitis medicamentosa:

• Increased topical decongestant use ("using nasal spray more than usual") indicates tachyphylaxis and rebound congestion 1
• Erythematous nasal septum and passages with crusting are pathognomonic findings from prolonged α-adrenergic spray use 1
• Persistent congestion despite escalating spray use demonstrates the rebound phenomenon 1
• Benzalkonium chloride in vasoconstrictor sprays used >30 days causes loss of ciliated epithelial cells and mucosal damage 1

Secondary Consideration: Chronic Rhinosinusitis

The 2-week duration with frontal/maxillary sinus tenderness and hyposmia raises concern for concurrent CRS, though diagnostic criteria require ≥12 weeks of symptoms 1:

• Current symptoms (nasal obstruction, facial pressure, hyposmia) match CRS criteria but duration is insufficient 1
• Absence of fever and purulent discharge argues against acute bacterial rhinosinusitis 1
• The 10-14 day threshold for bacterial sinusitis has not been met 1, 2

Immediate Management Algorithm

Step 1: Discontinue Topical Decongestants Immediately

• Complete cessation of all α-adrenergic nasal sprays (oxymetazoline, phenylephrine) is mandatory 1
• Continued use risks nasal septal perforation in rare cases 1

Step 2: Initiate Intranasal Corticosteroids

• Start twice-daily intranasal corticosteroid spray (fluticasone, mometasone, or budesonide) to control rebound congestion while decongestant effects dissipate 1, 3
• This is the cornerstone of rhinitis medicamentosa treatment 1

Step 3: Consider Short-Course Oral Corticosteroids

• Add oral prednisone 30-40mg daily for 5-7 days if symptoms are severe enough to prevent compliance with topical decongestant cessation 1
• This bridges the withdrawal period when rebound congestion peaks 1

Step 4: Nasal Saline Irrigation

• High-volume saline irrigation 2-3 times daily addresses crusting and promotes mucosal healing 1
• Particularly important given the crusting on examination 1

Evaluation for Underlying Conditions

Once rhinitis medicamentosa resolves (typically 2-4 weeks), evaluate for:

Allergic Rhinitis

• Skin prick testing or specific IgE testing to identify triggers that may have initiated decongestant use 1
• History of chronic nasal erythema suggests possible allergic component 1

Chronic Rhinosinusitis

• If symptoms persist beyond 12 weeks total, meet with documentation of mucosal inflammation (endoscopy or CT), formal CRS diagnosis is established 1
• Current 2-week duration is too short for CRS diagnosis 1

Atrophic Rhinitis (Less Likely)

• Crusting raises this possibility, but absence of fetor and normal turbinate appearance on exam make this unlikely 1
• Atrophic rhinitis shows "empty nose syndrome" with absent turbinates on CT 1

Critical Pitfalls to Avoid

Do not prescribe antibiotics at this time:

• No fever, no purulent discharge, and <10-14 day symptom duration means bacterial sinusitis criteria are not met 1, 2
• Antibiotic use would be inappropriate and contribute to resistance 1

Do not allow continued topical decongestant use "while transitioning":

• This perpetuates the cycle and delays recovery 1
• Abrupt cessation with corticosteroid support is the only effective approach 1

Do not confuse azelastine (antihistamine spray) with decongestant sprays:

• Azelastine does not cause rebound congestion and can be used safely 4
• Only α-adrenergic vasoconstrictors cause rhinitis medicamentosa 4

Expected Timeline

• Rebound congestion peaks at 3-7 days after decongestant cessation 5
• Symptom improvement begins at 1-2 weeks with intranasal corticosteroids 1
• Full resolution typically occurs by 4 weeks 1
• Reassess at 4-6 weeks: if symptoms persist, investigate for underlying allergic rhinitis or CRS requiring specialist referral 1

When to Refer to Otolaryngology/Allergy

Referral is indicated if: 1

• Symptoms persist beyond 4-6 weeks despite appropriate treatment
• Nasal polyps are identified on examination (none noted currently)
• Recurrent episodes requiring multiple oral corticosteroid courses
• Quality of life significantly impaired (voice changes and tinnitus warrant evaluation)
• Need for allergy testing and potential immunotherapy 1

The tinnitus since 2019 is likely unrelated to current rhinitis medicamentosa but warrants separate audiologic evaluation if not previously assessed.