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Diagnosis of Rhinitis

Rhinitis Diagnosis: Book Excerpts

• Ask the Following Questions - NASAL DISCHARGE
• Differential Diagnosis - Nasal Obstruction & Rhinorrhea
• Differential Diagnosis - Chronic Rhinitis
• Approach to the Diagnosis - NASAL DISCHARGE
• Approach to the Diagnosis - AURAL DISCHARGE (OTORRHEA)
• Approach to the Diagnosis - ORBITAL DISCHARGE
• History and physical examination - Rhinorrhea
• Diagnosis - Allergic rhinitis
• History and physical examination - Rhinorrhea
• History - Rhinitis
• Differential Overview - Nasal Congestion/Discharge
• Diagnosis - Allergic rhinitis
• Clinical Features and Diagnosis - Nasal Discharge
• History and physical examination - Rhinorrhea
• Approach to the Diagnosis - AURAL DISCHARGE (OTORRHEA)
• Approach to the Diagnosis - NASAL DISCHARGE
• Approach to the Diagnosis - ORBITAL DISCHARGE

Diagnosis of Rhinitis: medical news summaries:

The following medical news items are relevant to diagnosis and misdiagnosis issues for Rhinitis:

• Oral allergy syndrome
• Sinusitis factor in prolonged cough
• More news »

Diagnostic Tests for Rhinitis: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Rhinitis.

NASAL DISCHARGE: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is it unilateral or bilateral? Unilateral nasal discharge, especially if it is purulent, suggests acute sinusitis, Wegener's granulomatosis, neoplasm, foreign body, and syphilis. If the discharge is clear or mucoid, it could be just simply chronic sinusitis. Bilateral nasal discharge suggests an URI, especially if it is an acute onset. If it is a chronic condition and it is mucoid or clear, allergic rhinitis, chronic sinusitis, or vasomotor rhinitis should be suspected. Rarely, cerebral spinal fluid rhinorrhea is the problem.
2. Is there fever? The presence of fever makes acute sinusitis most likely if the discharge is unilateral, but if it is bilateral, one should suspect an acute viral URI. However, if there is significant pain associated with the fever, one should consider the possibility that there is an acute sinusitis.
3. Is it purulent, mucoid, or clear? The presence of a purulent discharge suggests acute sinusitis, chronic bacterial sinusitis, mucormycosis, Wegener's granulomatosis, neoplasm, foreign body, and syphilis. The presence of a mucoid discharge suggests allergic rhinitis or a chronic sinusitis. The presence of a clear discharge suggests cerebral spinal fluid rhinorrhea and senile rhinorrhea, especially if the patient is older. If there is unilateral face pain, one should consider cluster headache or migraine.
4. Is there pain? The presence of pain with fever or purulent discharge certainly suggests acute sinusitis. However, when there is pain with a clear discharge, one should think of cluster headache or migraine.
5. Is there sneezing or an allergy history? The presence of sneezing or an allergic history should suggest allergic rhinitis and sinusitis. However, allergic rhinitis and sinusitis may also occur without sneezing or an allergic history.

DIAGNOSTIC WORKUP

Routine orders for the workup of a nasal discharge include a CBC, sedimentation rate, chemistry panel, VDRL test, smear and culture of the nasal discharge, and x-rays of the sinuses. If the discharge is chronic and mucoid or clear, one should do a nasal smear for eosinophils and serum IgE level to look for allergic rhinitis. A trial of therapy may be indicated in these cases also. If Wegener's granulomatosis is suspected, serum for ANCA should be done.

If there is still diagnostic confusion after the above tests have been done, referral to an ear, nose, and throat specialist or an allergist is indicated. The specialist will perform nasopharyngoscopy and is in a better position to evaluate whether CT scans or bone scans are needed. Also, the specialist can better evaluate when the patient should undergo allergy skin testing, inhalation testing, or radioallergosorbent tests (RASTs).

