RIME - Nasal Congestion/Rhinorrhea Sylvia Robinson, MSIII April 7, 2011

History Intake

· Onset (sudden or gradual)

· Duration (days, weeks, seasonal, or year round)

· Severity (mild, day around, worsening, or improving)

· Nasal discharge (watery, mucous, purulent, bloody,)

· Associated Symptoms

o Fever (onset, duration, maximum, medication response)

o Cough (dry or productive, day or night occurrence)/SOB/Wheezing

o Myalgias, headache, facial pain

o Sore throat

· Sneezing, nasal and/or palatal purities

· Trauma

Physical Exam

· Edematous turbinate

· Nasal discharge (color and consistency varies)

· Mucosal erythema

· Cobblestoning of posterior oropharynx

· Dark discoloration beneath the eyes (“allergic shiner”)

· Transverse nasal crease across bridge of nose (“allergic salute”)

Differential diagnosis

	Viral rhinosinusitis		Allergic Rhinitis		Bacterial Sinusitis	Other Conditions
Causes	Rhinovirus, parainfluenza, adenovirus, Influenza, coronavirus, RSV		IgE mediated reaction to allergens (pollen, mold, dust mites, etc)		Bacterial: S. pneumoniae, H. influenzae, M. catarrahalis	-Foreign body -Structural abnormalities choanal atresia nasal polyps -Cystic Fibrosis -Congenital Syphilis (onset within 1^st 3 months of life) -Cocaine use (adolescent population)
Symptoms and Signs	Symptoms common to all: cough congestion rhinorrhea: usually watery in viral and allergic conditions, purulent in sinusitis
	-Myalgias -Low grade fever -Mild sore throat -Cervical adenopathy	-Sneezing -itchy eyes, nasal purities -Edematous pale to bluish turbinate -Cobblestoning -dark discoloration of under eyes -Nasal salute		-Fever -Headache and/or facial pain -Symptoms persist for greater than 2 weeks or worsen in severity over time
Diagnosis	-Clinical diagnosis	- Clinical diagnosis > 4% eosinophils on nasal smear		-Clinical diagnosis CT if intracranial or orbital complications suspected
Treatment	Supportive treatment -Saline drops and suction	Limit allergen exposure, intranasal corticosteroids, antihistamines		-Antibiotics

Sources: Pediatrics in Review, Uptodate, Nelson Textbook of Pediatrics 17^th ed.