Rhinorrhoea and chronic nasal discharge

Rhinorrhoea is nasal discharge, anterior or posterior (postnasal drip). Most cases are rhinitis or rhinosinusitis.

Mechanisms. Mucosal inflammation, vasodilation and glandular hypersecretion mediated by histamine, neural reflexes, and infection.

Classification. By character: clear (allergic, vasomotor, viral early, gustatory, CSF), mucoid, purulent (bacterial), blood stained, foul. By duration: acute (under 4 weeks), subacute, chronic (over 12 weeks). By side: unilateral or bilateral.

Key distinctions. Clear unilateral watery rhinorrhoea after head injury or surgery, worse on leaning forward, suggests CSF. Foul unilateral purulent discharge in a child suggests foreign body. Bilateral clear discharge with sneezing and itch suggests allergic rhinitis.

History. Duration, side, character, volume, triggers (allergens, cold air, food, exercise), sneezing, itch, obstruction, smell loss, facial pain, cough, throat clearing, ear symptoms, fever, epistaxis, head trauma, sinus or skull base surgery, asthma, atopy, occupational exposures, and use of topical decongestants.

Drug history. Topical decongestants, beta blockers, ACE inhibitors, alpha blockers, phosphodiesterase inhibitors, oral contraceptives, aspirin and NSAIDs, and cocaine.

Examination. Anterior rhinoscopy and nasal endoscopy (colour of mucosa, turbinates, discharge, polyps, mass, crusting, septal perforation), sinuses, ears, throat (postnasal drip, cobblestoning), lungs, eyes (conjunctivitis), lymph nodes, and tests for CSF leak (tilt forward test, halo sign on gauze).

Red flags

• Clear unilateral watery discharge after head injury or surgery, or with salty taste, headache or meningism (CSF)
• Unilateral bloody or foul discharge, mass or polyp
• Child with unilateral purulent foul discharge
• Facial swelling, orbital signs or visual change
• Fever and neck stiffness
• Septal perforation or crusting with systemic features (vasculitis)
• Diabetes or immunosuppression with black mucosa

Special groups. Children: viral rhinitis, adenoiditis, foreign body, allergic rhinitis, cystic fibrosis. Pregnancy: rhinitis of pregnancy. Older adults: gustatory and senile rhinorrhoea, and drug related rhinitis. Region specific: tuberculosis, rhinosporidiosis, leishmaniasis and fungal sinusitis in some regions.

Inflammatory and infective

• Acute viral rhinitis (common cold), influenza, COVID-19
• Allergic rhinitis (seasonal, perennial, occupational)
• Non-allergic rhinitis: vasomotor, gustatory, hormonal, cold air induced, drug induced, rhinitis medicamentosa, atrophic rhinitis, NARES
• Acute bacterial rhinosinusitis, chronic rhinosinusitis with or without polyps, allergic fungal sinusitis, odontogenic sinusitis
• Adenoiditis, postnasal drip syndrome

Structural and mechanical

• Foreign body, rhinolith
• Septal deviation and perforation
• Choanal atresia

Fluid leak

• CSF rhinorrhoea (trauma, surgery, spontaneous from raised pressure, tumour, congenital)

Neoplastic and systemic

• Nasal and sinus tumours (papilloma, carcinoma, lymphoma), nasopharyngeal carcinoma
• Granulomatosis with polyangiitis, sarcoidosis, tuberculosis, syphilis
• Cystic fibrosis, primary ciliary dyskinesia, immunodeficiency

Reasoning. Characterise the discharge, examine the nose with endoscopy, and test specifically for CSF leak, allergy, tumour and systemic disease when features point to them.

First line. Nasal endoscopy. Swab for culture only for chronic, treatment resistant or complicated infection.

Targeted tests.