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Nasal Obstruction & Rhinorrhea: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Physiologic
  –Nasal cycle
  –Nasopulmonary reflex
  –Puberty
  –Menstruation and pregnancy
• Congenital
  –Choanal atresia or stenosis
  –Cleft palate
  –Craniofacial syndromes such as Treacher Collins, Crouzon
• Cyst
  –Dermoid, meningocele, or encephalocele
  –Thornwaldt

• Infectious
  –Bacterial rhinosinusitis with Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, staph
  –Viral rhinosinusitis with rhinovirus, adenovirus, coxsackie

• Viral prodrome
  –Measles, mumps, mono, polio
• Fungal (if immunocompromised)
  –Aspergillosis, mucormycosis
• Inflammatory
  –Allergic rhinitis
  –Nasal polyps
  –Adenoid hypertrophy
  –Nasopharyngeal GERD
• Granulomatous
  –Sarcoidosis
  –Wegener syndrome
  –SLE
  –Churg-Strauss syndrome
• Traumatic
  –Foreign body
  –Septal hematoma
  –Septal abscess
• Neoplastic
  –Chordoma
  –Craniopharyngioma
  –Juvenile angiofibroma
  –Olfactory neuroblastoma
• Cystic fibrosis
• Thyroid disease (hypo- or hyper-)
• Ciliary dyskinesia
  –Kartagener, immotile cilia syndrome, etc.
• Chronic rhinitis

Workup and Diagnosis

• History
  –Onset, duration, severity, exacerbating and relieving factors, work of breathing
  –Family history
  –Environmental history: Pets, smoke exposure
• Physical exam
  –Passage of suction catheter to rule out atresia/stenosis
  –Direct rhinoscopy with otoscope, or with nasal speculum and headlight or head mirror
  –Fiberoptic rhinoscopy: Flexible well tolerated, rigid (better optics) only for older children
  –Examine nose before and after decongestion
• Allergy testing
  –In vitro (RAST) better tolerated in young children than in vivo (intradermal, prick skin testing)
  –Nasal cytology
  • Studies
    –Lateral neck X-ray: Useful for adenoid hypertrophy or nasopharyngeal cysts
    –Sinus X-ray: Limited utility, essentially replaced by CT
    –CT scan: Contrast only required if tumor suspected; if sinus surgery anticipated, need coronal views
    –MRI: Excellent for tumors, necessary for congenital cysts (differentiate meningocele from encephalocele); much too sensitive for sinusitis
    –Angiography: Useful for juvenile nasopharyngeal angiofibromas and other tumors requiring preoperative embolization

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Chronic Rhinitis: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Allergic rhinitis
  –Rhinorrhea is typically watery and profuse
  –May have associated sneezing, itchy eyes and nose (allergic salute)

• Infectious conditions
  –Chronic sinusitis: Typically has mucopurulent discharge; headache and fever may or may not be present
  –Succession of URIs: Can get associated bacterial overgrowth, typically group A β - hemolytic Streptococcus in young children; may have low-grade fever, lymphadenopathy, and weight loss
  –Congenital syphilis

• Nonallergic rhinitis
  –Typically due to irritants such as smoke or pungent odors
• Vasomotor rhinitis
  –A hyperactive cholinergic response
  –Postnasal drip is commonly associated
• Foreign body
  –Always consider when there is unilateral nasal discharge
  –Halitosis or generalized body odor (bromhidrosis) may be present
  • Nasal polyps
    –10% of children with CF develop polyps
    –Other causes include Kartagener syndrome (immotile cilia), recurrent sinusitis, aspirin intolerance
    –Woake syndrome includes polyps, broad nasal base, frontal sinus aplasia, bronchiectasis
  • Adenoid hypertrophy
    –Associated with mouth breathing, noisy respirations
    –Severe cases can result in obstructive sleep apnea
  • Juvenile nasopharygeal angiofibroma
    –Typically in adolescent males
    –Associated with recurrent epistaxis
  • Hormonal rhinitis (rare)
    –Pregnancy and hypothyroidism

