ADDICTED TO NOSE SPRAY

A case of “rebound rhinitis”

Professor Albert Monlezun was the quintessential scholar, actor and teacher. His true love was working on stage and behind the scenes at Le Petit Théâtre du Vieux Carré in the 1960s. This talented tenor turned to teaching biostatistics to pay the bills. His bellowing lectures defied dozing. He was the only biostatistics lecturer not intimidated by raucous second-year medical students.

Monlezun’s trademark was his omnipresent huge briefcase, a perceived necessary tool of his trade since statistical work was paper-driven in those mostly pre-computer days of the 1970s. The briefcase seemed attached to his arm by some sort of invisible tether. Monlezun toted it to every class and appointment and back and forth each day on the bus between his home in Mid-City to his office at Tulane Medical School.

A plastic bottle of Afrin was always nearby for his chronically stuffed-up nose. One day the spray bottle in his extra-large lab coat was empty. No problem. He opened that big briefcase exposing the largest cache of Afrin nasal spray I’d ever seen outside of a K&B.

Monlezun’s squirts of Afrin every couple of hours were classic signs of rhinitis medicamentosa – a congested nose caused by medication. A more descriptive and newer name for this disorder is rebound rhinitis. Persons with rebound rhinitis often have had underlying allergic or seasonal allergies that triggered an initial use of decongestant nose sprays, but their ongoing nasal stuffiness is chemically induced by the exact medication that helps in the short term.

Afrin, Mucinex Full Force, Dristan 12-hour, Vicks Sinex and Neo-Synephrine are some of the trade names of these over-the-counter culprits. A squirt constricts the small blood vessels at the surface of the nasal mucosa. The nasal airways seem to magically open as the engorged blood vessels shrink. The chemical vasoconstrictor also helps shut down mucus production.

The above and similar nasal decongestants are useful for the short-term treatment of nasal congestion from a common cold or an acute allergy attack. They also help stop nosebleeds. But when used for more than four or five days, trouble abounds.

The active ingredients in these nose sprays are adrenaline-like chemicals that can also increase blood pressure by constricting larger blood vessels in the body. These bottles contain warnings about use in the presence of heart disease or pre-existing high blood pressure.

Each nostril has its own blood supply and innervation. The nasal passages are lined with a rich network of microscopic interconnecting blood vessels. When these microscopic blood vessels are naturally engorged in one nostril, breathing switches to the other nostril. Just as a cleanup crew whisks through an airplane cabin between flights, the nostril cleanup crew rushes in to wash out pollen and other inhaled dirt trapped during the breathing process. Mucus-producing goblet cells lead the charge as various contaminants are blown out the nose or discreetly swallowed.

Decongestant sprays lead to long-term damage to the delicate cells and blood vessels lining the nasal passages. They become edematous or puffy with water. Inflammatory cells move in. Cell structures called cilia that gently move mucus along stop functioning. A brief blast of a nasal decongestant provides relief for an hour or so, but the inflammation in the nasal passages worsens.

Like Monlezun, the classic patient with chronic nasal congestion from rebound rhinitis sprays both nostrils every couple of hours even though lacking the running nose or sneezing that defines nasal and sinus allergies. Over time rebound rhinitis causes other complications including chronic irritation of the higher-up sinuses and enlargement of the nasal turbinates further compromising normal breathing. It becomes a vicious cycle. Breathing at night shifts from the nose to the mouth causing the onset of other problems from dry mouth to sore throat to sleep apnea.

The long term user develops both a psychological and physical dependence on these nasal sprays. If a person tries to stop using the sprays, they get other withdrawal symptoms unrelated to the stuffy nose – headaches, irritability, restlessness and sleep problems. The inside of the nose becomes irritated and red.

Rebound rhinitis affects both men and women equally. The typical sufferer is a young adult who keeps sniffing into their middle years. Persons with seasonal allergies and infections usually have the sudden onset of sneezing and a nose that runs like a faucet. On the other hand, a person with rebound rhinitis rarely sneezes or needs a Kleenex for a running nose.

According to local otolaryngologist Dr. Michael Ellis, common symptoms of rebound rhinitis include a constant nasal congestion relieved only temporarily with more and more nasal spray use, a thick postnasal sinus drip, soreness about the nasal area and thick crusts in the nose (see box).

Over time the senses of taste and smell are altered. Nasal polyps can sprout inside the nose further complicating breathing. Long-term misuse of nasal decongestant sprays can even burn a hole in the septum separating the two nostrils, a complication usually attributed to continued cocaine abuse.

The path to rebound rhinitis often starts with a common cold or a seasonal allergy attack that causes a person to wake up with a stuffy nose. A nasal decongestant provides almost instant relief with the stuffiness, but continued use for more than a week can cause dependency. After a couple of weeks, it is hard to be away from the spray for more than a few hours without the onset of profound rebound congestion within hours. The nose becomes a hostage to a vicious cycle of more and more frequent squirts of the decongestant, a dependence that can last for years.

It is almost impossible for most people with rebound rhinitis to stop cold turkey. Any underlying diagnosis, which led to the original use of the nasal decongestant, needs to be identified and treated in a more appropriate way. Often oral or nasal steroids can help break the vicious cycle by decreasing the swelling and inflammation in the nose. Like most medical problems today, the malady has spawned Web sites including www.afrinaddiction.com, which hawks a book about quitting.

I last saw Monlezun more than a decade ago. We were both shopping at the old Canal Villere at Canal Street and Carrollton Avenue. Tucked in his grocery cart were about a dozen boxes of Afrin. “I know, I know,” he said, “but I can no longer drink or smoke. Afrin is my sole remaining vice.”
 

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