NASAL DISCHARGE

Ask the Following Questions:

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).

Book Source Details

• Book Title: Algorithmic Diagnosis of Symptoms and Signs
• Author(s): R. Douglas Collins
• Year of Publication: 2003
• Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.

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More About This Book: Title: Algorithmic Diagnosis of Symptoms and Signs Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 0-7817-3805-9

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