Nasal Discharge

Nasal discharge (rhinorrhoea) refers to the drainage of fluid from the nose, which can vary in quality (clear, purulent, bloody, or watery). It is a common symptom that can reflect benign self-limiting illness, allergic conditions, or more serious underlying pathology such as sinusitis or cerebrospinal fluid (CSF) leak.

🧠 Pathophysiology

• 👃 The nasal mucosa produces mucus to trap pathogens and humidify air.
• 🦠 Infections and inflammation increase secretions through cytokine-mediated vascular permeability and glandular stimulation.
• ⚠️ Non-infective causes (allergy, structural problems, CSF leak) alter quality and volume of discharge.

🔎 Causes of Nasal Discharge

• 🦠 Infective:
  • Viral URTI (common cold – clear → mucopurulent).
  • Bacterial sinusitis (purulent, often unilateral, facial pain).
• 🌸 Allergic: Allergic rhinitis (clear, watery, itchy, sneezing, seasonal or perennial).
• 💊 Non-allergic rhinitis: Vasomotor rhinitis, medication-induced (e.g., topical decongestant overuse → rhinitis medicamentosa).
• 💉 Trauma/CSF leak: Watery, unilateral, worse on leaning forward; history of trauma or surgery.
• 🎗️ Neoplastic: Rare, but consider in persistent unilateral discharge, especially blood-stained with obstruction (e.g., sinonasal carcinoma, inverted papilloma).
• 👶 Foreign body (children): Foul-smelling, unilateral purulent discharge ± blood.

🩺 Clinical Assessment

• 📖 History: Onset, duration, nature of discharge (watery, mucoid, purulent, bloody), laterality, associated symptoms (fever, headache, anosmia, sneezing, trauma, weight loss).
• 👁️ Examination: Inspect external nose, anterior rhinoscopy with light or otoscope, sinus tenderness, lymph nodes. Red flags: persistent unilateral symptoms, epistaxis, orbital swelling, neurological symptoms.

🧪 Investigations

• Most cases (viral rhinitis, allergic rhinitis) → diagnosis is clinical.
• 🖼️ Imaging: CT sinuses if recurrent or complicated sinusitis.
• 💧 Beta-2 transferrin test: Highly specific for CSF in clear nasal fluid.
• 🔬 Swabs rarely indicated, except in recurrent/persistent bacterial sinusitis.

🛠️ Management

• 🌡️ Viral rhinitis: Self-limiting; supportive care (hydration, analgesia, saline sprays, decongestants short-term).
• 💊 Bacterial sinusitis: Analgesia, nasal irrigation; antibiotics if severe or persistent >10 days (first-line: phenoxymethylpenicillin or co-amoxiclav, per NICE guidance).
• 🌸 Allergic rhinitis: Allergen avoidance, intranasal corticosteroids, oral/non-sedating antihistamines.
• 💧 CSF leak: ENT/Neurosurgical referral, bed rest, possible surgical repair.
• 👶 Foreign body: Removal in ENT/ED setting.

📊 Differential Diagnosis Table

✅ Take-Home Messages

• Nasal discharge is usually benign but may signal serious underlying pathology if unilateral, persistent, or blood-stained.
• Always ask about trauma, foreign bodies, systemic features, and red flags.
• CSF rhinorrhoea must be recognised early to prevent meningitis.
• Management depends on the underlying cause, ranging from reassurance and antihistamines to surgical intervention.

Cases

• Case 1 — Viral Rhinitis: 24-year-old with 3 days of clear rhinorrhoea, sneezing, sore throat after contact with a cold. Dx: Viral URTI. Plan: Fluids, paracetamol/ibuprofen, saline irrigation; no antibiotics. Safety-net if fever/pain >5–7 days or orbital symptoms.
• Case 2 — Acute Bacterial Rhinosinusitis: 37-year-old, 10 days of yellow–green discharge, maxillary pressure, fever post-coryza. Dx: Post-viral bacterial sinusitis. Plan (UK): No/backup antibiotic or 5-day phenoxymethylpenicillin/doxycycline if systemically unwell; intranasal steroid; analgesia; safety-net for orbital/intracranial spread.
• Case 3 — Allergic Rhinitis: 19-year-old, seasonal clear discharge, itch/sneeze, itchy eyes; atopy. Dx: IgE-mediated rhinitis. Plan: Daily intranasal corticosteroid (first-line), non-sedating antihistamine, allergen avoidance; consider immunotherapy if refractory.
• Case 4 — Foreign Body (Child): 4-year-old with unilateral foul, purulent discharge and minor epistaxis; bead inserted “yesterday.” Dx: Nasal foreign body. Plan: No blind probing; parent’s kiss or ENT removal; treat infection only if cellulitis/systemic features; safety-net for aspiration.
• Case 5 — Chronic Rhinosinusitis with Polyps: 55-year-old, ≥12 weeks blockage, hyposmia, thick discharge; asthma/aspirin sensitivity. Dx: CRSwNP. Plan: Intranasal steroids ± short oral steroid burst, saline rinses; ENT if poor response in 3 months or unilateral polyp (rule out malignancy).
• Case 6 — CSF Rhinorrhoea: 40-year-old post minor head injury with unilateral clear “salty” drip worse leaning forward; recurrent meningitis. Dx: CSF leak. Plan: Urgent ENT/neurosurgery; send fluid for beta-2 transferrin; head elevation/avoid straining; repair source—prophylactic antibiotics not routine.
• Case 7 — Invasive Fungal Rhinosinusitis (Emergency): 62-year-old with poorly controlled diabetes, bloody/purulent discharge, severe facial pain, black eschar. Dx: Suspected mucormycosis. Plan: Immediate A&E/ENT admission, urgent imaging, IV amphotericin B, surgical debridement; optimise glycaemic control.
• Case 8 — Malignancy Red Flag: 68-year-old smoker with unilateral blockage, intermittent blood-stained discharge, facial numbness, persistent serous otitis media. Dx: Sinonasal/NPC tumour until proven otherwise. Plan: Two-week-wait ENT for endoscopy and imaging; avoid repeated empirical antibiotics.