TAP CHl Y HOC VIJT NAM TAP 459 • THANG 10 - SO 2 - 2017
KHAO SAT DAC DIEM LAM SANG, YEU TO NGUY ca vA DANH GIA KET QUA DIEU TRI N O I KHOA CtA VIEM MUI DO THUOC CO MACH TAI C H 6
Tran Vi£t Luan*, Le Thi Thu mhn**
TOM TAT
Dat van de: Viem mui do thuoc co mach tai cho la mot tinh trang^ benh gay ra bdi viec lam dung thuoc CO mach tai cho, dan tdi tinh trang nghet mQi tien tnen xau d|n. Cf Viet nam, viec lam dung thuoc co m?ch tai cho de dieu_^tn; nghet mui gay ra tinh viem mui do thuoc kha pho bien. Muc tieu: khao sat dac diem lam sang, yeu to nguy cd va danh gia ket qua dieu tri noi khoa cua viem mui do thuoc co mach tai cho. Phu'dng phap nghien cu'u: mo ta, tien cini cd can thiep lam sang. Ket qua: 30 benh nhan viem mui do thuoc tai benh vien quan Thu OLTC, TP. Ho Chi Mmh bj viem mui do thuoc du'dc du^a vao nghien cu'u. Mire dp nghet mui nang chiem 40%, nghet mtJi vira chiem 613%. Noi soi mui sau dat thuoc co mach: 100% ghi nh|n niem mac mui phii ne, cuon mui du'di qua phat;
96,7% CO niem mac miji khong hoac kem co hoi. Sau dieu trj ngi khoa vdi corticoid udng, corticoid tai cho va xit mui vdi nu'dc muoi sinh ly 0,9%: 96,7% ngu'ng di/dc thuoc co mach (86,7% tot, 10%_ trung binh).
K€t luan: sir dung thuoc co mach tai cho vdi thdi gian ngan nhatja 12 ngay se du'a den viem mQi do thuoc.
vdi cac bieu hien nghet mui, phu ne mem mac, qua phat cuon du'di. Oieu tr; ngi khoa doi vdi tinh trang nay la kha hieu qua va an toan.
SUMMARY
CLINICAL MANIFESTATIONS & RISK FATORS OF R H I N I T I S MEDICAMENTOSA
INDUCED BY TOPICAL NASAL DECONGESTANTS AND EFFECTIVENESS OF
ITS TREATMENT
Introduction: rhinitis medicamentosa induced by overuse of topical nasal decongestants is a condition characterized by progressive nasal congestion. In Vietnam, the overuse of topical nasal decongestants that resulting in rhinitis medicamentosa is common.
Objective: to describe dinical manifestations, risk factors of rhinitis medicamentosa induced by overuse of topical nasal decongestants and to evaluate the effectiveness of the treatment for this condition.
Method: descriptive prospective study with inten/ention. Results: 30 patients suffering from rhinitis medicamentosa in Thu Due distnct hospital. Ho Chi Mmh a t / were included in this study, 40% of pahents had moderate nasal congestion, 60% had severe nasal congestion. Nasal endoscopy showed
*Dalhoc Ykhoa Pham Ngoc Thach
**benh vien Quan Thu Ddc Tp. Ho Chi Minh Chiu trach nhiem chinh: Tran Viet Luan Eniail: [email protected] Ngay nhan bai: 12.8.2017 Ngay phan bien khoa hoc: 29.9.2017 Ngay duyet bai: 4.10.2014
100% patients had nasal mucosa swelling and infenor turbinate hypertrophy; 96.7% had no response with topical nasal decongestants. 96.7% successfully stopped using topical decongestants after the medical treatment with oral steroid, topical nasal sterciid, and normal saime spray (good result: 86.7%, medium result: 10%). Conclusion: 12 days using topical nasal decongestants is the shortest time can lead to rhinitis medicamentosa with nasal congestion, mucosal swelling and infenor turbinate hypertrophy. Medical treatment for rhinitis medicamentosa is effective and safe.
I. DAT VAN OE
Viem mui do thuoc la tinh trang nghet miii tai hoi tren nhij'ng benh nhan da sd dyng thudc thdng miJi tai chd hay toan than (nhii'ng thudc x\t miji nhu' oxymetazoline, xylometazoline, naphazollne, pseudoephedrine...) trong mpt thdi glan keo dai, do lam co mach d niem mac mui.