  Workup and Diagnosis

  • History
    –Onset, duration, and severity of symptoms
    –Character of nasal discharge: Purulent vs clear
    –Unilateral or bilateral
    –History of associated atopic conditions such as
  • environmental allergies, asthma, eczema
    –Family history of atopic conditions
  • Physical exam
    –Complete HEENT examination
    –Degree and type of nasal discharge
    –Characteristics of nasal turbinates such as enlargement,
  • color (redness indicates infection, pale or blue color indicates allergy)
    –Allergic features such as allergic “shiners,” Dennie lines, high-arched palate
  • Labs
    –Nasal smear
    –PMNs indicate an infectious process, whereas eosinophils are consistent with an allergic response
  • Radiology
    –Lateral head/neck films reveal adenoidal size and configuration, may show polyps

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

NASAL DISCHARGE: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The diagnosis of nonbloody rhinorrhea is not usually difficult in the acute cases because it is frequently due to the common cold or allergic rhinitis (in which case the history will be helpful). When the 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.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

AURAL DISCHARGE (OTORRHEA): Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The approach to the diagnosis of an aural discharge is similar to the approach for discharges from any body orifice. After careful examination for a foreign body or obstruction, the discharge is cultured and appropriate therapy begun. A gram stain of the material often aids in the determination of the most appropriate antibiotic. If the discharge is chronic, x-rays of the mastoids and petrous bones may be necessary, as well as tomography. Obviously, referral to an otolaryngologist is wise at this point.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

ORBITAL DISCHARGE: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Anatomy has served us well in developing a differential, although the cause of a discharge from the eye is often easy to establish. Foreign bodies, trauma, toxins, and conjunctivitis are the conditions most commonly responsible. This is why in the approach to the diagnosis one will first examine the eye carefully under magnification and use fluorescein to rule out a foreign body or laceration. Then, a careful history of exposure to toxins (e.g., industrial) is in order. Finally, if the discharge is unilateral, a smear and culture of specific bacteria are valuable before treatment. If it is bilateral, allergy should be considered, as well as refractive errors. Tonometry should be performed. Referral to. an ophthalmologist may be appropriate at any one of these stages (when in doubt, refer it out).

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

Rhinorrhea: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Begin the history by asking the patient if the discharge runs from both nostrils. Is the discharge intermittent or persistent? Did it begin suddenly or gradually? Does the position of his head affect the discharge?

Next, ask the patient to characterize the discharge. Is it watery, bloody, purulent, or foul smelling? Is it copious or scanty? Does the discharge worsen or improve with the time of day? Also, find out if the patient is using medications, especially nose drops or nasal sprays. Has he been exposed to nasal irritants at home or at work? Does he experience seasonal allergies? Did he recently experience a head injury?

Examine the patient’s nose, checking airflow from each nostril. Evaluate the size, color, and condition of the turbinate mucosa (normally pale pink). Note if the mucosa is red, unusually pale, blue, or gray. Then examine the area beneath each turbinate. (See Using a nasal speculum, page 546.) Make sure to palpate over the frontal, ethmoid, and maxillary sinuses for tenderness.

To differentiate nasal mucus from cerebrospinal fluid (CSF), collect a small amount of drainage on a glucose test strip. If CSF (which contains glucose) is present, the test result will be abnormal. Finally, using a nonirritating substance, make sure to test for anosmia.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Allergic rhinitis: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Microscopic examination of sputum and nasal secretions reveals large numbers of eosinophils. Blood chemistry shows normal or elevated IgE. A definitive diagnosis is based on the patient’s personal and family history of allergies as well as physical findings during a symptomatic phase. Skin testing paired with tested responses to environmental stimuli can pinpoint the responsible allergens given the patient’s history. In patients who can’t tolerate skin testing, the radioallergosorbent test may be helpful in determining specific allergen sensitivity.

To distinguish between allergic rhinitis and other nasal mucosa disorders, remember these differences:

❑ In chronic vasomotor rhinitis, eye symptoms are absent, rhinorrhea is mucoid, and seasonal variation is absent.

