CHAPTER 22 Nasal symptoms and sinus congestion

Concern about symptoms of the “common cold” accounts for a significant proportion of primary care visits by both children and adults, especially in the winter months. Symptoms include nasal congestion, rhinorrhea, postnasal drip, sneezing, itchy nose, watery and itchy eyes, and frontal headache. Severe symptoms are associated with ageusia (loss of taste) and anosmia (loss of smell).

The nose humidifies, warms, and filters inspired air. The nasal turbinates promote turbulent airflow that causes particulate matter to fall on the mucosa, where it is swept away by ciliated pseudostratified columnar cells to the nasopharynx. Rhinitis, or inflammation of the mucous membranes, is a frequent nasal symptom that is caused by bacterial or viral infection, a response to allergens, or a response to medication or extremes in environmental temperature.

Nasal polyps, septal deviation, or congenital anomaly can cause nasal obstruction. In children, nasal obstruction is very frequently unilateral and may be secondary to a foreign body inserted into the nose.

Respiratory epithelium lines the paranasal sinuses and creates drainage into the nasal cavity via the superior meatus and middle meatus. The maxillary sinus is the most frequently involved paranasal sinus because its ciliated cells carry maxillary sinus drainage against gravity. When drainage systems become impaired as a result of mucosal edema, mechanical obstruction, or impaired ciliary activity, viruses and bacteria proliferate.

The paranasal sinuses include the frontal, ethmoid, maxillary, and sphenoid (Figure 22-1). Most sinus infections are caused by bacteria common to the nasopharynx that proliferate when local or systemic defenses are impaired. The most common causative organisms producing bacterial sinusitis in both adults and children are Streptococcus pneumoniae and Haemophilus influenzae. Sinusitis may also be associated with allergies and asthmatic exacerbations or with contiguous infection of the mouth or face.

FIGURE 22-1 Anterior and lateral views of the paranasal sinuses.

(From Barkauskas VH, Baumann L, Darling-Fisher C: Health and physical assessment, ed 3, St Louis, 2002, Mosby.)

Diagnostic reasoning: focused history

What symptoms will help me narrow the possibilities?

Key questions

Can you describe your symptoms?

How long have they been present?

Do you have a history of nasal problems?

Do the symptoms occur at any particular time of the year?

Is there a family history of allergies or asthma?

Duration of symptoms/history of problems

Acute symptoms of rhinitis or sinus congestion, usually lasting 48 to 72 hours, are caused by edematous mucosa obstructing the sinus ostia. If a person has no history of similar symptoms but has systemic symptoms, such as fever, myalgias, and chills, acute infectious rhinitis caused by rhinoviruses or parainfluenza virus is likely.

Chronic rhinitis lasting weeks to years is rarely infectious; rather it is often associated with anatomical abnormalities that impair the sinus drainage system, although the mucociliary clearance mechanisms are normal.

Seasonal occurrence of symptoms

Suspect allergic rhinitis if a person describes seasonal occurrence of nasal symptoms associated with sneezing, wheezing, and itchy or burning eyes. A distinguishing feature of the allergic individual is the propensity to develop sustained IgE response after antigenic stimulation. IgE is an antibody capable of interacting with target cells that release mediators on contact with specific antigens. This reaction is the manifestation of an allergy.

Persons with perennial allergies have an allergen present in the environment on a year-round basis from such sources as animal dander, house dust, mold, feathers, and cockroaches. Seasonal allergies usually occur in early spring (tree pollens), early summer (grass pollens), and early fall (weed pollens).

Family history

Family history of asthma or allergies is frequently associated with allergic rhinitis. Other symptoms may include a sensation of head stuffiness, ear discomfort, fatigue, and a scratchy or mild sore throat.

If I suspect sinus problems, what do I need to know?

Key questions

How long have you had these symptoms?

Do you have pain? Can you point to the areas of pain?

Do your symptoms change with position changes?

Do you have a history of sinus problems?

