Nasal congestion and rhinorrhea (runny nose) are extremely common problems that commonly occur together but occasionally occur alone.
Topic Resources
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 history and physical examination alone CT considered in patients with diabetes, immunocompromise, or signs of serious illness | |
Watery discharge; sneezing; watery, itchy eyes; pale, boggy nasal mucosa, especially inferior turbinates Symptoms often seasonal or with exposure to possible triggers | History and physical examination Allergen skin testing (percutaneous/intradermal) Allergen blood testing (specific IgE) | |
Chronic rhinitis with atrophic and sclerotic mucous membranes, patency of nasal passages, crust formation, a foul odor | Physical examination alone Sometimes biopsy, which shows the normal ciliated columnar epithelium converted to stratified squamous (squamous metaplasia) and the lamina propria reduced in amount and vascularity | |
Decongestant overuse | Rebound congestion as decongestant wears off Pale, markedly swollen mucosa | History and physical examination alone |
Unilateral, foul-smelling (sometimes blood-tinged) purulent discharge in a child | History and physical examination alone | |
Recurrent watery discharge; sneezing; red, swollen mucosa No identifiable triggers | History and physical examination alone | |
Watery to mucoid discharge; accompanied by sore throat, malaise, erythematous nasal mucosa | History and physical examination alone | |
CT = computed tomography; IgE = immunoglobulin E; URI = upper respiratory infection | ||
Cold and 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 cycle 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 prolonged 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 (focusing on the turbinates) is inspected for the presence of polyps, 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, acute (bacterial) sinusitis is suspected when purulent rhinorrhea persists for > 10 days along with fatigue and cough. Nasal polyps, which are smooth, fleshy, gray, and translucent outgrowths of the nasal mucosa, may be visualized in patients with cystic fibrosis, allergic rhinitis, prolonged aspirin use, or chronic rhinosinusitis.10 days along with fatigue and cough. Nasal polyps, which are smooth, fleshy, gray, and translucent outgrowths of the nasal mucosa, may be visualized in patients with cystic fibrosis, allergic rhinitis, prolonged aspirin use, or chronic rhinosinusitis.
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, biopsy, and histopathological examination for the presence of fungal hyphae. In patients with chronic or seasonally recurring nasal symptoms, allergy testing using percutaneous or intradermal skin testing or allergen-specific serum immunoglobulin E (IgE) may help identify an allergic etiology.
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
In addition to symptomatic therapy, the underlying disease should be treated as appropriate.
Viral congestion and rhinorrhea are primarily managed with supportive therapies such as ambient air humidification and nasal saline (hypertonic saline may osmotically reduce congestion), followed by nonanticholinergic second-generation antihistamines (eg, cetirizine or fexofenadine) as needed. First-generation oral antihistamines (eg, diphenhydramine) have been used because of their anticholinergic properties unrelated to their H2-blocking properties. However, patients using first-generation oral antihistamines must be warned about the risk of sedation, as well as potential paradoxical effects such as confusion, nervousness, and in rare cases, agitation. are primarily managed with supportive therapies such as ambient air humidification and nasal saline (hypertonic saline may osmotically reduce congestion), followed by nonanticholinergic second-generation antihistamines (eg, cetirizine or fexofenadine) as needed. First-generation oral antihistamines (eg, diphenhydramine) have been used because of their anticholinergic properties unrelated to their H2-blocking properties. However, patients using first-generation oral antihistamines must be warned about the risk of sedation, as well as potential paradoxical effects such as confusion, nervousness, and in rare cases, agitation.
Allergic rhinitis causing congestion and rhinorrhea can be treated with antihistamines; in such cases, nonanticholinergic second-generation antihistamines (eg, cetirizine or fexofenadine) as needed are used because they have fewer adverse effects compared to first-generation antihistamines. Nasal corticosteroids (eg, fluticasone 2 sprays in each nostril daily) also help relieve symptoms.causing congestion and rhinorrhea can be treated with antihistamines; in such cases, nonanticholinergic second-generation antihistamines (eg, cetirizine or fexofenadine) as needed are used because they have fewer adverse effects compared to first-generation antihistamines. Nasal corticosteroids (eg, fluticasone 2 sprays in each nostril daily) also help relieve symptoms.
Chronic rhinosinusitis with nasal polyps are treated with intranasal corticosteroids as first-line therapy, with additional antibiotic therapy (eg, amoxicillin-clavulanate) as needed. (See also treatment of Chronic rhinosinusitis with nasal polyps are treated with intranasal corticosteroids as first-line therapy, with additional antibiotic therapy (eg, amoxicillin-clavulanate) as needed. (See also treatment ofchronic rhinosinusitis and nasal polyps.)
Although topical or oral decongestants can temporarily relieve congestion, they should be avoided to prevent rebound congestion and cardiac complications. Prolonged use of topical decongestants can cause rhinitis medicamentosa, and prolonged use of oral decongestants can increase blood pressure and heart rate.
Antihistamines are not recommended for children < 2 years and decongestants are not recommended for children < 6 years.
Geriatrics Essentials: Nasal Congestion and Rhinorrhea
Antihistamines, particularly first-generation antihistamines such as diphenhydramine, can have sedating and anticholinergic effects, leading to an increased risk of falls and urinary retention; therefore, a decreased dosage should be used in older adults. Similarly, adrenergic agents should be used with the lowest dosage that is clinically effective to prevent hypertensive episodes.Antihistamines, particularly first-generation antihistamines such as diphenhydramine, can have sedating and anticholinergic effects, leading to an increased risk of falls and urinary retention; therefore, a decreased dosage should be used in older adults. Similarly, adrenergic agents should be used with the lowest dosage that is clinically effective to prevent hypertensive episodes.
Key Points
Most nasal congestion and rhinorrhea are caused by URIs or allergies.
Consider a foreign body in children.
Consider rebound congestion due to topical decongestant overuse.