❑ In infectious rhinitis (the common cold), the nasal mucosa is beet red; nasal secretions contain polymorphonuclear, not eosinophilic, exudate; and signs and symptoms include fever and sore throat. This condition isn’t a recurrent seasonal phenomenon.

❑ In rhinitis medicamentosa, which results from excessive use of nasal sprays or drops, nasal drainage and mucosal redness and swelling disappear when such medication is withheld.

❑ In children, differential diagnosis should rule out a nasal foreign body, such as a bean or a button.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Rhinorrhea: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Begin the history by asking the patient if the discharge runs from both nostrils. Is the discharge intermittent or persistent? Did it begin suddenly or gradually? Does the position of his head affect the discharge?

Next, ask the patient to characterize the discharge. Is it watery, bloody, purulent, or foul smelling? Is it copious or scanty? Does the discharge worsen or improve with the time of day? Find out if the patient is using any medications, especially nose drops or nasal sprays. Has he been exposed to nasal irritants at home or at work? Does he experience seasonal allergies? Did he recently experience a head injury?

Examine the patient’s nose, checking airflow from each nostril. Evaluate the size, color, and condition of the turbinate mucosa (normally pale pink). Note if the mucosa is red, unusually pale, blue, or gray. Then examine the area beneath each turbinate. (See Using a nasal speculum, page 690.) Be sure to palpate over the frontal, ethmoid, and maxillary sinuses for tenderness.

To differentiate nasal mucus from cerebrospinal fluid (CSF), collect a small amount of drainage on a glucose test strip. If CSF (which contains glucose) is present, the test result will be abnormal. Finally, using a nonirritating substance, be sure to test for anosmia.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Rhinitis: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. Characteristics of rhinitis. What are the specific symptoms (i.e., stuffiness, itching, clear or purulent drainage)? Are symptoms unilateral or bilateral? When did the symptom(s) begin? Ask what the patient believes caused the symptoms.

B. Chronology. How often and when do symptoms occur? Do they predominate at certain times of the year?

 C. Associated symptoms. What other symptoms are associated? What makes the symptoms better or worse? Associated complaints (e.g., frank fatigue, irritability, depression, or chest symptoms) tend to point to untreated allergic causes, systemic disease, or drug-induced illness (Table 6.2).

 D. Pertinent medical history. Include questions about atopic disease, upper respiratory allergies, asthma, nasal surgery, serious infections, and current prescription medication use.

E. Lifestyle history. This discussion should address tobacco (personal use or use by those at home), alcohol or other recreational drug use, over-the-counter medication, herbal remedies, and pets in the home.

F. Family history. Is there a family history of allergies or other relevant systemic diseases?

G. Occupational history. Are there suspected environmental irritants?

Physical examination

A. General inspection of the patient frequently offers clues to the cause of the rhinitis. For example, “allergic shiners” (infraorbital, bluish discoloration of the skin) or a crease at the lower part of the nose from repeated rubbing are common physical findings of allergic rhinitis.

 B. Focused physical examination (PE). Evaluate vital signs (especially temperature) and the ears, nose, and throat, including examination for lymphadenopathy and thyroid disease. A competent examination of nasal passages requires a nasal speculum (a 4–5 mm ear speculum on a handheld otoscope is acceptable for children) and a good light source. Carefully place the nasal speculum vertically into each vestibule. Insert a handheld otoscope light source through the speculum to survey for nasal patency, mucosal color (pale, red or bluish), degree and location of edema, presence and type of nasal drainage (thin, clear, thick, purulent, unilateral, or bilateral), anatomic deformities (bone spurs, septal deviation), and the presence of polyps or other masses. If swollen nasal turbinates block the view, apply a short-acting decongestant spray, then reexamine in 10 minutes. Evaluation of the posterior portion of the nose is often difficult or impossible with a nasal speculum and light source. A flexible nasopharyngoscope permits examination of the structures between the nasal vestibule and the larynx (1).

Assess the lungs and skin for signs of atopic disease (wheezing or eczema) (Chapters 8.9 and 13.4).

 C. Additional physical examination. If systemic illness is suggested after the focused examination, a thorough multisystem PE is necessary (Table 6.2).

