NASAL DISCHARGE

NASAL DISCHARGE: Excerpt from Differential Diagnosis in Primary Care

With nasal discharge (rhinorrhea and postnasal drip), anatomy is the key. In visualizing the structure from outside in, one encounters the external nares, the choana with the turbinates, the maxillary, ethmoid, frontal and sphenoid sinuses, and the nasopharynx with the openings of the eustachian tubes surrounded by the adenoids. In addition, the inferior meatus provides the opening for the nasolacrimal ducts. The etiologies of a nonbloody discharge of the nose are almost invariably inflammatory (infectious or allergic), but a fracture of the sinuses or cribriform plate may cause a cerebrospinal fluid (CSF) rhinorrhea. As in nonbloody discharges elsewhere, it is incumbent on the diagnostician to keep the possibility of neoplasm, foreign body, and other causes of obstruction in mind, because these may set the stage for infection. Nasal conditions causing acute nonbloody rhinorrhea include the common cold (due to any one of at least 60 viruses), viral influenza, pertussis, measles, and allergic rhinitis (hay fever). The discharge is at first clear; however, after a few hours of obstruction, secondary bacterial infection may set in and the discharge often becomes purulent. Chronic rhinitis is usually allergic, bacterial, or fungal (as in mucormycosis), but it can be on an autoimmune basis (Wegener granulomatosis). Toxins in the environment (e.g., smoke) may cause serous rhinorrhea. Too-frequent use of nasal sprays should always be considered. The sinuses may be inflamed in the same conditions that involve the nose. However, concern about whether a discharge is coming from the sinuses arises when the discharge becomes purulent, when there is associated pain over the sinus, or when the discharge becomes chronic. In chronic sinusitis the discharge may frequently be a postnasal drip. The nasopharynx is also involved by the same viral, bacterial, and fungal conditions as the rest of the nasal passages, but, in addition, diphtheria may begin here. If the adenoids become large enough, they may obstruct the nasal canals and produce a secondary bacterial rhinitis with discharge. Because the nasolacrimal ducts open into the inferior meatus, any eye condition that may cause excessive tearing may also produce rhinorrhea. The unilateral rhinorrhea of histamine headaches is partially related to this mechanism, as is trigeminal neuralgia.

Approach to the Diagnosis

The diagnosis of nonbloody rhinorrhea is not usually difficult in acute cases because it is frequently due to the common cold or allergic rhinitis (in which case the history will be helpful). When rhinorrhea persists, a smear for eosinophils and appropriate skin testing are useful if the discharge is nonpurulent; a Gram stain, culture for bacteria and fungi, and x-rays of the sinuses will be valuable if the discharge is purulent. Cerebrospinal rhinorrhea is a possibility.

Other Useful Tests

1. CBC (infection)
2. Sedimentation rate (infection)
3. Tuberculin test
4. Venereal disease research laboratory (VDRL) test
5. Fluorescent treponemal antibody absorption (FTA-ABS) test (more definitive test for syphilis)
6. ANA analysis (collagen disease)
7. Antineutrophil cytoplasmic antigen (ANCA) antibodies for Wegener granulomatosis
8. Fungal culture (mucormycosis)
9. Nasopharyngoscopy (neoplasm, granuloma)
10. CT scan of brain and sinuses (neoplasm, sinus abscess)
11. Biopsy
12. Radioimmunosorbent assay (RISA) study of CSF (cerebrospinal rhinorrhea)

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Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins MD, FACP
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins MD, FACP Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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