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Symptom sorter on runny nose

GPs Dr Keith Hopcroft and Dr Vincent Forte continue their series on making sense of common but often tricky symptoms

GPs Dr Keith Hopcroft and Dr Vincent Forte continue their series on making sense of common but often tricky symptoms

Though not usually viewed as a significant symptom, a runny or discharging nose is very bothersome to those who suffer it. Many of its pathologies overlap with the causes of the ‘blocked nose'. The cause is rarely sinister, but referral for further assessment may be necessary if it persists.

Differential diagnosis

Common

• URTI, including common cold

• Allergic rhinitis (seasonal or perennial)

• Vasomotor rhinitis

• Sinusitis

• Infected nasal mucosal lesion

Occasional

• Polyps

• Rhinitis medicamentosa

• Cocaine abuse

• Cluster headaches (though these will usually present with pain)

• Chemical irritation (smoke, fumes)

• Nasal foreign body (usually in children)

• Drug side-effects

Rare

• Malignancy

• CSF rhinorrhoea following head injury

• Barotrauma or ‘sinus squeeze'

• Corynebacterium diphtheriae infection


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Possible investigations

Usually none. Sinus X-rays, CT scan and allergy tests likely to be ordered by specialist after referral rather than in primary care.

Top tips

• Use an auriscope with the largest available speculum to look into the nasal cavity – tell patients to hold their breath or the lens will steam up.

• Intermittently runny nose associated with a nasal obstruction that is dependent on position – for example, disappears when lying down – suggests a single nasal polyp.

• Patients who describe their runny nose as ‘just like turning on a tap' probably have vasomotor rhinitis.

• Remember to inquire about non-prescribed medication. Cocaine abuse, or the use of over-the-counter sympathomimetic drops, may be very relevant in making a diagnosis and the response to any OTC treatments such as intranasal steroids might help guide diagnosis and further treatment.

Red flags

• Intranasal foreign bodies are relatively common in toddlers – beware unilateral foul-smelling nasal discharge in a child.

• A persistent, blood-stained discharge requires investigation, especially if associated with unilateral nasal obstruction.

• Clear unilateral nasal discharge after direct trauma to the face may represent CSF leakage from an ethmoidal skull fracture. Occasionally this can present some time after the injury, so beware the late presentation.

Dr Keith Hopcroft is a GP in Basildon, Essex

Dr Vincent Forte is a GP in Gorleston, Norfolk

Quick sorter runny nose Runny nose

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