Etiology
The most common causes (see table Some Causes of Nasal Congestion and Rhinorrhea) are the following:
Some Causes of Nasal Congestion and Rhinorrhea
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 drug 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
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, or exposure to potential triggering allergens (numerous) should be determined. A unilateral, clear, watery discharge, particularly when following head trauma, can signify cerebrospinal fluid (CSF) leak. CSF discharge also can occur spontaneously in obese women in their 40s, 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 URI).
Past medical history should seek known allergies and existence of diabetes or immunocompromise. Drug history should ask 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) presence of any foreign body.
Red flags
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 should undergo 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
Specific conditions are treated. Symptomatic relief of congestion can be achieved with topical or oral decongestants. Topical decongestants include oxymetazoline, 2 sprays each nostril once/day or bid for 3 days. Oral decongestants include pseudoephedrine 60 mg bid. Prolonged use should be avoided.
Viral rhinorrhea can be treated with oral antihistamines (eg, diphenhydramine 25 to 50 mg po bid), which are recommended because of their anticholinergic properties unrelated to their H2-blocking properties.
Allergic congestion and rhinorrhea can be treated with antihistamines; in such cases, nonanticholinergic antihistamines (eg, fexofenadine 60 mg po bid) as needed provoke fewer adverse effects. Nasal corticosteroids (eg, mometasone 2 sprays each nostril daily) also help allergic conditions.
Antihistamines and decongestants are not recommended for children < 6 years.