» READ BOOK EXCERPT ONLINE »

Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Nasal Congestion/Discharge: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Common cold

❑ Allergic rhinitis

❑ Vasomotor rhinitis

❑ Nasal polyp

❑ Sinusitis

❑ Drugs

❑ Deviated septum

❑ Intranasal foreign body

❑ Sarcoidosis

❑ Cerebrospinal fluid leak

❑ Wegener granulomatosis

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Allergic rhinitis: Diagnosis
(Handbook of Diseases)

Microscopic examination of sputum and nasal secretions reveals large numbers of eosinophils. Blood chemistry studies show normal or elevated IgE levels, possibly linked to seasonal overproduction of interleukin-4 and -5 (involved in the allergic inflammatory process). A firm diagnosis rests on the patient’s personal and family history of allergies and on physical findings during a symptomatic phase. Skin testing, paired with tested responses to environmental stimuli, can help pinpoint the responsible allergens when interpreted in light of the patient’s history.

To distinguish between allergic rhinitis and other disorders of the nasal mucosa, remember these differences:

With chronic vasomotor rhinitis, eye symptoms are absent, rhinorrhea is mucoid, and seasonal variation is absent.

CLINICAL TIP: With infectious rhinitis (the common cold), the nasal mucosa is red; nasal secretions contain polymorphonuclear, not eosinophilic, exudate; and signs and symptoms include fever and sore throat. This condition isn’t a recurrent seasonal phenomenon.

With rhinitis medicamentosa, which results from excessive use of nasal sprays or drops, nasal drainage and mucosal redness and swelling disappear when such medication is withheld.

In children, a differential diagnosis should rule out the presence of a foreign body in the nasal passage, such as a bean or a button.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

Nasal Discharge: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Anatomic

Choanal Atresia/Stenosis

Unilateralchoanal atresia may produce persistent mucous discharge from thenose, as may unilateral or bilateral choanal stenosis.

Flexible endoscopy is diagnostic.

CT is used to delineate anatomy priorto surgery.

Adenoid Hypertrophy

Common causeof upper airway obstruction and may not only cause snoring but also rhinorrhea.

Lateral radiograph of upper airwaydemonstrates adenoid enlargement.

Rhinitis

Infectious

Viral

Most commoncause of nasal discharge is viral upper respiratory infection. Normal preschool-or school-aged child has average of 6–8 of these infections/yr.Rhinoviruses are most frequent pathogens. Others include parainfluenzaviruses, respiratory syncytial virus, influenza viruses, and adenoviruses.

Nasal discharge may be clear and wateryor mucopurulent. Associated findings include fever, headache, malaise,anorexia, myalgia, cough, sore throat, and vomiting. Infants maybe irritable and restless, with difficulty in feeding and sleeping.Nasal turbinates are inflamed and edematous. Nasal wash viral culturesare confirmatory but unnecessary in most clinical situations.

Bacterial

Purulentnasal discharge may signify secondary bacterial infection. Excoriationof nares or cervical lymphadenitis suggests that pathogen is S.aureus or group A Streptococcus.

Infection with C. diphtheriae, indicatedby white or yellow membrane lining nose, is rare.

Positive bacterial culture of dischargeis diagnostic.

Allergic Rhinitis

Occurs inresponse to specific allergens. Common seasonal allergens are airborne pollensand molds, whereas common perennial allergens are dust mites andanimal allergens (dog and cat danders). Food allergens are rarecauses of isolated rhinitis.

Usual clinical manifestations are nasalcongestion, rhinorrhea, and sneezing.

Allergic conjunctivitis with itchy, tearyeyes is also commonly associated with allergic rhinitis.

Long-standing rhinitis may cause mouthbreathing, snoring during sleep, malaise, fatigue, and recurrentotitis media with middle ear effusion. Nasal mucosa is pale andturbinates are enlarged. Nasal discharge is usually clear. Purplediscoloration below eyes indicates venous nasal congestion. It isalso common to observe upward rubbing of nose (nasal salute). Enlargementof tonsils and adenoids also may occur.

