Nasal Congestion — Full Text

Nasal Congestion — a stuffed up &/or runny nose, is obviously a very common symptom.  The following discussion outlines how we clinicians approach it, including a few subtleties, & some obscure diagnoses in the rare case that symptoms drag on & treatment hasnโ€™t helped.

See also Diagrams — Upper Respiratory System Anatomy.

Causes of Nasal Congestion or Discharge

xxxCommon Diagnoses We Make At First

โ€ข Common Cold (if <2 wks)
โ€ข Allergic Rhinitis (“allergies”) [quite common]
โ€ข Rhinitis Medicamentosa
โ€ข Sore in the Nose (Furuncle) **
โ€ข Perforated / Deviated Nasal Septum **
โ€ข Foreign Body (young children) **
Sinusitis (not as common as people think)x
xxxxxxRarer Conditions  

โ€ข Nasal Polyps
โ€ข Adenoid Enlargement
โ€ข Auto-Immune Diseases

**  Can see in nose without ENT referral

“ENT” = Ear-Nose-Throat specialist (a.k.a. Otorhinolaryngolgist)

Nasal Symptoms Going On Less Than 2 Weeks

A person with only nasal congestion / runny nose is very unlikely to have Covid-19. The possibility is greater if there are other symptoms like fever, body aches, and cough. Every site has its own way of doing Covid tests before letting anyone with symptoms inside the building. The rest of this discussion assumes that Covid-19 is not a possible diagnosis.

Most patients with a stuffed-up, runny nose have a Common Cold, due to one of many viruses.  Colds last 10-14 days, so during that time we don’t expend a lot of time or money searching among the other possibilities.  However, if certain symptoms or features are present, we do make other diagnoses during the first 2 weeks of illness, as follows:

**  Allergic Rhinitis (“allergies”) —  We’ll diagnose this early, instead of a Cold, if any of the following:

  • Sneezing is prominent, especially if itchy eyes are too
  • Thereโ€™s a history of frequent โ€œcoldsโ€ in the past, especially if any lasted over 3 weeks (i.e. they weren’t really Colds)
  • Exam is obvious for any of the classic signs of allergies:
    • Pale/gray, boggy mucus membranes inside the nose
    • Darkened lower eyelids (โ€œallergic shinersโ€)
    • Horizontal crease across the tip of the nose (โ€œallergic saluteโ€)

Then we give Allergy Medication, available over-the-counter; if the patient feels a lot better, we’re confident in our diagnosis.

**  Rhinitis Medicamentosa  —  Fancy name for โ€œaddictionโ€ to certain over-the-counter nasal sprays or drops, after using them every day for as little as just 4 days.  The medicines work so well in alleviating congestion by constricting the blood supply, that when they wear off, thereโ€™s a big rebound.  After 4 days, the nose canโ€™t live without them.

If symptoms have been going on <2 wks, the patient may well have a viral Cold, but may still need help stopping the medicines.ย  Iโ€™ve seen people hooked on these products for years!!!ย  Click the disease link for description of what causes it, & what treats it.

**  Acute Sinusitis  —  Everyone says their โ€œsinuses are acting up,โ€ but sinusitis isnโ€™t that common.  Unfortunately, clinicians have diagnosed it so frequently as an excuse to give antibiotics, that itโ€™s become an expected answer + solution.  Whoโ€™d ever waste time & insurance co-pay (or, for the uninsured, full-pay) to hear, โ€œItโ€™s just a coldโ€?

When we say โ€œAcute Sinusitisโ€ we imply itโ€™s due to bacteria, which is actually a bit rare (see Differences Among Germs).  One study squirted Rhinovirus (the typical cold virus) into noses of volunteers; a fair number of subsequent CT scans came out abnormal (in people who by definition clearly had โ€œjust a coldโ€).

The diagnosis of acute sinusitis is clinical, meaning thereโ€™s no good way to tell for sure besides our experience.  X-rays are notorious for being either false-positive or false-negative.  Various professional organizations have their suggestions.  My criteria are either of the following:

  • Fever, with facial pressure & sinus tenderness (or tenderness when tapping the upper teeth) on just one side of the face.  Patients with neurological symptoms (confusion, stiff neck, double vision, etc.) get sent right to the ER to rule out spread to the brain (this is real rare).
  • Symptoms began as a common cold or allergies, but changed & worsened 7-10 days into the illness.  In most cases, this is the key finding.

Green nasal discharge would only impress me if it persists throughout the day (not just mainly in the morning, after bacteria have grown overnight).  But Iโ€™d also want to hear about significant facial pressure.  The more itโ€™s just on one side of the face, the more convincing [odds are that bacteria just happened to invade a single sinus].  Iโ€™m also more willing to make the diagnosis for immunocompromised patients, who get bad complications from bacterial infections.

**  Sores in the Nose (Furuncles)  —  These are Boils, usually caused by Staphylococcal bacteria (Staph). They tend to occur at the entry to the nose, due to germ overgrowth during/after a cold, or sometimes from nose-picking.  The Herpes simplex Virus can occur anywhere on the head-and-neck (Herpes simplex Type-1); Herpes simplex Type-2 can arise anywhere genital secretions happened to wind up; both are rare in the nose, though not impossible.  Immunocompromised patients can have a variety of infections.

