Nasal drip (rhinorrhoea)

Probability diagnosis

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

Serious disorders not to be missed

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

Pitfalls (often missed)

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

Masquerades checklist

Drugs: topical OTC→rhinitis medicamentosa; narcotics

Hypothyroidism

Key history

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. Also check for presence of allergic rhinitis or sinusitis. Ask if there is a possible history of head trauma, nose problems or nasal surgery. Also take a drug history, including OTC medications esp. sympathomimetics, illicit drugs, prescribed drugs.

Key examination

Look for cause. Inspect nose and nasal cavity with a Thudicum speculum or large auriscope. Note the position of the septum, nature of nasal mucosa and look for polyps or other tumours.

Key investigations

Usually none required. Consider:

• micro/culture of discharge

• X-ray sinuses

• CT scan

• allergy testing

Diagnostic tips

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.