Obviously a very common complaint, interesting for a few subtleties, & some obscure diagnoses to consider in the rare case that symptoms drag on & your treatment hasn’t helped.
Differential Dx — Nasal Congestion / Discharge
Initial Diagnoses to Consider
Nasal Symptoms of <2 Wks Duration
The patient invariably has a Viral URI, i.e. common cold. However, any of the other conditions noted above are allowed to begin on Day #1 and present before Day #15. Consider other diagnoses during the first 2 weeks as follows:
Allergic Rhinitis — Diagnose this at onset, instead of a URI, if any of the following:> Sneezing is prominent, especially if itchy eyes are too > There’s a Hx of frequent “colds,” especially if any lasted >3 weeks > Exam is obvious for any of the classic stigmata:
- very pale/gray and boggy nasal mucosa
- “allergic shiners” (darkened lower lids)
- “allergic salute” (horizontal crease across the tip of the nose).
Rhinitis Medicamentosa — Elicit a history of daily over-the-counter nasal sprays or drops (except pure saline) for at least 4-5 days. Brands include Afrin®, etc. Generic ingredients may be oxymetazoline, phenylephrine, naphazoline, or xylometazoline
If symptoms have been going on <2 wks, they may well have a URI, but will need help stopping the topicals (click for treatment). I’ve seen patients who’ve begun Tx for a common cold, & were still hooked on them, daily, 5 years later.
Acute Sinusitis — Everyone says their “sinuses are acting up,” though acute sinusitis isn’t common. Unfortunately, clinicians have diagnosed it so frequently as an excuse to Rx antibiotics, that it’s become an expected answer + solution. Who’d ever waste time & co-pay to hear “it’s just a cold”?
When we say “Acute Sinusitis” we imply bacterial; please be real strict with yourself when considering this entity. The diagnosis is clinical; radiology is no help. Various professional organizations have chimed in with suggestions. Either of the following scenarios warrants the diagnosis:
- Fever, with unilateral facial pressure & sinus tenderness (or maxillary tooth tenderness to percussion with a tongue blade). This constellation is not common, so you won’t find yourself overusing antibiotics. Patients with CNS symptoms get sent right to the ER (this is real rare).
- Symptoms began as a URI or allergies, but changed & worsened 7-10 days into the illness. In most cases, this is the key finding.
The diagnostic threshold may be lower for immunocompromised patients.
Green nasal discharge would only impress me if it persists throughout the day. But I’d also want to hear about significant facial pressure. The more unilateral, the more convincing [odds are that bacteria just happened to invade a single sinus]. Don’t bother attempting to transilluminate — virtually no sensitivity nor specificity (i.e. no accuracy either way).
The Infectious Disease Society of America recently published guidelines on Dx & Tx of Bacterial Sinusitis.
Local Nasal Lesions — Staphylococcal furuncles (a.k.a. “boils”) can occur in the anterior nasal vestibule, due to overgrowth during/after a cold, or sometimes from nose-picking. Herpes simplex Type-1 can occur anywhere on head-and-neck mucosa; Type-2 can arise anywhere genital secretions happened to wind up. Immunocompromised patients can have a variety of infections.
All these are uncommon. The chief complaint may be nasal discomfort rather than congestions. Often you can see such lesions if you search carefully with a large otoscope speculum (assuming you don’t have a bona fide nasal speculum).
Perforated Septum — Causes a sense of nasal congestion because a breath of air shunts through the hole, so the patient feels incomplete inspiration. Perforations, usually caused by snorting stimulants, are easy to see.
Sometimes you can shine a penlight into one nostril, & see it through the other.
Deviated Septum — Doesn’t cause any symptoms per se, but can truly exacerbate mild allergic rhinitis. Many people can’t recall remote trauma and don’t even know they have a problem.
Foreign Body — The leading diagnosis of unilateral nasal discharge in a young child. Usually all you see is mucus. A parent might be able to dislodge it by giving gentle mouth-to-mouth breaths while occluding the other nostril; if not, ENT probably needs to extract it.
Nasal Polyps — Idiopathic sinus growths that extend into the nasal cavity, polyps are often visible with a penlight or otoscope (use large speculum) as whitish / grayish masses. They may be associated with allergic rhinitis. Polyps are easily visible on non-contrast CTs, which we might order for chronic nasal congestion [see below].
