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
-
CBC (infection)
- Sedimentation rate (infection)
- Tuberculin test
- Venereal disease research laboratory (VDRL) test
- Fluorescent treponemal antibody absorption (FTA-ABS) test (more
definitive test for syphilis)
- ANA analysis (collagen disease)
- Antineutrophil cytoplasmic antigen (ANCA) antibodies for Wegener
granulomatosis
- Fungal culture (mucormycosis)
- Nasopharyngoscopy (neoplasm, granuloma)
- CT scan of brain and sinuses (neoplasm, sinus abscess)
- Biopsy
- Radioimmunosorbent assay (RISA) study of CSF
(cerebrospinal rhinorrhea)
Pictures
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.
More About Rhinitis
More Medical Textbooks Online about Rhinitis
Review other book chapters online related to Rhinitis:
Medical Books Excerpts
- Rhinorrhea
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
- [ read ]
- Rhinorrhea
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Rhinitis
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
» Next page: ORBITAL DISCHARGE (Differential Diagnosis in Primary Care)
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