Approach to the Problem
Investigating the causes of nasal swelling and discharge involves acquiring a careful history that includes the duration and timing of symptoms, the environment in which the symptoms occurred, whether anything has relieved the symptoms, and to what extent the problem has disrupted the child’s daily functioning. Radiological studies may be useful in select cases. Noting the age of the patient is important because the sinus and nasopharyngeal complex changes with growth, and potential infectious causes of rhinorrhea vary with age.
Key Points in the History
• Rhinorrhea accompanying viral infections may be associated with fever, cough, and/or lymphadenopathy.
• Most rhinorrhea from viral upper respiratory tract infections resolves in 6 to 10 days.
• Prolonged purulent rhinorrhea (>10 days) or acute symptoms including headache, facial pain, and/or fever are suggestive of bacterial rhinosinusitis.
• Increased cough while supine and halitosis are symptoms of bacterial rhinosinusitis.
• Seasonal allergic rhinitis is generally accompanied by sneezing and intense nasal pruritus, and is often associated with ocular pruritus.
• Children with allergic rhinitis often have family members with atopic diseases.
• Fits of sneezing that occur soon after rising from sleep and nasal symptoms in the presence of specific allergens, such as dust or animals, are characteristic of seasonal allergic rhinitis.
• Chronic use of decongestant nasal sprays can result in paradoxical nasal swelling and rebound congestion.
• Rhinorrhea in the setting of exposure to cold outdoor temperatures is suggestive of vasomotor rhinitis.
• Children with impetigo generally do not complain of pain at the affected site.
• Nasal drainage resulting from a foreign body, typically occurring in younger children, is usually acute, unilateral, and often associated with a foul odor.
• Recurrent nasal infections or persistent inflammation may contribute to the development of nasal polyps.
• Direct trauma to the nose may result in a septal hematoma, manifesting as pain and nasal congestion; occluding one nostril at a time after trauma should still allow child to breathe through the open nostril in the setting of septal hematoma.
Key Points in the Physical Examination
• Viral rhinorrhea may be of varied color, thickness, and amount.
• Tenderness over the facial bones and increased headache and/or facial pain on forward bending of the neck are signs of sinusitis.
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