Acute symptoms

Acute sinusitis is an abrupt onset of infection of one or more of the paranasal sinuses, and it occurs when the sinus ostia become obstructed, usually after an upper respiratory tract infection. Sinusitis is frequently associated with a sore throat, often irritated by postnasal discharge, facial or tooth pain, or headache over the affected sinus, as well as morning periorbital swelling, fever, and malaise. Other less common causes include anatomical abnormality, adenoid hypertrophy, and contiguous infection, such as a dental abscess or periorbital cellulitis.

Location of pain

An adult patient with sinusitis most often reports a prolonged cold with symptoms of nasal congestion and facial pain. Children rarely complain of headache or facial pain. The location of pain may indicate which sinus is involved. Pain of maxillary sinusitis occurs over the sinuses and is sometimes perceived as a maxillary toothache. Frontal sinusitis produces a frontal headache that is worse on morning wakening. Ethmoid sinusitis causes pain that refers to the vertex, forehead, or occipital or temporal region, whereas the pain of sphenoid sinusitis is perceived on the top of the head.

Position change

Maxillary sinusitis produces pain that worsens with bending or leaning forward. The postnasal discharge associated with sinusitis produces a cough that worsens while lying down.

Chronic symptoms

Chronic symptoms can be caused by prolonged obstruction of the osteomeatal complex, which leads to dysfunction of ciliary motility and movement of mucus within the sinuses. Local factors that cause mechanical obstruction include adenoid hypertrophy, conchae bullosa, nasal polyps, foreign bodies, and nasal deviations. Adults with symptoms that last more than 3 weeks experience upper molar pain or headache, postnasal drip, and rarely have a fever. In children, chronic sinusitis is defined as the presence of symptoms for longer than 30 days.

Do associated symptoms provide any clues?

Key questions

Do you have other acute symptoms, such as cough, fever, or muscle aches?

Do you have other chronic symptoms, such as eye pain, bad breath, or fatigue?

Other acute symptoms

Acute bacterial infection of the nasal and sinus mucosa is characterized by the presence of purulent nasal discharge. Acute rhinitis caused by a bacterial or viral infection produces systemic symptoms, such as fever, myalgia, and chills. Allergic rhinitis is associated with sneezing, nasal congestion, clear and profuse rhinorrhea, and pruritus of the nose, palate, pharynx, and middle ear. Eye complaints include conjunctival irritation, itching, erythema, and tearing. Ear complaints involve a feeling of fullness in the ears with popping. Sinus complaints are pressure and/or pain of the cheeks, forehead, or behind the eyes.

Acute sinusitis in children involves the presence of symptoms for less than 30 days, a persistent cough, fever with a temperature greater than 39° C (102.2° F) for more than 3 days, and malodorous breath. The maxillary and ethmoid sinuses are most commonly affected, with the frontal sinus occasionally and the sphenoid sinus rarely affected.

Chronic symptoms

Chronic sinusitis involves long episodes of inflammation or repeated infections that lead to anatomical destruction. The recurrent symptoms interfere with daily activities and are not relieved with nonpharmacological measures or over-the-counter medications. Patients often report a cold that does not go away, eye pain, halitosis, chronic cough, fatigue, anorexia, and malaise.

Is it viral or bacterial?

Key questions

What color is your nasal drainage?

How long have you had these symptoms?

Acute rhinitis caused by a bacterial or viral infection produces yellow or green purulent nasal discharge. Watery or clear discharge occurs with allergic reactions. Symptoms of viral upper respiratory tract infections in children persist 5 to 10 days and then gradually subside. Many children may have up to eight colds per year.

Are symptoms unilateral or bilateral?

Key question

Is the symptom on one side or both sides?

Infectious rhinitis and allergic rhinitis are usually bilateral. Unilateral symptoms are more indicative of an anatomical cause, such as nasal polyps, septal deviation, or a foreign body (typically occurs in children).

Are there risk factors that will narrow the diagnosis?

Key questions

Do you smoke?

Are you exposed to others who smoke?

Do you have any other health problems?

Have you had a recent history of head or facial trauma?

Have you been diving or swimming?

Have you been exposed to infections in day care, school, or work settings?

Are you pregnant?

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