Runny/Discharging Nose
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
| URTI | Allergic Rhinitis | Vasomotor Rhinitis | Acute Sinusitis | Mucosal Infection | |
|---|---|---|---|---|---|
| Long History | No | Possible | Possible | No | No |
| Sneezing | Yes | Yes | Possible | Possible | Possible |
| Facial Pain | Possible | No | No | Yes | No |
| Fever | Possible | No | No | Yes | No |
| Purulent Discharge | Possible | No | No | Yes | Possible |
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.