Tinh trang nay thu'dng xay ra sau vai hay nhleu ngay sd dyng nhu'ng loai thuoc nay [3]. Benh nhan thu'dng cd gang tang ca lieu lu'dng va tan sd cua thudc khi da bat dau viem mui do thuoc.
Tinh trang nay cang luc cang xau hdn. Khi do, niem mac miji phu ne, do nghet miji tai hoi, cuoi ciJng cd the se d i n den tang san cuon mui du'di vinh v i l n va nghet miji thu'dng xuyen [2],[3],[5].
Thuat ngO' viem mui do thudc cung du'dc sd dung de md ta tinh trang nghet mui nhieu hdn sau khi SLr dung cac loai thudc khac ngoai thudc co mach mui. NhUng loai thudc nay bao gom thuoc doi khang 6 giao cam, thudc chdng loan than, thudc tranh thai, thuoc ha huyet ap [1].[5].
Tuy nhien, cd che gay ra nghet mui giij'a thuoc CO mach tai chd va thudc uong cd sd khac biet.
Trong nghien cu'u nay, chung tdi chi de cap den viem miji do thudc co mach tai chd.
Tinh hinh su' dyng thudc khdng toa d Viet Nam rat pho bien, dan den viec tam dyng thuoc la dieu khd tranh khdi. Khong kho khan khi tim mua thudc co mach tai quay thuoc. Do dd, tinh hinh viem mui do thuoc d Viet Nam cung a n dddc quan tam va chiing tdi thu'c hien de tai nay vdi myc tieu: Khao sat dae dii'm lam sang, yeu to nguy cd va danh gia ket qua dieu tri ngi khoa viem mdi do thudc co mach tai cho.
II. o d l TU'pNG VA PHUONG PHAP NGHIEN Cl>U 2.1 Odii tu'dng nghien cu'u
Tieu chi chon benh: Benh nhan du 3 tieu chuan chan doan VMDT cua Walker 3S (nam 277
VIETNAM MEDICAL JOURNAL N°2 - OCTOBER - 2017 1952) bao gom: tien sd dung thudc, nghet mui
tai hdi nhieu hdn va le thugc thudc, khdng dap Omg vdi thudc co mach tai chd, den kham tai benh vien quan Thu Du'c tu" thang 9/2014 den 6/2015."
Tieu chuan loai triT: Nhij'ng tru'dng hdp nghet mui tren nhO'ng ddi tudng sau: benh nhan dang bj viem mui cap, polyp miji dp 3 trd len, da dddc can thiep cuon miii dudi: be, dot, phau thuat..
2.2 Phu'dng phap tien hanh
Bdde 1: Hdi tien sd benh ly gay nghet mQi kem t>enh sd, tan suat va tac dung phu khi diing thudc
Bu'dc 2: Cho benh nhan t d danh gia mdc dp anh hu'dng cua nghet mui theo thang diem cua Likert JS du'a ra nam 1952 [5].
Bang 2.1 Mu'c 6q anh hu'dng ciia nghet mui theo Likert
Diem 0 1 2 3
Mu'c do anh hu'dng ciia nghet mui Khdng danq chu y Nhe, danq chu y nhuhq khdnq phien toai
ViTa phai, dang chu y va cd lo ngai nhu'ng khdnq thu'dnq xuyen Nang, rat lo ngai va thu'dng xuyen.
Bu'dc 3; Kham qua ndi soi mui xoang tru'dc va sau CO mach
Bu'dc 4: Gul di do khf ap mui tru'dc dieu trj tai benh vien Nguyen Tri Phu'dng
Bu'dc 5: Tien hanh dieu tri ndi khoa vdi corticoid uong, steroid xit miji va rda miji.
- Prednisolone udng: vdi lieu 30mg/ngay uong mpt lan sau khi an sang, keo dai 5 ngay.
Sau dd giam lieu va ngu'ng prednisolone uong.
- Steroid xit mui vdi fluticasone propionate fSO pg/xjt), lieu 2 xit moi ben x 2 Ian/ngay trong 2-4 tuan clio den khi nghet miji giam dang ke [4].
- Rda mQi vdi nifdc muoi sinh ly 0,9% dang phun sddng : 2 xit moi ben x 4 Ian/ngay.
Bdde 6: Kham, cho benh nhan ty" danh gia anh hu'dng cua nghet mui, ghi nhan nhii'ng tac dung phu trong qua trinh dieu trj, npi soi mui xoang va do lai khi ap mui sau 4 tuan.