Suspect the triad of nasal polyposis, asthma, & aspirin hypersensitivity if a patient has polyps plus another of the entities. Therefore, warn anyone with asthma & nasal polyps that they could DIE from aspirin or NSAIDs.
Nasal Symptoms >2 Weeks Duration
Now you can’t call it a URI, because nasal viruses don’t last that long. We’ll assume there’s no history compatible with Rhinitis Medicamentosa, and that our exam is completely normal. Check the ears for retracted TMs, suggesting Eustachian Tube Dysfunction due to allergies (or at least treated as such). Let’s say that’s also unrevealing. Then we’re left with:
- Allergic Rhinitis
- Bacterial Sinusitis
Go empirically with the former, since the latter is much less common (unless you identify key findings as noted above). Treat with a daily dose of both a non-sedating antihistamine and nasal steroid spray (2 sprays in each nostril). Give lots of refills, & tell them to return if not better. Patients all improve, virtually guaranteed.
And if not??? First, make sure they’re using the nasal spray correctly. Lots of people don’t, unless you take time to explain; package inserts aren’t always ideal. Here’s how NOT to use them:
The people above will only shoot the spray into the anterior part of the nose. Just like inserting a nasogastric tube — you don’t want to follow the contour of the external nose (i.e. nasal bone), but rather aim straight in. Think of the nasal anatomy:
However, this won’t work:
Much less this:
That’s because the plastic straw inside the bottle can’t catch any liquid unless the bottle is held vertically.
So have patients bend their head forward; then an upright bottle will aim straight for the turbinates. Best to bend even a little more than the guy in the sketch below.
Also teach patients to:
- occlude the other nostril while spraying (not shown in pix above)
- shake the bottle well before each spray
- pause 30-60 seconds before repeating in a given nostril.
If proper use of nasal steroids doesn’t solve the problem within a week, you’re forced to consider rarer conditions. Start with sinusitis, an empiric diagnosis since plain x-rays have poor sensitivity and specificity. Give a week of antibiotic like amoxicillin-clavulanate, to cover Pneumococcus, H. influenza, & beta-lactamase-producing Moraxella catarrhalis [more on antibiotics next postings].
If the patient improves rapidly, you’re done. If they don’t start to feel better until Day #4-5, extend the course. Nobody knows how long to treat; one study found 3 days worked, ENT’s may Rx up to 6 weeks. If you really don’t like giving empiric antibiotics, order a non-contrast CT.
If the CT finds sinusitis, you still can’t be sure, because specificity isn’t so good. There’s no way to distinguish bacterial from viral disease. Still, with no response to allergy Tx, there’s rationale for antibiotics. However, sensitivity is good; indeed, all studies of Chronic Sinusitis use the CT as a gold standard in judging signs-and-symptoms scoring algorithms. So if the CT is normal, there’s no sinusitis.
The non-contrast CT will also find polyps, plus a whole host of unusual tumors and granulomatous diseases that require biopsy. Send any of these findings to ENT.
Chronic nasal congestion, no response to proper allergy therapy, and a normal sinus CT? Well, there’s a condition called “Laryngopharyngeal Reflux,” essentially cough / nasopharyngeal Sx due to GERD. There’s no gold standard like esophageal pH monitoring, so its validity [reality] may be questionable.
- Inquire about GER symptoms; if positive, treat.
- If no GER Sx & undiagnosed nasal congestion? Well, I suppose you can give a PPI & see what happens. Harmless enough.
- Order a simple CBC & Sed Rate (ESR). Anemia of Chronic Disease or elevated ESR will alert you to occult disorders for ENT to identify.
Or bail out to ENT anyway. They’ll perform nasal endoscopy, & may find something that the CT might miss, like adenoid hypertrophy [though really large adenoids are usually seen] & mucosal lesions. Such cases will be rare.
In children & even young adults, maybe send to ENT first, to get endoscopy and thus avoid the radiation from a CT.
That’s it for nasal congestion. If you speak Spanish, click for a funny anecdote.
Next time we’ll move into the realm of microbiology & even address therapeutics — Bugs & Drugs.