Nasal Congestion and Rhinorrhea: A Merck Manual of Patient Symptoms podcast

Nasal congestion and rhinorrhea (runny nose) are extremely common problems that commonly occur together but occasionally occur alone.

Etiology

The most common causes (see Table 2: Approach to the Patient With Nasal and Pharyngeal Symptoms: Some Causes of Nasal Congestion and Rhinorrhea) are the following:

• Viral infections
• Allergic reactions

Table 2
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Some Causes of Nasal Congestion and Rhinorrhea Cause Suggestive Findings Diagnostic Approach Acute sinusitis Mucopurulent discharge, often unilateral Red mucosa Sometimes a foul or metallic taste, focal facial pain or headache, and erythema or tenderness over the maxillary or frontal sinus Clinical evaluation CT considered in patients with diabetes, immunocompromise, or signs of serious illness Allergies Watery discharge; sneezing; watery, itchy eyes; pale, boggy nasal mucosa Symptoms often seasonal or with exposure to possible triggers Clinical evaluation Decongestant overuse Rebound congestion as decongestant wears off Pale, markedly swollen mucosa Clinical evaluation Nasal foreign body Unilateral, foul-smelling (sometimes blood-tinged) discharge in a child Clinical evaluation Vasomotor rhinitis Recurrent watery discharge; sneezing; red, swollen mucosa No identifiable triggers Clinical evaluation Viral URI Watery to mucoid discharge; accompanied by sore throat, malaise, erythematous nasal mucosa Clinical evaluation

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 > 1 day 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.

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

The following findings 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 2: Approach to the Patient With Nasal and Pharyngeal Symptoms: 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.

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 yr.

Geriatrics Essentials

Antihistamines can have sedating and anticholinergic effects and should be given in decreased dosage in the elderly. Similarly, sympathomimetics should be used with the lowest dosage that is clinically effective.

Key Points

• Most nasal congestion and rhinorrhea are caused by URI or allergies.
• A foreign body should be considered in children.
• Rebound from topical decongestant overuse should also be considered.

Last full review/revision July 2012 by Marvin P. Fried, MD