Bdde 7: Tong hdp va phan ti'ch ket qua.
TTeu d i i danh gia ket qua dTeu tri: Chung toi xay du^g tieu chi danh gia ket qua vdi 3 mu'c dp:
TohBenh nhan nguTig sd dung thudc eo maeh oMdc dp nghet mui 0 - 1 diem
oNpi soi: kicii thu'dc va niem mac cuon du'di binh thu'dng hoac gan nhu' binh thu'dng
Trung binh. Ngulig sd dyng thudc co mach oMdc dp nghet mui: 2 diem
oNpi soi: cuon dddi giam qua phat phu ne so vdi tru'dc khi dieu trj
Xau, Khdng ngu'ng dddc thudc _ oHoac mdc dp nghet mCii: 3 diem
oHoac ndi soi: cuon du'di qua phat phiJ ne khdng thay ddi so vdi tru'dc khi dieu tri.
III. KET QUA VA BAN LUAN
3.1 Dac diem djch t e hoc: Mau nghien cihi tren 30 binh nhan viem mui do thuoc, tuoi trung binh la 39 (tuoi trung vj la 37, khoang tu' vi la 27 - 45). Trong dd tuoi cao nhat la 72 tudi, ttiap nhat la 20 tudi. Gidi tinh 21 nam (70%) va 9 nti' (30%).
3.2 Van de suT dung thuoc: Trong so 30 benh nhan VMDT, khoang 66,68% (gom 20 benh nhan) sd dung thudc co mach miji naphazoline 0,05% (rhinex). Ty le benh nhan SLT dung thuoc CO maeh miJi xylometazoline 0 , 1 % (otilin) va oxymetazoline hydroclorid 0,05% (eoldi-B) la nhd nhau, cung chiem 13,33% (gom 4 benh nhan). Cdn lai 3,33% (gom 1 benh nhan) la t^ le benh nhan dung ket hdp thuoe co mach mui naphazoline 0,05% (rhinex) vdi xylometazoline 0 , 1 % (otilin). Od cung chinh la ty le benh nhan dung ket hdp thuoc co mach miJi naphazollne 0,05% (rhinex) va oxymetazoline hydroclorid 0,05% (coldi-B). Dieu nay lien quan den tinh ph6 bien cLia thuoc tren thj trddng hien nay.
Sd benh nhan dung thudc co mach mui td 3-5 ddt chiem ty le cao, khoang 56,7% (gom 17 benh nhan). Sd benh nhan sd dung thuoc co mach miJl td 1-2 ddt chiem t / le la 30% (gom 9 benh nhan) va thap nhat la so benh nhan su' dyng thuoc co mach mQi tren 5 ddt chiem ty le 13,3% (gom 4 benh nhan). Khoang 60% benh nhan (gom 18 ngu'di) cd thdi gian su'dung thuoc tur 14-30 ngay. Sd benh nhan cd thdi gian sii' dung thudc co mach mQi chiem ty le 36,7% tren 30 ngay (gom 11 ngu'di) va rat it benh nhan siT dung thudc co mach mui du'di 14 ngay, khoang 3,3%, (gom 1 ngu'di) dan den VMDT.
Tong sd ngay suf dung thudc co maeh mui i't nhat la 12 (1 benh nhan), vdi so ngay diling la 6 trong 2 ddt lien tiep va nhieu nhat la 450 ngay (1 benh nhan), vdi sd ngay dijng la 90 trong 5 ddt lien tiep.
Trong so 30 benh nhan bj VMDT, khoang 56,7% (gom 17 ngu'di) su" dung thuoc co mach mui t d 3-4 Ian/ngay. Ty le su" dung thuoc co mach mui tren 7 Ian/ngay cQng kha cao, chiem 23,3% (gom 7 ngu'di). So benh nhan su' dung thuoc eo mach mui t d 5-7 Ian/ngay chiem ty Iel3,3% (gom 4 ngu'di). Ty le thap nhat la benh nhan sd dung thudc eo mach mui tu" 1-2 Ian/ngay^chiem 6,7% (gom 2 ngu'di).
