Nasal drip (rhinorrhoea)

Question 1

Probability diagnosis

Answer 1

Upper respiratory tract infection esp. common cold

Rhinitis: acute infective, allergic, vasomotor

Vasomotor stimulation e.g. cold wind, smoke, irritants

Sinusitis→post-nasal drip

Senile rhinorrhoea

Question 2

Serious disorders not to be missed

Answer 2

Vascular:

• Cluster headache

Infection:

• Chronic infective granulomas e.g. TB

Cancer/tumour:

• Malignancy: nasal fossa, sinus, nasopharynx

Other:

• CSF rhinorrhoea—post head injury
• Wegener’s granulomatosis

Question 3

Pitfalls (often missed)

Answer 3

Nasal foreign body e.g. in toddlers

Trauma ± blood

Adenoid hypertrophy

Illicit drugs e.g. cocaine, opioids esp. heroin

Inhaled irritant gases or vapour

Rarities:

• Choanal atresia
• Barotrauma

Question 4

Masquerades checklist

Answer 4

Drugs:

• topical OTC→rhinitis medicamentosa
• narcotics

Hypothyroidism

Question 5

Key history

Answer 5

Elicit nature of discharge: watery, mucoid, bloody, ?offensive and volume.

Is it acute or chronic, intermittent or continuous?

Associations: respiratory symptoms, nasal blockage, post-nasal drip, headache, local pain.

Check for possible influence of physical factors: wind, cold, irritants, smoke.

Check for presence of allergic rhinitis or sinusitis.

Ask if history of head trauma, nose problems or nasal surgery.

Drug hx, including OTC medications esp. sympathomimetics, illicit drugs, prescribed drugs.

Question 6

Key examination

Answer 6

Look for cause.

Inspect nose and nasal cavity with a Thudicum speculum or large auriscope;

• position of the septum
• nature of nasal mucosa
• polyps or other tumours

Question 7

Key investigations

Answer 7

Usually none required.

Consider:

• micro/culture of discharge
• X-ray sinuses
• CT scan
• allergy testing

Question 8

Diagnostic tips

Answer 8

Beware of persistent blood-stained discharge esp. if unilateral and obstruction.

Clear discharge following direct facial or head injury may represent CSF leakage from a skull fracture.