Nasal Congestion

Nasal congestion is a common complaint in primary care. Although usually a sequela of an upper respiratory infection, it can also be a sign of acute or chronic illness. Regardless of its cause, the successful management of nasal congestion often significantly improves patients’ quality of life.

Differential Diagnosis

• Upper respiratory infection
  –Most common cause of nasal congestion
  –Respiratory droplet spread, 1–2 day incubation, duration 7–14 days
  –Cough, rhinorrhea, fever, malaise
  –Viral etiology (adenovirus, rhinovirus)
• Perennial allergic rhinitis
  –Family history of allergy
  –Onset <20 years
  –Persistent watery nasal discharge
  –No variation with season
  –Pale, bluish, watery, nasal mucosa
• Seasonal allergic rhinitis
  –Itchy, teary eyes
  –Sneezing
  –Watery nasal discharge
  –Varies with season
  –Exposure to allergen (dust, mold, pollen)
  –Pale, bluish, watery, nasal mucosa
• Perennial nonallergic rhinitis
  –No variation with season
  –Obstruction may alternate nares
  –Swollen nasal mucosa
• Sinusitis (acute or chronic)
  –Patients often have a history of sinusitis
  –Craniofacial discomfort
  –Sinus headaches
  –Pain with percussion of teeth in maxillary sinusitis
  –Retro-orbital pain upon coughing or sneezing in cases of ethmoid sinusitis
  –Mucopurulent nasal drainage
• Rhinitis medicamentosa (rebound rhinitis)
  –Prolonged use of intranasal decongestants
• NARES
• Nasal polyps
• Vasomotor rhinitis
• Foreign body in nose
• Intranasal cocaine use
  –May see nasal septum perforation
• Medication side effects (e.g. aspirin, β-blockers, NSAIDs, oral contraceptives, reserpine, and thioridazine)
• Idiopathic rhinitis
• Less common etiologies include cystic fibrosis, Wegener's granulomatosis, folliculitis of nasal hair, congenital abnormality, sarcoidosis

Workup and Diagnosis

• History and physical examination with attention to head and neck
  –Onset, duration, recurrence pattern, associated symptoms (e.g., cough, fever, itchy palate or eyes), medication/illicit drug use, and family history
  –Examine the eyes, ears, sinuses, nares, oral mucosa, tongue, posterior pharynx, neck, chest, and heart in all cases
• Allergy (skin prick) testing to common inhaled antigens will be positive in patients with perennial and seasonal allergic rhinitis (perform only if chronic or recurrent)
• Nasal lavage with identification of cell type
  –Increased eosinophils in NARES and perennial and seasonal allergic rhinitis
  –Increased PMNs in infectious etiologies
• Rhinoscopic exam/flexible nasopharyngolaryngoscopy may reveal polyps, deformity, mucosal inflammation, or discharge draining from sinus meatus
• CT scan of the sinuses is usually reserved for patients who are resistant to medical therapy for 6–8 weeks
  –May see opacification and air fluid levels in sinusitis
• Nasal cultures have low specificity and are of little clinical value

Treatment

• Initial symptomatic treatment with intranasal saline lavage may provide short-term symptomatic relief
• Intranasal decongestants (e.g., oxymetazoline, phenylephrine) or oral decongestants (e.g., pseudoephedrine, phenylephrine, ipratropium)
• Treat sinusitis (but never viral URI) with antibiotics
  –First-line agents include amoxicillin, trimethoprimsulfamethoxazole, or doxycycline
  –Amoxicillin plus clavulanic acid is indicated if a β-lactamase-producing strain is suspected
  –Surgery may be indicated for recurrent disease
  • Allergic rhinitis
    –Intranasal steroids: Budesonide, fluticasone
    –First- or second-generation antihistamines
    –Cromolyn sodium
    –Allergen avoidance
  • Perennial nonallergic rhinitis is treated with decongestants and intranasal steroids for symptoms
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Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

Other Book Chapters Related to Nose symptoms

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

More About Causes of Nose symptoms

• Back to symptom: Nose symptoms: Introduction (review 1244 causes)
• Next Book Extract About Nose symptoms: Nasal Obstruction & Rhinorrhea (In A Page: Pediatric Signs and Symptoms)
• All Book Extracts: All Online Book Extracts for Nose symptoms

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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