Vdi tdng thdi gian thdi gian sd dung thuoc du'dc ti'nh nhu' sau: Tong thdi gian dung thuoc = so ngay dimg thudc/ddt *sd ddt diJng thudc. Ket
TAP CHi Y HOC VIET HAM TAP 459 • T H A H G 10 • SO 2 - 2017 qua nghien cdu cho thay tdng thdi gian sd dung
thudc eao nhat la 450 ngay, thap nhat la 12 ngay, thdi gian sir dung trung binh la 69,6 ngay [50% so ngu&i tham gia nghien culi od thdi gian SIS' dung tit 30 ngay trd xudng, khoang td phan vi ta 21-50 ngay (tire 50% ddi tu'dng cd thdi gian sd"
dung thuoe trong khoang thdi gian nay)].
Tom lai: Neu chi d 1 hoac 2 ddt diing thuoc CO mach tai cho thi phai dung t d 14 ngay trd len mdi bj VMDT. Neu dung thudc chi 5 ngay thi phai diing den 3 ddt mdi bj VMDT. It nhat dung thuoc keo dai 6 ngay ^ong 2 ddt se bj VMDT. Tong sd ngay dung ^ i thieu la 12 ngay se dan den VMDT.
3.3 Dac diem lam sang: Qua phdng van va tham hdi tien sii" benh ly, nhu'ng nguyen nhan hay tien canbenh ly d u ^ den phai dung thudc co mach tei chd dddc ghi nhan lai. Trong do: viem miJi di iing chiem ty le cao nhat 53,3% (gom 16 benh nhan), nhiem triing du'dng ho hap tren cliiem 36,6% (gom 11 benh nhan), viem mui xoang man tinh chiem ty ie 13,3% (gom 4 benh nhan), cac ly do khac vi du nhu' tien sir cd tiep xuc vdi khdi bul, hda chat, thudc la... chiem 16,7% (gom 5 benh nhan). Nghien cdu cua Yuta cho thay benh ly sd dyng thuoc nhieu nhat la viem cap tinh, ke dd la viem mui di dng [6].
Mdc do nghet mui theo thang diem Likert JS (nam 1932) [5] vdi 4 dp, ghi nhan ket qua nhu' sau; ty le benh nhan bi nghet mQi d mu'c dp nang, rat lo ngai va thu'dng xuyen chiem 40%
(gom 10 benh nhan). Cdn lai la so benh nhan bi nghet mui d mufc dp vira phai, dang chu y va cd lo ngai nhdng khdng thu'dng xuyen chiem ty le 60% (gom 20 benh nhan), cao gap 1,5 lan. Hoan toan khdng cd benh nhan nao nghet mQi nhe hoac khdng nghet mui lai sd dung thudc co mach mQi tai cho.
Tru'dc kill dat thuoc co mach, danh gia qua ngi soi, quan sat ghi nhan 100% benh nhan (gom 30 ngu'di) cd niem mac mui phu ne va cd cuon mui dddi qua phat. Sau khi dat thudc co
mach, 100% benh nhan (gom 30 ngu'di) ed niem mac mQi phii ne, cuon mui dddi qua phat, 96,7%
(gom 29 ngu'di) cd niem mac mui eo hoi kem hoac khdng va 3,3% (gom 1 ngu'di) veo vach ngan.
Sau khi dung thudc co mach, 53,3% (16 ngu'di) khdng bj^ bat ky tac dung phy nao, 30%
(9 ngu'di) cd bleu hien hoi hop, lo lang; 20% (6 ngu'di) ed nhjp tim nhanh, 13,3% (4 ngu'di) tang huyet ap va 6,7% (2 ngu'di) loan nhjp tim.
Khoang 33% benh nhan (gom 10 ngu'di) dddc thu'c hien khi ap mQi tru'dc va sau khi dieu trj. Vi khi ap mQi giup danh gia nghet mui nhu' mdt phu'dng tien danh gia khach quan trieu chuYig nghet mui cua benh nhan nen chung tdi khdng cd y djnh so sanh va di sau vao phan tich ky sy khac biet ve ket qua thu du'dc khi danh gia trieu chu'ng nghet mQi theo chii quan eua benh nhan va phan loai dp nghet mui khach quan tliep thdng so tong trd khang qua mui d 150 Pa. 6 nhieu benh nhan, do khi ap mui cho ket qua binh thu'dng nhu'ng lai than phien nghet mui va ngddc lai. Do chu ky mQl, lu'u lu'dng khi qua mui d moi ben khac nhau d ciing mdt thdi diem, trd khang mui do vay cung khac biet. Tuy vay, tong Idu lu'dng khi la khdng ddi. Khi trd khang mui thay dol thi luU lu'dng qua mui cung thay ddi theo, trong khi ap lire la hang dinh (150 Pa). Do dd, khi danh gia dp nghet mui khach quan ta chi ran dy'a vao trd ktiang mQi. Sd dl ta chpn d ap Idc 150 Pa vi theo ket qua cua nhieu nghien cdu ve khi ap mQi thi hau het cac ca the binh thu'dng deu dat tdi ap lyc nay va d miTc nay luong khi qua mQi sinh ly hdn. Trong nghien cdu cua chung tdi, chi sd tdng trd khang tru'dc va sau khi dat thudc co mach khac biet khdng y nghla (p<0,05) cang gdp phan cung edchan doan benh.
