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Probability diagnosis

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Upper respiratory tract infection esp. common cold

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Rhinitis: acute infective, allergic, vasomotor

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Vasomotor stimulation e.g. cold wind, smoke, irritants

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Sinusitis→post-nasal drip

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Senile rhinorrhoea

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Serious disorders not to be missed

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Vascular:

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  • Cluster headache

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Infection:

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  • Chronic infective granulomas e.g. TB

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Cancer/tumour:

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  • Malignancy: nasal fossa, sinus, nasopharynx

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Other:

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  • CSF rhinorrhoea—post head injury

  • Wegener’s granulomatosis

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Pitfalls (often missed)

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Nasal foreign body e.g. in toddlers

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Trauma ± blood

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Adenoid hypertrophy

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Illicit drugs e.g. cocaine, opioids esp. heroin

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Inhaled irritant gases or vapour

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Rarities:

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  • Choanal atresia

  • Barotrauma

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Masquerades checklist

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Drugs: topical OTC→rhinitis medicamentosa; narcotics

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Hypothyroidism

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Key history

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Elicit nature of discharge: watery, mucoid, bloody, ?offensive and volume. Is it acute or chronic, intermittent or continuous? Associations: respiratory symptoms, nasal blockage, post-nasal drip, headache, local pain. Check for possible influence of physical factors: wind, cold, irritants, smoke. Also check for presence of allergic rhinitis or sinusitis. Ask if there is a possible history of head trauma, nose problems or nasal surgery. Also take a drug history, including OTC medications esp. sympathomimetics, illicit drugs, prescribed drugs.

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Key examination

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Look for cause. Inspect nose and nasal cavity with a Thudicum speculum or large auriscope. Note the position of the septum, nature of nasal mucosa and look for polyps or other tumours.

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Key investigations

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Usually none required. Consider:

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  • micro/culture of discharge

  • X-ray sinuses

  • CT scan

  • allergy testing

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Diagnostic tips

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Beware of persistent blood-stained discharge esp. if unilateral and obstruction. Clear discharge following direct facial or head injury may represent CSF leakage from a skull fracture.

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