• CSF leak: collect fluid and send for beta-2 transferrin (highly sensitive and specific; glucose alone is unreliable), then CT cisternography or high resolution CT skull base and MRI to localise the defect.
• Allergic rhinitis: skin prick tests or specific IgE.
• Chronic rhinosinusitis: CT sinuses without contrast, after medical treatment.
• Tumour or mass: CT and MRI, and biopsy.
• Systemic: ANCA, angiotensin converting enzyme, antinuclear antibody, chest radiograph, HIV and syphilis serology, sweat chloride in children, immunoglobulins, and nasal nitric oxide or ciliary studies for primary ciliary dyskinesia.
• Fungal sinusitis: nasal debris microscopy, fungal culture and histology.

Limitations. Beta-2 transferrin can be falsely positive in liver disease. Nasal discharge character poorly predicts bacterial infection. CT is abnormal in many asymptomatic adults.

CSF rhinorrhoea. Head of bed at 30 degrees, avoid nose blowing, straining and sneezing with the mouth closed, urgent ENT and neurosurgery referral for repair, and treat meningitis if suspected (ceftriaxone 2 g IV every 12 hours with dexamethasone 10 mg IV every 6 hours for 4 days). Prophylactic antibiotics are debated and decided by specialists.

Foreign body. Removal under direct vision; button battery or magnet needs immediate removal.

Viral rhinitis. Saline irrigation, paracetamol 1 g orally every 4 to 6 hours (maximum 4 g in 24 hours), and ipratropium bromide 0.06 percent nasal spray, 2 sprays to each nostril three to four times daily for troublesome watery discharge. Avoid antibiotics.

Allergic and non-allergic rhinitis.

• Intranasal corticosteroid: mometasone 50 micrograms, 2 sprays to each nostril once daily (maximum 200 micrograms daily), or fluticasone propionate 50 micrograms, 2 sprays to each nostril once daily.
• Loratadine 10 mg orally once daily or cetirizine 10 mg orally once daily (5 mg in renal impairment); intranasal azelastine 0.1 percent, 1 spray to each nostril twice daily.
• Ipratropium bromide 0.03 percent nasal spray, 2 sprays to each nostril two or three times daily for watery vasomotor or gustatory rhinorrhoea.
• Saline irrigation, allergen avoidance, and montelukast 10 mg orally at night when asthma coexists. Allergen immunotherapy by specialists.

Acute bacterial rhinosinusitis. Amoxicillin 500 mg orally three times daily for 5 days (maximum 3 g daily); penicillin allergy: doxycycline 200 mg orally on day 1 then 100 mg daily for 5 days (avoid in pregnancy and under 12 years). Intranasal corticosteroid and saline irrigation.

Chronic rhinosinusitis. Saline irrigation, intranasal corticosteroid, prednisolone 30 mg orally daily for 7 to 14 days for polyps, and ENT referral for surgery after 3 months of medical treatment.

Rhinitis medicamentosa. Stop the decongestant, with intranasal corticosteroid and saline irrigation.

Complicated sinusitis. Admit; ceftriaxone 2 g IV every 12 hours plus metronidazole 500 mg IV every 8 hours; urgent imaging and surgical review.

Systemic and neoplastic disease. Urgent ENT referral with biopsy. Granulomatosis with polyangiitis: prednisolone 1 mg/kg orally daily (maximum 60 to 80 mg) with rituximab or cyclophosphamide by specialists.

Monitoring. Review at 2 to 4 weeks for response. Review after 3 months for chronic disease.

Referral and escalation. Same day for suspected CSF leak, complicated sinusitis or meningitis. ENT within 2 weeks for unilateral bloody or foul discharge, mass, or persistent unilateral discharge. ENT routine for chronic rhinosinusitis refractory to 3 months of medical treatment.

Admission criteria. CSF leak, meningitis, orbital or intracranial complication, or systemic illness.

Discharge and safety netting. Return for fever with stiff neck, severe headache, eye swelling or visual change, clear watery discharge after injury, persistent unilateral bloody discharge, or facial swelling.