3.4 Oanh gia ket qua Sieu trj: Trong 30 benh nhan VMDT da du'dc dieu trj, 50 % benh nhan (gom 15 ngu'di) dieu tri trong 4 tuan, 43,3%
(gom 13 ngydl) dieu tri trong 2 tuan va chi 6,7%
(gom 2 ngydi) dieu tri trong vdng 3 tuan.
~
„Thdi gian su*
dung tliuoc Cngay)
< 1 4 1 4 - 3 0
> 3 a
Tiidi gian dieu tri (ngay) 14
1(100%) 11(61,1%) 1(9,1%)
2 1 0(0%) 1(5,7%) 1(9,1%)
*i(
28 0(0%) 6(33,3%) 9(81,8%) em dinf) cii
P 0,01*
nil xac Fistier Trong so nhOUg benh nhan co thdi gian si dung thuoc co mach tai cho tren 30 ngay, so benh nhan phai trai qua 28 ngay ngay dieu tri chiem ty ie la 81,8% (gom 9 benh nhan). Trong l<hi ty le nay 6 nhO'ng ngu'di sir dung thuoc co mach tiJ 14-30 ngay la 33,3% (gom 6 benh nhan) va du'di 14 ngay la 0% Nhifng sir k h k biet nay co <i nghta thong ke (p<0,05). Hau het benh nhan (29 ngirdi), khoang 96,7% ngu'ng sCr dung diTdc thuoc co mach tai cho va chi 1 benh nhan (chiem ty le 3,3%) khong ng'uTig sir dijng thuoc co mach, dii rang co do nghet mui cd giam.
VIETNAM MEDICAL JOURNAL N°2 - OCTORFH - 7017
Bang 3.2 Su* cai tliien ngliet mui tiieo tlianq diem Lii<ert iviu'c do anil iiu'dng ciia
hgiiet m i i i Tru'dc dieu trj
Klibnq Nhe Vu'a phai
Nanq
Sau dieu tri Khong
0 0 7(38,9%)
0
Nhe 0 0 11(61,1%)
9(81,8%)
Vira phai 0 0 0 3(18,2%)
Nanq 0 0 0 0
p 0,02«
Ooi vdi nhu'ng ngddi tryde dieu trj cd myc dp nghet mui la vu^ phai (gom 18 trddng hdp) thi cd khoang 38,9% (gom 7 tru'dng hdp) khdng cdn trieu chdng nghet mui, 6 1 , 1 % (gom 11 trydng hdp) cdn nghet mQi mire dp nhe. Trong khi nhu'ng ngddi tru'dc dieu tri cd myc do nghet mui rat nang (12 tru'dng hdp) thi cd khoang 81,8%
(9 trydng hdp) giam xudng myc dp nhe va cdn 18,2% (3 tru'dng hdp) cdn nghet mQi d myc dp vita phai. Nhu'ng sd cai thien nay cd y nghTa thdng ke (p<0,02).
Qua npi soi, sau khi dieu tri, chya dat thudc thi cd 73,3% benh nhan (gom 22 ngu'di) cd niem mac mui binh thu'dng, 30% benh nhan (gom 9 ngddi) cd niem mac mQi van cdn phu ne va chi cdn 10% benh nhan {gom 3 ngu'di) cd cuon mQi dydi qua phat va so vdi tru'dc dieu tri thi cd sy cai thien ro ret. Sau khi dieu tri va sau khi dat thudc CO mach thi cd 73,3% benh nhan (gom 22 ngu'di) ed niem mac mQi trd lai binh thu'dng, 90% benh nhan (gom 27 ngu'di) cd niem mac mui CO hoi, niem mac mui phu ne chi cdn 7%
benh nhan (gom 2 ngu'di) va chi cdn 3% (gom 1 ngydi) cd cuon mui dddi qua phat va so vdi tru'dc dieu tri thi hau het khac biet cd y nghTa thong ke (p<0,05) (ngoai tru' tinh chat veo vach ngan).
