Runny/Discharging Nose

Though not usually viewed as a significant symptom, this is very bothersome to those that suffer it. Many of the pathologies overlap with the causes of the ‘Blocked nose’ – please refer to this chapter too, as appropriate. The cause is rarely sinister, but referral for further assessment may be necessary if it persists in spite of treatment.

Published: 2nd August 2022 | Updated: 15th August 2022

Differential diagnosis

Common Diagnoses

  • URTI Including Common Cold
  • Allergic Rhinitis (Seasonal or Perennial)
  • Vasomotor Rhinitis
  • Sinusitis
  • Infected Nasal Mucosal Lesion (Herpes Simplex, Impetigo)

Occasional Diagnoses

  • Polyps
  • Rhinitis Medicamentosa
  • Cocaine Abuse
  • Cluster Headaches (Though these will Usually Present with the Pain)
  • Chemical Irritation (Smoke, Fumes)
  • Nasal Foreign Body (Usually Seen in toddlers or Children)
  • Drug Side Effects (e.g. Α-Blockers, Calcium Channel Blockers)

Rare Diagnoses

  • Malignancy
  • CSF Rhinorrhoea Following Head Injury
  • Barotrauma (‘Sinus Squeeze’)
  • Corynebacterium Diphtheriae Infection

Ready reckoner

Key distinguishing features of the most common diagnoses

URTIAllergic RhinitisVasomotor RhinitisAcute SinusitisMucosal Infection
Long HistoryNoPossiblePossibleNoNo
Facial PainPossibleNoNoYesNo
Purulent DischargePossibleNoNoYesPossible

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, e.g. 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 enquire about non-prescribed medication. Cocaine abuse, or the use of OTC 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 the unilateral foulsmelling nasal discharge in a child.
  • A persistent bloodstained 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.
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Website disclaimer

Pulse Reference is based on the best-selling book Symptom Sorter.

The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.

This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.