Nasal discharge

Synonym: rhinorrhoea

Nasal discharge is a very common problem, especially amongst children. We have all suffered from it many times in our lives.

Aetiology¹

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 cocaine².

• 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.

Diagnosis³

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.

Investigations

• 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 sinusitis⁴.

• 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

Coryza

See the separate Common Cold - Coryza article.

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.

Several broad-spectrum antiviral drugs have demonstrated inhibitory activity against the rhinoviruses that cause coryza, but further research is needed⁵.

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 states that there is no evidence to support the use of antibiotics in most cases of acute exacerbations of rhinosinusitis, in rhinosinusitis following viral infections or in chronic rhinosinusitis. Antibiotic therapy should be reserved for patients who have had more than three episodes of acute bacterial rhinosinusitis in the preceding year, those with severe disease and those with underlying diseases such as immune deficiency. Amoxicillin/clavulanate is the preferred option⁶.

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 patients⁶.

See the separate Sinusitis article for more details.

Endoscopic sinus surgery should be reserved for patients who fail to respond to adequate medical treatment, although consensus on what is 'adequate' (in terms of nature and duration) is lacking⁶.

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 cough⁷.

Allergy

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 anosmia⁸. 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 with social delay⁹. 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 sinusitis⁸.

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 turbinoplasty¹⁰.

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 discharge¹¹. In older patients there may even be unexpected lesions like a basal cell carcinoma¹².

• Granulomatosis with polyangiitis is a rare condition that can present with nasal discharge, usually between the ages of 30 and 50 although it can also occur in children¹³.

• 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 required¹⁴.