Rhinorrhea
Rhinorrhea: Excerpt from Handbook of Signs & Symptoms (Third Edition)
Common but rarely serious, rhinorrhea is the free discharge of thin nasal mucus. It can be self-limiting or chronic, resulting from a nasal, sinus, or systemic disorder or from a basilar skull fracture. Rhinorrhea can also result from sinus or cranial surgery, excessive use of vasoconstricting nose drops or sprays, or inhalation of an irritant, such as tobacco smoke, dust, and fumes. Depending on the cause, the discharge may be clear, purulent, bloody, or serosanguineous.
History and physical examination
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.
Medical causes
Basilar skull fracture
A tear in the dura can lead to cerebrospinal rhinorrhea, which increases when the patient lowers his head. Other findings include epistaxis, otorrhea, and a bulging tympanum from blood or fluid. A basilar fracture may also cause a headache, facial paralysis, nausea and vomiting, impaired eye movement, ocular deviation, vision and hearing loss, a depressed level of consciousness, Battle’s sign, and raccoon eyes.
Common cold
An initially watery nasal discharge may become thicker and mucopurulent. Related findings include sneezing, nasal congestion, a dry and hacking cough, a sore throat, mouth breathing, and a transient loss of smell and taste. The patient may also experience malaise, fatigue, myalgia, arthralgia, a slight headache, dry lips, and a red upper lip and nose.
Nasal or sinus tumors
Nasal tumors can produce an intermittent, unilateral bloody or serosanguineous discharge that may be purulent and foul smelling. Nasal congestion, postnasal drip, and a headache may also occur. In advanced stages, paranasal sinus tumors may cause a cheek mass or eye displacement, facial paresthesia or pain, and nasal obstruction.
Rhinitis
Allergic rhinitis produces an episodic, profuse watery discharge. (A mucopurulent discharge indicates infection.) Typical associated signs and symptoms include increased lacrimation; nasal congestion; itchy eyes, nose, and throat; postnasal drip; recurrent sneezing; mouth breathing; an impaired sense of smell; and a frontal or temporal headache. Also, the turbinates are pale and engorged; the mucosa, pale and boggy.
With atrophic rhinitis, the nasal discharge is scanty, purulent, and foul smelling. Nasal obstruction is common, and the crusts may bleed on removal. The mucosa is pale pink and shiny.
With vasomotor rhinitis, a profuse and watery nasal discharge accompanies chronic nasal obstruction, sneezing, recurrent postnasal drip, and pale, swollen turbinates. The nasal septum is pink; the mucosa, blue.
Sinusitis
With acute sinusitis, a thick and purulent nasal discharge leads to a purulent postnasal drip that results in throat pain and halitosis. The patient may also experience nasal congestion, severe pain and tenderness over the involved sinuses, fever, headache, and malaise.
With chronic sinusitis, the nasal discharge is usually scanty, thick, and intermittently purulent. Nasal congestion and low-grade discomfort or pressure over the involved sinuses can be persistent or recurrent. The patient may also be suffering from a chronic sore throat and nasal polyps.
With chronic fungal sinusitis, the clinical picture resembles that of chronic bacterial sinusitis. However, some cases — especially patients who are immunocompromised — may progress rapidly to exophthalmos, blindness, intracranial extension and, eventually, death.
Other causes
Drugs
Nasal sprays or nose drops containing vasoconstrictors may cause rebound rhinorrhea (rhinitis medicamentosa) if used longer than 5 days.
Surgery
Cerebrospinal rhinorrhea may occur after sinus or cranial surgery.
Special considerations
You may have to prepare the patient for X-rays of the sinuses or skull (if you suspect a skull fracture) and a computed tomography scan. You may also need to administer an antihistamine, a decongestant, an analgesic, or an antipyretic. Advise the patient to drink plenty of fluids to thin secretions.
Pregnancy causes physiologic changes that may aggravate rhinorrhea, resulting in eosinophilia and chronic irritable airways.
Pediatric pointers
Be aware that rhinorrhea in children may stem from choanal atresia, allergic or chronic rhinitis, acute ethmoiditis, or congenital syphilis. Assume that unilateral rhinorrhea and nasal obstruction is caused by a foreign body in the nose until proven otherwise.
Geriatric pointers
Elderly patients may suffer increased adverse reactions to drugs used to treat rhinorrhea, such as elevated blood pressure or confusion.
Pictures
Book Source Details
- Book Title: Handbook of Signs & Symptoms (Third Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.
More About Vasomotor rhinitis
More Medical Textbooks Online about Vasomotor rhinitis
Review other book chapters online related to Vasomotor 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: Allergic rhinitis (Professional Guide to Diseases (Eighth Edition))
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