Nasal discharge is a very common problem, especially amongst children. We have all suffered from it many times in our lives.
The most important causes are:
- Coryza, ie the common cold.
- Hay fever: this is usually seasonal and predictable each year.
- Perennial rhinitis: this is rhinitis which occurs all year round and is usually due to allergy.
- Rebound congestion can occur when topical decongestant drugs are stopped. These are usually drugs like ephedrine or xylometazoline drops but can include abuse of cocaine.
- Nasal polyps are usually the result of chronic allergy or inflammation but they also result in persistent nasal discharge.
- Cerebrospinal fluid (CSF) rhinorrhoea is a rare but important cause which can follow a head injury. The meninges are torn and cerebrospinal fluid leaks down the nose. Ascending infection may cause meningitis.
The diagnosis of each is based largely on the history.
- Establish when onset began.
- Note whether there is pyrexia, aching or malaise suggesting infection.
- Note whether there is a predictable periodicity as with hay fever. If it is perennial, ask whether going away on holiday makes any difference.
- Note whether there are watery eyes or wheezing, suggesting allergy.
- Establish what the discharge is like. It may be clear and watery, viscous, yellow or green or possibly blood-stained.
- Ask whether the patient has tried self-medication. If so, note what was tried and with what result. Look out for long-term use of topical decongestants.
- Note occupation and hobbies, especially if linked to a dusty environment.
- Young adults may need to be asked specifically about cocaine.
If there is not rapid resolution, examination is required, as there may be unexpected findings, including polyps or foreign bodies. Good light and a nasal speculum are required.
- Culture will guide any antibiotic therapy.
- X-ray of sinuses may show clouding from infection.
- Nasal discharge cytology is sometimes used to diagnose allergic fungal sinusitis.
- Specialist investigation (eg, CT scanning and screening tests for cystic fibrosis) may be required to rule out the rarer causes.
Management of specific clinical scenarios
See separate article Upper Respiratory Infections - Coryza.
Coryza is an extremely common condition caused by a rhinovirus, although a number of other viruses may cause similar symptoms. The incubation period is 12-48 hours.
Otitis media may well occur in children under the age of 5 and especially in those below the age of 18 months. In small children the angle of the Eustachian tube to the pharynx is less acute and so coughing and sneezing are more likely to project material into the middle ear.
Secondary infection of mucus can lead to sinusitis and even bronchitis, especially when immunity is impaired by diseases such as cystic fibrosis or by smoking. Being exposed to cold, especially if core temperature drops, does predispose to the illness and the virus grows best in tissue cultures just below 37°C.
Benefit from antivirals has not been demonstrated. Attention should be directed to less specific antiviral agents, as there may be a number of viruses that can cause the illness.
Persistent nasal discharge
This may be caused by allergy or infection but the constant production of excessive mucus predisposes to infection that may perpetuate the condition. A European Position Paper published in 2012 stated that antibiotic therapy should be reserved for children with complications or concomitant disease that could be exacerbated by acute rhinosinusitis (eg, asthma, chronic bronchitis). Options recommended include amoxicillin, amoxicillin/clavulanate or a cephalosporin.
The management of rhinosinusitis and nasal polyposis should be primarily medical. Nasal douching with saline, topical and oral antihistamines and topical and oral corticosteroids may benefit different subgroups of patients.
See separate article Sinusitis for more details.
Endoscopic sinus surgery should be reserved for patients who fail to respond to medical treatment.
Persistent nasal discharge can produce a postnasal drip (PND) that causes a chronic cough or even hoarseness from dripping down on to the vocal cords. Because it is unclear whether the mechanisms of cough are the PND itself or direct irritation or inflammation of the cough receptors located in the upper airway, there has been a recent move by respiratory physicians to replace the term PND with the term upper airway cough syndrome when discussing cough associated with upper airway conditions. Recent evidence implicates lower cough receptors in the aetiology of upper airway cough.
Nasal discharge is often a feature of allergic phenomena. Allergic rhinitis may be seasonal, often due to pollen, or perennial, often due to the house dust mite. The 'summer cold' is often really hay fever. Treatment may consist of an antihistamine, preferably of a non-sedating nature or topical steroid or cromoglicate preparations. Congestion of the nasal mucosa can lead to nosebleeds.
Nasal polyps may also develop, leading to constant discharge, obstruction and anosmia.They may also lead to snoring or stuffy nose and nasal obstruction. The catarrhal child is likely to have impaired hearing with possible delay of speech and social delay.Hearing tests and screening in young children are important if there is cause for concern. Chronic suppurative otitis media may develop. Inflammation may also block the drainage ducts of the sinuses and cause acute sinusitis.