Qua khf ap mQi, tryde dieu trj, trong so 4 tru'dng hdp (40%) nghet mui d mdc dp nang.
Sau dieu trj, 1 tru'dng hdp (25%) nghet mui cai thien d mire dp trung binh va 3 tru'dng hdp (75%) d mye dp it. Tryde dieu tri, tat ca 6 tru'dng hdp (60%) cai thien nghet mui td mdc do trung binh ve it (100%).
Chi 1 ngydi cd ket qua dieu trj xau (phai ddt cuon mui du'di) chiem 3,3%, ket qua dieu tn tdt ehiem 86,7% (26 ngydi), edn lai la ket qua dieu trj trung binh chiem 10% (3 ngddi).
Viec sy dung corticoid tai eho va dddng toan than deu ed the dan den nhu'ng tac dung phy nhy viem loet da day - ta trang, tang huyet ap, chay mau mui - loet mui, phu do giu" muoi - nddc, suy thydng than ..Trong qua trinh dieu tri chi 16,7% (5 trddng hdp) viem da day, cac tac dung phu khac hau nhd khdng xay ra d cac trydng hdp cdn lai.
*kiem djnh McNemar IV. KET LUAN
Co sy lien quan gida nghet mui hay do thoi quen d u ^ den phai diing thudc co maeh tai eho gap d nhu'ng benh nhan ed tien can benh ly viem mQi di dng (53,3%), viem hd hap tren (36.6%), tiep xuc khdi byi, hda chat, thuoc la (16,7%), viem xoang man (13,3%), qua phat cuon du'di (10%), veo vach ngan ( 3 % ) . . .
i t nhat dung thuoe keo dai 6 ngay trong 2 ddt se bi VMDT. Tong sd ngay dung toi thieu la 12 ngay se dan den VMDT. So lan su" dung trong ngay cang cao thi thdi gian su" dung trung binh cang dai va sd khac biet nay cd y nghTa thong ke (p<0,05)
Myc dp nghet mui nang chiem 40%, mdc do nghet mQi vda chiem 60%. Qua npi soi, sau dat thudc co mach, 100% ghi nhan niem mac mui phu ne, cuon mui du'di qua phat
Bleu tri ndi khoa viem mQi do thudc vdi corticoid udng, steroid xjt mui va rya mui vdi muoi sinh ly du'dc danh gia la hieu qua, eai thien qua myc dp nghet mui theo thang diem Likert, qua ndi soi va qua khi ap mui. 96,7 %)het le thudc. Ket qua dieu tri du'dc danh gia tot chiem 86,7%, trung binh chiem 10% va 3,3% la xau Phddng phap dieu trj tddng do! an toan, it tac dyng phu. Benh nhan sau khi ngdng dddc thuoc CO mach (het le thuoc thudc) can tiep tuc dieu trj benh nen nhd viem mQi di irtig, viem xoang man, veo vach ngan ...
TAI LIEU T H A M KHAO
1. Graf P(2005)"Rhinitis medicamentosa: a review of causes and treatmenr. Treat Respir Med. 4:21-9 2. Graf P, 3uto 3E (1994). "Decongestion effect
and rebound swelling of the nasal mucosa during 4-week use of oxymetazoline ORL".
J.Otorhinoiaryngol RelatSpec; 56: 157-60 3. Petruson B, Hansson HA (1982). "Function and
structure of the nasal mucosa after 6 weeks' use of nose-drops". Acta Otxiiaryngol, 94: 563-9 4. Vaidyanathan. S, Williamson. P, Clearie.
K, Khan. F, Lipworth.B (2010) "Fluticasone reverses oxymetazoline-induced tachyphylaxis of response and rebound congestion". 182(1): 19-24 5. Walker 3S. " Rhinitis medicamentosa". 3
Allergy. 1952; 23: 183-6
6. Yuta A, Ogawa Y. (2010) "Clinical review of 33 cases of rhinitis medicamentosa by decongestant nassi\ s^ra>i"Allergic in Japanese,l^2{X):Vi-2,
280
