What is the standard approach for evaluating chronic left-sided nasal congestion?

Evaluation of Chronic Left-Sided Nasal Congestion

Begin with a detailed symptom assessment to determine if this represents chronic rhinosinusitis (CRS), and if symptoms meet diagnostic criteria, proceed directly to nasal endoscopy as the essential next step to visualize the nasal cavity and document objective evidence of inflammation. 1

Initial Clinical Assessment

Symptom Characterization (Duration ≥12 weeks)

Determine if the patient has at least 2 of the following 4 cardinal symptoms: 1, 2

• Nasal obstruction/congestion (unilateral in this case)
• Anterior or posterior mucopurulent drainage
• Facial pain, pressure, or fullness
• Decreased sense of smell (hyposmia/anosmia)

Important caveat: Unilateral symptoms warrant heightened concern for structural abnormalities, neoplasia, or other serious pathology that requires urgent evaluation. 1

Key Historical Elements to Elicit

• Pattern and triggers: Determine if symptoms worsen with environmental exposures, suggesting allergic component 1, 3
• Response to prior medications: Previous trials of intranasal corticosteroids, antihistamines, or antibiotics 3
• Associated symptoms: Purulent discharge (suggests bacterial component), clear discharge (suggests allergic/vasomotor), epistaxis or unilateral bleeding (red flag for neoplasia) 1
• Occupational exposures: Critical for occupational rhinitis diagnosis 1
• Medication history: ACE inhibitors, phosphodiesterase-5 inhibitors, overuse of topical decongestants causing rhinitis medicamentosa 1

Essential Diagnostic Procedures

Nasal Endoscopy (Primary Diagnostic Tool)

Nasal endoscopy is strongly preferred over anterior rhinoscopy and should be performed in all patients with suspected CRS to establish objective evidence of disease. 1 This is particularly critical for unilateral symptoms to rule out serious pathology.

Key findings to document: 1

• Purulent (not clear) mucus or edema in the middle meatus or anterior ethmoid region
• Presence or absence of nasal polyps
• Septal deviation or anatomic abnormalities
• Masses or concerning lesions (especially with unilateral presentation)

Clinical pearl: Addition of nasal endoscopy to symptom assessment substantially increases diagnostic accuracy for CRS when compared to CT imaging as the gold standard. 1

When to Obtain CT Imaging

CT scanning is NOT routinely indicated at initial presentation but should be strongly considered in the following scenarios: 1

• After failure of appropriate medical therapy (intranasal corticosteroids + saline irrigation for 8-12 weeks) with continued symptoms and abnormal endoscopy 1
• Atypical symptoms or physical findings suggesting complications or alternative diagnoses 1
• Unilateral symptoms that raise concern for structural abnormality or neoplasia 1
• Pre-surgical planning if endoscopic sinus surgery is being considered 1

Imaging modality selection: 1

• CT without contrast is the gold standard for evaluating sinonasal anatomy and inflammation
• MRI with contrast is indicated if neoplasia or invasive fungal sinusitis is suspected
• Plain radiographs have no role in CRS evaluation 1

Allergy Evaluation

Allergy testing should be performed in patients with recurrent or chronic rhinosinusitis, particularly when: 1, 3

• History suggests environmental triggers
• Symptoms include clear rhinorrhea, sneezing, or ocular symptoms
• Initial medical therapy fails

Preferred method: Skin testing is preferred over serum-specific IgE testing due to higher sensitivity (70-75%), lower cost, and immediate results. 1

Specialized Testing (When Indicated)

Consider in Refractory Cases:

• Acoustic rhinometry or rhinomanometry: Objective measurement of nasal obstruction, particularly useful when anatomic abnormalities are suspected or to assess response to therapy 1
• Nasal cytology: Not routinely recommended, but >10% eosinophils may suggest NARES (non-allergic rhinitis with eosinophilia syndrome) in skin test-negative patients 1
• Immunodeficiency workup: For recurrent acute rhinosinusitis (≥4 episodes/year) or CRS refractory to standard therapy 1

Critical Red Flags Requiring Urgent Evaluation

Unilateral nasal congestion specifically warrants immediate concern for: 1

• Neoplasia (benign or malignant)
• Inverted papilloma
• Fungal sinusitis
• Foreign body
• Severe septal deviation or anatomic obstruction

These conditions require prompt nasal endoscopy and often imaging (CT or MRI with contrast) to exclude serious pathology. 1

Algorithmic Approach Summary

1. Confirm symptom duration ≥12 weeks and presence of ≥2 cardinal symptoms 1, 2
2. Perform nasal endoscopy to document objective inflammation (purulent mucus, edema, polyps) 1
3. If endoscopy shows inflammation: Initiate medical therapy (intranasal corticosteroids + saline irrigation) 2
4. If endoscopy is normal but symptoms persist: Consider allergy testing, acoustic rhinometry, or CT imaging to identify non-inflammatory causes 1, 3
5. If unilateral symptoms or concerning findings: Obtain CT or MRI imaging urgently to exclude neoplasia or serious structural pathology 1
6. If medical therapy fails after 8-12 weeks: Obtain CT imaging and consider referral to otolaryngology 1, 2

Common pitfall to avoid: Do not obtain CT imaging as the initial diagnostic test in primary care; nasal endoscopy provides superior diagnostic yield and avoids unnecessary radiation exposure in uncomplicated cases. 1