Positive history of other atopic diseases(e.g., asthma and eczema) is common.

History and physical exam may be diagnosticof allergic rhinitis.

If >10% of cells seen onnasal smear are eosinophils, allergic rhinitis is likely. Definitivediagnosis rests on detection of immunoglobulin E (IgE) antibodyfor specific allergens.

Positive skin test results (prick orintradermal) are evidence of allergen-specific IgE. When skin testresult is questionably positive, radioallergosorbent test (RAST),which measures specific IgE antibody in serum, may be performed.

Elevated total serum IgE is usuallynegative in children with allergic rhinitis and is not recommendedas screening test.

Nonallergic Rhinitis with Eosinophilia

Children have perennial symptoms and nasaleosinophilia, but they lack specific IgE antibodies in serum andskin tests are negative.

Nonallergic Rhinitis without Eosinophilia

Vasomotor rhinitis describes individualswith nonallergic noninfectious rhinitis without eosinophilia. Rhinitiscan occur with exposure to cold air, high humidity, inhaled irritants,and strong odors.

Drug-Induced

Severaldrugs may produce rhinitis, including angiotensin-converting enzymeinhibitors, beta-blockers, NSAIDs, oral contraceptives, reserpine,phentolamine, methyldopa, and guanethidine.

Rhinitis medicamentosa is overuse ofnasally inhaled decongestant agents (e.g., phenylephrine or oxymetazoline),which should not be given for >5 days at a time.

Repeated use of cocaine also may causerhinitis.

Sinusitis

Inflammationof 1 or more paranasal sinuses, which include ethmoid, maxillary,frontal, and sphenoid sinuses.

Anterior ethmoid, maxillary, and frontal sinusescommunicate with nasal cavity through middle meatus, whereas posteriorethmoid and sphenoid sinuses open into nasal cavity below superiorturbinates.

Ethmoid and maxillary sinuses are presentat birth. Frontal sinus also exists but is small and does not enlargeuntil about 7 yrs of age.

Sphenoid sinus is pea sized by age4 yrs.

Sinus inflammation is often associatedwith viral URI. In many instances, it is self-limited and resolveswithout any specific treatment. Most episodes of acute sinusitisare thought to be bacterial complications of viral URIs.

Risk factors for sinusitis includeallergic rhinitis, cystic fibrosis, immotile cilia syndrome, facialtrauma, and mechanical obstruction (choanal atresia, deviated septum,nasal polyps, foreign body, tumor).

Usual pathogens causing acute sinusitisare same ones that cause acute otitis media: S. pneumoniae, nontypeableH. influenzae, and M. catarrhalis. S. aureus and anaerobic bacteriaare most common pathogens causing chronic sinusitis.

Usual clinical presentation of acutesinusitis is persistent nasal discharge and cough for >10 daysor high fever and purulent nasal discharge for >3 days.Discharge can be clear, mucoid, or purulent, and cough must be presentin daytime but can be worse at night. Sinus tenderness and headachealso may occur.

Although diagnosis is usually clinical,CT can be confirmatory by demonstrating sinus opacification or air-fluidlevel. This study is usually performed for suspected orbital abscessor intracranial complications. Sinus cultures may reveal specificpathogens.

Foreign Body

Foreign body in nasal passage can cause unilateral,purulent, foul-smelling discharge. History and physical exam includingrhinoscopy confirm diagnosis.

Cerebrospinal Fluid (CSF) Rhinorrhea

After nasaltrauma, CSF rhinorrhea usually indicates skull fracture, usuallythrough cribriform plate.

Less common cause is temporal bonefracture, where fluid enters nasopharynx via eustachian tube.

Other causes may be congenital or acquired(inflammatory bone erosion, neoplasm).

Measurement of >50 mg/dLglucose in nasal discharge indicates presence of CSF. Intrathecalinjection of radioisotope or dye with subsequent nuclear scintigraphyor CT, respectively, often demonstrates site of leak.

