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ULY CLINIC

17 Septemba 2025, 11:59:30

Rhinorrhea

Rhinorrhea is the free discharge of nasal mucus, which may be clear, purulent, bloody, or serosanguineous. It can be self-limiting or chronic and results from nasal, sinus, or systemic disorders, trauma, surgery, irritants, or medications. Unlike congestion, rhinorrhea indicates active mucus or fluid secretion rather than obstruction alone.

Pathophysiology

Rhinorrhea arises from increased nasal mucus production, vascular permeability, or cerebrospinal fluid leakage:

Inflammatory causes: Viral infections, allergic rhinitis, bacterial sinusitis
Mechanical or structural causes: Nasal trauma, foreign body, tumors
Post-surgical or iatrogenic: Sinus or cranial surgery, ET intubation
Drug-induced: Vasoconstrictive nasal sprays (rhinitis medicamentosa)
Trauma-related: Basilar skull fractures causing CSF rhinorrhea

Contributing mechanisms include:

Mucosal irritation or inflammation → increased secretion
Vascular permeability changes → exudation of plasma or blood
Obstruction of sinus drainage → accumulation and secondary infection
CSF leak → direct fluid discharge from dura tear

History and Physical Examination

History should include:

Onset, duration, progression
Laterality: unilateral or bilateral
Frequency: intermittent or persistent
Character: watery, purulent, bloody, foul-smelling
Triggers: allergens, irritants, medications, trauma
Associated symptoms: headache, fever, cough, anosmia, postnasal drip
Recent surgeries or trauma

Physical examination:

Inspect nasal passages for airflow, discharge, mucosa color, swelling, crusts
Palpate frontal, ethmoid, maxillary sinuses for tenderness
Use nasal speculum to visualize turbinates, septum, and internal lesions
Differentiate nasal mucus from CSF with glucose testing
Assess anosmia

Classification of Rhinorrhea (by Type)

Type	Characteristics	Typical Location	Clinical Notes
Clear, watery	Profuse, thin	Both nares	Common in allergic rhinitis or viral infection
Purulent	Thick, opaque	Unilateral or bilateral	Suggests bacterial sinusitis
Bloody	Serosanguineous	Often unilateral	Could indicate trauma, tumor, or anticoagulant effect
CSF leak	Clear, watery, increases with head lowering	Often unilateral	Basilar skull fracture or post-surgery; requires urgent evaluation

Medical causes

Cause	Laterality	Onset	Key Features	Systemic Signs	Pathophysiology	Management
Basilar skull fracture	Usually unilateral	Abrupt	CSF rhinorrhea, epistaxis, otorrhea	Headache, facial paralysis, ocular/vision deficits, Battle’s sign	Dural tear with CSF leakage	Neurosurgical consult, head elevation, strict monitoring
Common cold (viral)	Bilateral	Gradual	Watery then mucopurulent discharge, sneezing, nasal congestion	Mild malaise, low-grade fever, cough, myalgia	Viral infection → mucosal inflammation & hypersecretion	Symptomatic: hydration, rest, analgesics
Allergic rhinitis	Usually bilateral	Episodic	Profuse watery discharge, sneezing, itchy eyes/nose	May have conjunctival injection	IgE-mediated hypersensitivity → mucosal edema & mucus secretion	Antihistamines, intranasal corticosteroids, allergen avoidance
Sinusitis (acute bacterial)	Unilateral or bilateral	Gradual	Thick purulent discharge, postnasal drip, sinus tenderness	Fever, malaise, headache	Secondary bacterial infection obstructing sinus drainage	Antibiotics, analgesics, saline irrigation
Nasal/sinus tumors	Usually unilateral	Insidious	Bloody or serosanguineous discharge, nasal obstruction	Facial pain, cheek mass, eye displacement	Structural lesion causing local bleeding and obstruction	ENT referral, imaging, surgical excision
Vasomotor rhinitis	Bilateral	Chronic	Profuse watery discharge, recurrent postnasal drip	Chronic congestion	Autonomic imbalance → vascular dilation & mucus overproduction	Avoid triggers, saline irrigation, intranasal antihistamines
Rhinitis medicamentosa	Bilateral	Days after prolonged use	Rebound congestion, watery discharge	None systemic	Rebound hyperemia from overuse of nasal decongestants	Discontinue offending agent, symptomatic relief
Post-surgery (sinus/craniotomy)	Usually unilateral	Post-procedure	Clear or serosanguineous discharge	Mild local edema	Disruption of mucosa or dura	Monitor, head elevation, possible imaging

Assessment and Diagnostic Workup

Blood tests: CBC, coagulation profile if bleeding suspected
Imaging: X-ray, CT sinuses/skull for trauma, tumor, or chronic sinusitis
Speculum and endoscopic examination: Evaluate nasal anatomy, polyps, masses
CSF testing: Glucose, beta-2 transferrin if suspected CSF leak
Allergy testing: Skin prick or IgE levels for suspected allergic rhinitis

Management principles

Treat underlying cause (infection, allergy, trauma, structural lesion)
Supportive care: hydration, saline nasal sprays, analgesics
Medications: antibiotics, antihistamines, corticosteroids as indicated
Surgical intervention: CSF leak repair, tumor excision, sinus drainage
Patient education: proper use of nasal sprays, allergen avoidance, head elevation

Patient counseling

Explain cause and expected duration
Emphasize hydration and symptom monitoring
Teach proper use of medications and sprays
Advise seek urgent care for unilateral, bloody, or CSF-like discharge
For chronic allergy: discuss environmental control measures

Pediatric considerations

Consider foreign body in unilateral rhinorrhea
Other causes: choanal atresia, allergic or chronic rhinitis, acute ethmoiditis, congenital infections
High vigilance for obstructive symptoms in neonates

Geriatric considerations

Older adults are more susceptible to adverse drug reactions (antihistamines, decongestants)
Structural changes or chronic diseases may complicate presentation

References

Buttaro TM, Tybulski J, Bailey PP, Sandberg-Cook J. Primary Care: A Collaborative Practice. St. Louis, MO: Mosby Elsevier; 2008.
Colyar MR. Well-Child Assessment for Primary Care Providers. Philadelphia, PA: F.A. Davis; 2003.
Lehne RA. Pharmacology for Nursing Care (7th ed). St. Louis, MO: Saunders Elsevier; 2010.
McCance KL, Huether SE, Brashers VL, Rote NS. Pathophysiology: The Biologic Basis for Disease in Adults and Children. Maryland Heights, MO: Mosby Elsevier; 2010.
Sommers MS, Brunner LS. Pocket Diseases. Philadelphia, PA: F.A. Davis; 2012.