All these are uncommon.  The main symptom may be nasal discomfort rather than congestion.  We can usually see such sores if we look carefully into the front of a nostril as best we can.

**  Perforated Septum  —  This causes a sense of nasal congestion because a breath of air shunts through the hole, so the person feels incomplete inspiration.  Perforations, usually caused by snorting stimulants, are easy to see.  Often we can shine a penlight into one nostril, & see it through the other.

**  Deviated Septum  —  Usually caused by trauma, this doesnโ€™t cause any symptoms on its own, but can make mild allergies feel lots worse.  Many people canโ€™t recall long-ago trauma and donโ€™t even know they have a problem.

**  Foreign Body  —  This is the leading diagnosis for one-sided nasal discharge in a young child, who stuck a bean/toy/other object (“foreign body”) inside.  Usually all we see is a nostril full of mucus.  A parent might be able to dislodge it by giving gentle mouth-to-mouth breaths in the child’s mouth while pressing the other nostril shut; if not, an ENT specialist probably needs to extract it in an ER.

**  Nasal Polyps  —  These are benign sinus tumors (growths; not cancer) that extend into the nasal cavity.  Theyโ€™re sometimes visible with a penlight or otoscope (what we use to look in an ear) as whitish / grayish growths [see link for pictures].  They may be associated with allergies.  Polyps are easily visible on CT scans, which we might order for chronic nasal congestion.

Thereโ€™s a condition that includes the 3-combo of nasal polyps, asthma, & aspirin allergy; the last one can be severe.  Therefore, we need warn anyone with both nasal polyps & any chance of having asthma, that they could die from aspirin or NSAID medications (not acetaminophen, the ingredient in Tylenolยฎ).

Nasal Symptoms Lasting Over 2 Weeks

Now we canโ€™t call it a Common Cold, because viruses in the nose donโ€™t last that long.  If we can’t see anything special in the nose (like diseases in the table with **), possibilities are:

  • Allergic Rhinitis (โ€œallergies;โ€ โ€œhay feverโ€)
  • Rhinitis Medicamentosa
  • Sinusitis
  • Rare Conditions (see Table)

Allergic Rhinitis is the most common of all.  We’re especially convinced if there’s lots of sneezing, or the patient has had recurrent episodes in the past.  Allergy Medication works very well, & proves our diagnosis for all practical purposes.  But — Warning: I’ve seen many patients not get relief because they used the nasal sprays incorrectly (see above link).

Rhinitis Medicamentosa, as noted above, is when people use over-the-counter decongestant sprays or drops for 4 or more days.  Then there’s “rebound congestion” — the spray works so well, that the nose swells even more when the medicine wears off.  I’ve seen patients who must have had a cold, but wound up “hooked” on their nasal sprays for years.

If there’s no history to suggest Rhinitis Medicamentosa, & properly-used Allergy Treatment doesnโ€™t solve the problem within 1-2 weeks, weโ€™re forced to consider rarer conditions.  Plain x-rays have too many false-positives & false-negatives to be helpful.  There are three options:

1.  Consider Chronic Sinusitis.  Technically, should have symptoms for 3 months to make this diagnosis, but few patients or providers will wait that long.  Patient with bad nasal congestion needs at least one other symptom:

  • Lots of green mucus
  • Facial pain, pressure, or fullness
  • Loss of sense of smell (in children, a chronic cough instead)

We can then try antibiotics for 1 week.  If thereโ€™s significant improvement, weโ€™d continue treatment 3-4 weeks total.  If no improvement, weโ€™d stop antibiotics & proceed to #2 or #3 below. We want to limit antibiotic use as much as possible, to prevent bacteria from developing resistance.

2.  We order a CT scan of the sinuses, looking for:

The problem with CT scans is that they employ lots more radiation than plain x-rays, conferring a small lifetime risk of cancer.  So we prefer to avoid them in persons under 30 (it takes lots of years for a cancer to evolve).  See Radiation Risks for ballpark estimates of risk from different types of tests.

3.  We might refer directly to ENT specialists, who can examine the nose by endoscopy first.  If the CT showed an abnormality, endoscopy would be necessary anyway, for biopsy.  But if the CT really did look like Chronic Sinusitis, we might first try 3-4 weeks of antibiotics along with Allergy Medications (even if they hadn’t worked on their own) and 1-2 weeks of oral steroids.

NOTE —  The following patients with Chronic Sinusitis absolutely must be referred to ENT Specialists:

  • Antibiotics failed in the past
  • Immunocompromised
  • Nasal Polyps as well (which donโ€™t get better with nasal steroid sprays)
  • Recurrent fevers, or any hint the infection is spreading to the eye or brain (very rare; send to E.R.)

And thatโ€™s it for nasal congestion.  If you speak Spanish, click for a funny anecdote.

See also Nasal Congestion for the clinicianโ€™s condensed thought-process when face-to-face with a patient.

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