Diagnostic Approach

Cause ofnasal discharge often can be determined by history and physicalexam. Most common causes are viral upper respiratory infection andallergic rhinitis.

Nasal smear that shows many eosinophilssuggests allergic rhinitis, either seasonal or perennial, althoughthis same finding may occur with subgroup of nonallergic rhinitis.

Skin testing remains principal methodof diagnosis with allergic disease. When skin test is definitelypositive, there is little need for other tests. When skin test isquestionably positive, RAST, which measures specific IgE antibodyin serum, may be performed.

Nasal foreign body and sinusitis areother common causes of nasal discharge. Foul-smelling unilateraldischarge usually occurs with foreign body. Diagnosis of sinusitisis usually clinical.

CT of sinuses should usually be reservedfor children with orbital or CNS complications or when sinus surgeryis contemplated.

CSF rhinorrhea is rare occurrence butcan be associated with recurrent meningitis. Special imaging studiescan be used to locate site of leak.

» READ BOOK EXCERPT ONLINE »

Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Rhinorrhea: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Begin the history by asking the patient if the discharge runs from both nostrils. Is the discharge intermittent or persistent? Did it begin suddenly or gradually? Does the position of his head affect the discharge? Does anything make it better? Does anything make it worse?

Next, ask the patient to characterize the discharge. Is it watery, bloody, purulent, or foul smelling? Is it copious or scanty? Does the discharge worsen or improve with the time of day? Also, find out if the patient is using medications, especially nose drops or nasal sprays. Has he been exposed to nasal irritants at home or at work? Does he experience seasonal allergies? Did he recently experience a head injury?

Examine the patient's nose, checking airflow from each nostril. Evaluate the size, color, and condition of the turbinate mucosa (normally pale pink). Note if the mucosa is red, unusually pale, blue, or gray. Then examine the area beneath each turbinate. (See Using a nasal speculum, page 542.) Be sure to palpate over the frontal, ethmoid, and maxillary sinuses for tenderness.

To differentiate nasal mucus from cerebrospinal fluid (CSF), collect a small amount of drainage on a glucose test strip. If CSF (which contains glucose) is present, the test result will be abnormal. Finally, using a nonirritating substance, be sure to test for anosmia.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

AURAL DISCHARGE (OTORRHEA): Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The approach to the diagnosis of an aural discharge is similar to the approach for discharges from any body orifice. After careful examination for a foreign body or obstruction, the discharge is cultured and appropriate therapy begun. A gram stain of the material often aids in the determination of the most appropriate antibiotic. If the discharge is chronic, x-rays of the mastoids and petrous bones may be necessary, as well as tomography. Obviously, referral to an otolaryngologist is wise at this point.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

NASAL DISCHARGE: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

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.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

ORBITAL DISCHARGE: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Anatomy has served us well in developing a differential, although the cause of a discharge from the eye is often easy to establish. Foreign bodies, trauma, toxins, and conjunctivitis are the conditions most commonly responsible. This is why in the approach to the diagnosis one will first examine the eye carefully under magnification and use fluorescein to rule out a foreign body or laceration. Then, a careful history of exposure to toxins (e.g., industrial) is in order. Finally, if the discharge is unilateral, a smear and culture of specific bacteria are valuable before treatment. If it is bilateral, allergy should be considered, as well as refractive errors. Tonometry should be performed. Referral to an ophthalmologist may be appropriate at any one of these stages (when in doubt, refer it out).

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

 » Next page: Signs of Rhinitis

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Choose ... Alzheimers & Dementia Asthma Child ADHD ADHD in Adults Allergy Hypertension Bipolar Breast Cancer Celiac Disease Crohns Disease Colon Cancer Contraception Diabetes Cancer Depression Erectile Disorder Cholesterol COPD GERD Heartburn/Reflux Metabolic Syndrome Migraine/Headache Multiple Sclerosis Obesity Osteoporosis Overactive Bladder Psoriasis Sexual Disorder Sleep Disorders Smoking The Pill Ulcerative Colitis All Common Mistakes

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