Etiology of Nasal Congestion and Rhinorrhea
The most common causes (see table ) are the following:
Dry air may provoke congestion. Acute sinusitis Sinusitis Sinusitis is inflammation of the paranasal sinuses due to viral, bacterial, or fungal infections or allergic reactions. Symptoms include nasal obstruction and congestion, purulent rhinorrhea... read more 
is slightly less common, and a nasal foreign body Nasal Foreign Bodies Nasal foreign bodies are found occasionally in young children, the intellectually impaired, and psychiatric patients. Common objects pushed into the nose include cotton, paper, pebbles, beads... read more 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 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, 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 upper respiratory infection [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 ).
In children, unilateral foul-smelling discharge suggests a nasal foreign body Nasal Foreign Bodies Nasal foreign bodies are found occasionally in young children, the intellectually impaired, and psychiatric patients. Common objects pushed into the nose include cotton, paper, pebbles, beads... read more . If no foreign body is seen, sinusitis Sinusitis Sinusitis is inflammation of the paranasal sinuses due to viral, bacterial, or fungal infections or allergic reactions. Symptoms include nasal obstruction and congestion, purulent rhinorrhea... read more 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 of Nasal Congestion and Rhinorrhea
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 2 times a day for 3 days. Oral decongestants include pseudoephedrine 60 mg 2 times a day. Prolonged use should be avoided.
Viral rhinorrhea can be treated with oral antihistamines (eg, diphenhydramine 25 to 50 mg orally 2 times a day), 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 orally 2 times a day) 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.
Geriatrics Essentials
Antihistamines, particularly first-generation antihistamines such as diphenhydramine, can have sedating and anticholinergic effects and should be given in decreased dosage in older people. 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.
Drugs Mentioned In This Article
| Drug Name | Select Trade |
|---|---|
oxymetazoline |
12 Hour Nasal , Afrin, Afrin Extra Moisturizing, Afrin Nasal Sinus, Afrin No Drip Severe Congestion, Dristan, Duration, Genasal , Mucinex Children's Stuffy Nose, Mucinex Full Force, Mucinex Moisture Smart, Mucinex Sinus-Max, Mucinex Sinus-Max Sinus & Allergy, NASAL Decongestant, Nasal Relief , Neo-Synephrine 12-Hour, Neo-Synephrine Severe Sinus Congestion, Nostrilla Fast Relief, Reliable-1 12 hour Decongestant, Rhinase D, RHOFADE, Sinex 12-Hour, Sudafed OM Sinus Cold Moisturizing, Sudafed OM Sinus Congestion Moisturizing, Upneeq, Vicks Qlearquil Decongestant, Vicks Sinex, Vicks Sinex Severe, Visine L.R., Zicam Extreme Congestion Relief, Zicam Intense Sinus |
pseudoephedrine |
Contac Cold 12 Hour, Dimetapp Decongestant, Drixoral, ElixSure Cold, ElixSure Congestion, Entex, Genaphed , KidKare , Myfedrine, NASAL Decongestant, Nasofed, Nexafed, PediaCare Infants' Decongestant, Pseudo-Time, Silfedrine, Sudafed, Sudafed 12 Hour, Sudafed 24 Hour, Sudafed Children's Nasal Decongestant, Sudafed Congestion, Sudafed Sinus Congestion, Sudogest, Sudogest 12 Hour, Sudogest Children's , Tylenol Children's Simply Stuffy, Zephrex-D |
diphenhydramine |
Aid to Sleep, Alka-Seltzer Plus Allergy, Aller-G-Time , Altaryl, Banophen , Benadryl, Benadryl Allergy, Benadryl Allergy Children's , Benadryl Allergy Dye Free, Benadryl Allergy Kapgel, Benadryl Allergy Quick Dissolve, Benadryl Allergy Ultratab, Benadryl Children's Allergy, Benadryl Children's Allergy Fastmelt, Benadryl Children's Perfect Measure, Benadryl Itch Stopping, Ben-Tann , Compoz Nighttime Sleep Aid, Diphedryl , DIPHEN, Diphen AF , Diphenhist, DiphenMax , Dytan, ElixSure Allergy, Genahist , Geri-Dryl, Hydramine, Itch Relief , M-Dryl, Nighttime Sleep Aid, Nytol, PediaCare Children's Allergy, PediaCare Nighttime Cough, PediaClear Children's Cough, PHARBEDRYL, Q-Dryl, Quenalin , Siladryl Allergy, Silphen , Simply Sleep , Sleep Tabs, Sleepinal, Sominex, Sominex Maximum Strength, Theraflu Multi-Symptom Strip, Triaminic Allergy Thin Strip, Triaminic Cough and Runny Nose Strip, Tusstat, Unisom, Uni-Tann, Valu-Dryl , Vanamine PD, Vicks Qlearquil Nighttime Allergy Relief, Vicks ZzzQuil Nightime Sleep-Aid |
fexofenadine |
Allegra, Allegra Allergy 12 Hour , Allegra Allergy 24 Hour, Allegra Children's Allergy , Allegra Children's Allergy ODT, Allegra ODT, Allergy Relief, Children's Allergy |
mometasone |
Asmanex, Asmanex HFA, Elocon, Nasonex, Propel, Propel Contour, PROPEL Mini, PROPEL Mini with Straight Delivery System, SINUVA |
