Nasal congestion and rhinorrhea (runny nose) are extremely common problems that commonly occur together but occasionally occur alone.
Etiology of Nasal Congestion and Rhinorrhea
The most common causes (see table Some Causes of Nasal Congestion and Rhinorrhea) are
Some Causes of Nasal Congestion and Rhinorrhea
Cause | Suggestive Findings | Diagnostic Approach* |
|---|---|---|
Mucopurulent discharge, often unilateral Red mucosa Sometimes a foul or metallic taste, focal facial pain or headache (often positional), and erythema or tenderness over the maxillary or frontal sinus | Usually clinical examination alone CT considered in patients with diabetes, immunocompromise, or signs of serious illness | |
Watery discharge; sneezing; watery, itchy eyes; pale, boggy nasal mucosa Symptoms often seasonal or with exposure to possible triggers | Clinical examination alone | |
Decongestant overuse | Rebound congestion as decongestant wears off Pale, markedly swollen mucosa | Clinical examination alone |
Unilateral, foul-smelling (sometimes blood-tinged) discharge in a child | Clinical examination alone | |
Recurrent watery discharge; sneezing; red, swollen mucosa No identifiable triggers | Clinical examination alone | |
Watery to mucoid discharge; accompanied by sore throat, malaise, erythematous nasal mucosa | Clinical examination alone | |
* Clinical examination is always done but is mentioned in this column only when that can be the sole means of diagnosis. | ||
CT = computed tomography; URI = upper respiratory infection | ||
Dry air may provoke congestion. Acute sinusitis is slightly less common, and a nasal foreign body is unusual (and occurs predominantly in children).
Patients who use topical decongestants for > 3 to 5 days often experience significant rebound congestion when the effects of the decongestants wear off, causing them to continue using the decongestant in a vicious circle of persistent, worsening congestion. This situation (rhinitis medicamentosa) may persist for some time and may be misinterpreted as a continuation of the original problem rather than a consequence of treatment.
Evaluation of Nasal Congestion and Rhinorrhea
History
History of present illness should determine the nature of the discharge (eg, watery, mucoid, purulent, bloody) and whether discharge is chronic or recurrent. If recurrent, any relation to patient location, season, and exposure to potential triggering allergens (numerous) should be determined. A unilateral, clear, watery discharge, particularly after head trauma, can indicate a cerebrospinal fluid (CSF) leak. CSF discharge can also occur spontaneously in women who are in their 40s and have obesity, secondary to idiopathic intracranial hypertension.
Review of systems should seek symptoms of possible causes, including fever and facial pain (sinusitis); watery, itchy eyes (allergies); and sore throat, malaise, fever, and cough (viral upper respiratory infection [URI]).
Past medical history should seek known allergies and existence of diabetes or immunocompromise. Drug (prescription, over-the-counter, illicit) history should include asking specifically about topical decongestant use.
Physical examination
Vital signs are reviewed for fever.
Examination focuses on the nose and area over the sinuses. The face is inspected for focal erythema over the frontal and maxillary sinuses; these areas are also palpated for tenderness. Nasal mucosa is inspected for color (eg, red or pale), swelling, color and nature of discharge, and, particularly in children, the presence of a foreign body.
Red flags
The following findings in patients with nasal congestion or rhinorrhea are of particular concern:
Unilateral discharge, particularly if purulent or bloody
Facial pain, tenderness, or both
Interpretation of findings
Symptoms and examination are often enough to suggest a diagnosis (see table Some Causes of Nasal Congestion and Rhinorrhea).
In children, unilateral foul-smelling discharge suggests a nasal foreign body. If no foreign body is seen, sinusitis is suspected when purulent rhinorrhea persists for > 10 days along with fatigue and cough.
Testing
Testing is generally not indicated for acute nasal symptoms unless invasive sinusitis is suspected in a diabetic or immunocompromised patient; these patients usually require CT.
If a CSF leak is suspected, a sample of the discharge should be tested for the presence of beta-2 transferrin, which is highly specific for CSF.
Treatment of Nasal Congestion and Rhinorrhea
Antihistamines and decongestants are not recommended for children < 6 years.
Geriatrics Essentials: Nasal Congestion and Rhinorrhea
Key Points
Most nasal congestion and rhinorrhea are caused by URIs or allergies.
Consider a foreign body in children.
Also consider rebound congestion due to topical decongestant overuse.