Turbinate hypertrophy may be caused by long-standing allergic rhinitis (seasonal and perennial). It can also be caused by inflammation (eg, rhinitis caused by the common cold), and long-term use of over-the-counter (OTC) vasoconstrictive nasal sprays. Treatment consists of alleviating symptoms with a steroid nasal spray and antihistamines for allergies, and discontinuing habitual use of OTC vasoconstrictive nasal sprays. Persistent symptoms may require surgical procedures to shrink the turbinates, such as microdebrider-assisted or laser-assisted turbinoplasty.
Less common causes
- Nasal injury and foreign bodies should not be forgotten. Small children push things into their noses and this may present as a foul and chronic discharge.In older patients there may even be unexpected lesions like a basal cell carcinoma.
- Wegener's granulomatosis is a rare condition that can present with nasal discharge, usually between the ages of 30 and 50 although it can also occur in children.
- CSF rhinorrhoea implies fracture of the cribriform plate. There is a clear discharge of CSF that tests positive for glucose. A glucose oxidase stick can be used. CT scan and referral to a neurosurgeon are required.
Further reading and references
Alavi SM, Nashibi R; Nasal tuberculosis in a 56 year old woman. Caspian J Intern Med. 2014 Winter5(1):49-51.
Prabhu SM, Irodi A, George PP, et al; Missed intranasal wooden foreign bodies on computed tomography. Indian J Radiol Imaging. 2014 Jan24(1):72-4. doi: 10.4103/0971-3026.130703.
Stewart M, Ferguson B, Fromer L; Epidemiology and burden of nasal congestion. Int J Gen Med. 2010 Apr 83:37-45.
Nozad CH, Michael LM, Betty Lew D, et al; Non-allergic rhinitis: a case report and review. Clin Mol Allergy. 2010 Feb 38:1.
Kaliner M; Rhinosinusitis, World Allergy Organization, 2004
Beule AG; Physiology and pathophysiology of respiratory mucosa of the nose and the paranasal sinuses. GMS Curr Top Otorhinolaryngol Head Neck Surg. 20109:Doc07. doi: 10.3205/cto000071. Epub 2011 Apr 27.
Walker S, Sheikh A; Rhinitis. BMJ. 2002 Feb 16324(7334):403.
Rane SR, Kadgi NV, Agrawal SA, et al; Nasal discharge cytology an important diagnostic method for allergic fungal sinusitis: report of three cases. J Clin Diagn Res. 2014 Mar8(3):121-2. doi: 10.7860/JCDR/2014/6671.4130. Epub 2014 Mar 15.
Jefferson TO, Tyrrell D; Antivirals for the common cold. Cochrane Database Syst Rev. 2001(3):CD002743.
Yu L, Xu X, Wang L, et al; Capsaicin-sensitive cough receptors in lower airway are responsible for cough hypersensitivity in patients with upper airway cough syndrome. Med Sci Monit. 2013 Dec 319:1095-101. doi: 10.12659/MSM.889118.
Newton JR, Ah-See KW; A review of nasal polyposis. Ther Clin Risk Manag. 2008 Apr4(2):507-12.
Roberts G, Xatzipsalti M, Borrego LM, et al; Paediatric rhinitis: position paper of the European Academy of Allergy and Clinical Immunology. Allergy. 2013 Sep68(9):1102-16. doi: 10.1111/all.12235. Epub 2013 Aug 19.
Radiofrequency tissue reduction for turbinate hypertrophy; NICE Interventional Procedures Guidance, June 2014
Kiger JR, Brenkert TE, Losek JD; Nasal foreign body removal in children. Pediatr Emerg Care. 2008 Nov24(11):785-92
Parker WL, Lessard ML; A case of epiphora and recurrent basal cell carcinoma of the nasal tip and review of acquired nasolacrimal system obstruction. Can J Plast Surg. 2004 Winter12(4):201-4.
Bohm M, Gonzalez Fernandez MI, Ozen S, et al; Clinical features of childhood granulomatosis with polyangiitis (wegener's granulomatosis). Pediatr Rheumatol Online J. 2014 May 2612:18. doi: 10.1186/1546-0096-12-18. eCollection 2014.
Ailawadhi P, Agrawal D, Mahapatra AK; Novel treatment of traumatic CSF rhinnorhea using titanium mesh and onlay graft. J Pediatr Neurosci. 2010 Jan5(1):25-6. doi: 10.4103/1817-1745.66678.
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