What causes cold feet, dry burning sensation around the face and eyes, lethargy, malaise, sinusitis, and nasal mucosa hypertrophy?

Differential Diagnosis: Cold Feet, Facial Burning, Lethargy, and Nasal Symptoms

This constellation of symptoms—cold feet, dry burning sensation around the face and eyes, lethargy, malaise, sinusitis, and nasal mucosa hypertrophy—most likely represents chronic rhinosinusitis with systemic manifestations, though atrophic rhinitis and medication-induced rhinitis must be excluded. 1

Primary Diagnostic Considerations

Chronic Rhinosinusitis

Chronic rhinosinusitis is the most probable diagnosis given the combination of nasal symptoms with systemic features. 1, 2

• Nasal mucosa hypertrophy with sinusitis indicates chronic inflammatory changes, typically involving turbinate enlargement from persistent mucosal edema 1
• Systemic symptoms including fatigue, general malaise, and an ill-defined feeling of unwellness are more prominent in chronic sinusitis than local symptoms 1
• The dry burning sensation around face and eyes may represent facial pressure and discomfort characteristic of chronic disease 3, 2
• Lethargy and malaise are recognized systemic manifestations, with chronic rhinosinusitis causing reduced quality of life and workplace productivity 4

Atrophic Rhinitis (Critical to Exclude)

Paradoxically, atrophic rhinitis can present with nasal dryness yet be perceived as severe congestion despite enlarged nasal cavities. 1, 5

• Primary atrophic rhinitis features progressive nasal mucosa atrophy, nasal crusting, and nasal dryness from glandular cell atrophy 1, 5
• The dry burning sensation fits with nasal dryness as a cardinal feature 5
• "Empty nose syndrome" on CT shows characteristic bone resorption and absent turbinates—the opposite of hypertrophy 1
• However, your description of nasal mucosa hypertrophy makes primary atrophic rhinitis less likely, though secondary atrophic rhinitis from chronic sinusitis remains possible 1

Drug-Induced Rhinitis

Medication history is essential, as multiple drug classes cause rhinitis with nasal congestion. 1

• ACE inhibitors are currently the most common antihypertensive medications causing rhinitis symptoms 1
• Beta-blockers occasionally elicit rhinitis symptoms 1
• Alpha-receptor antagonists (for benign prostatic hypertrophy) cause drug-induced rhinitis 1
• Phosphodiesterase-5 inhibitors (erectile dysfunction medications) induce nasal congestion 1
• Rhinitis medicamentosa from overuse of intranasal decongestants (oxymetazoline, phenylephrine) causes rebound congestion and mucosal changes 1

Diagnostic Algorithm

Step 1: Medication Review

• Obtain complete medication history, specifically asking about ACE inhibitors, beta-blockers, alpha-blockers, erectile dysfunction medications, and topical nasal decongestants 1
• If using topical decongestants for >3-5 days, suspect rhinitis medicamentosa 1

Step 2: Nasal Endoscopy

• Examine for turbinate hypertrophy versus atrophic changes with abnormally wide nasal cavities 1
• Look for purulent discharge suggesting bacterial infection 1, 2
• Assess for nasal polyps, which may contribute significantly to symptoms and occur with chronic rhinitis 1
• Evaluate for crusting and dryness suggesting atrophic rhinitis 1, 5

Step 3: CT Imaging

• CT scan of paranasal sinuses is the gold standard for confirming chronic rhinosinusitis, showing mucosal thickening, air-fluid levels, or opacification 6
• In atrophic rhinitis, CT shows resorption of underlying bone and absence of identifiable turbinates ("empty nose syndrome") 1
• Correlate imaging findings with clinical symptoms, as up to 40% of asymptomatic adults have abnormalities on sinus CT 6

Step 4: Consider Underlying Conditions

• Allergic rhinitis may coexist and worsen chronic sinusitis 1, 4
• Hormonal factors in women (pregnancy, menstrual cycle) can cause rhinitis 1
• Immune deficiency predisposes to chronic sinusitis 1
• Ciliary dysfunction and cystic fibrosis alter mucus clearance 1

Treatment Approach Based on Diagnosis

If Chronic Rhinosinusitis Confirmed:

• Intranasal corticosteroids (mometasone, fluticasone, beclomethasone) are cornerstone therapy to reduce mucosal inflammation 2
• Nasal saline irrigation 2-3 times daily to improve mucociliary clearance 7, 2
• Systemic antibiotics (amoxicillin-clavulanate preferred over amoxicillin alone) for 5-7 days in adults if bacterial infection suspected 7, 8
• Target common pathogens: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis in acute cases; Staphylococcus aureus and anaerobes in chronic cases 1, 8

If Atrophic Rhinitis Suspected:

• Regular nasal lavage with saline or sodium bicarbonate solution 2-3 times daily as foundation of treatment 5, 7
• Periodic debridement of crusts to prevent obstruction 5
• Topical antibiotics (mupirocin) added to lavage for purulent secretions 5, 7
• Systemic antibiotics targeting Klebsiella ozaenae, S. aureus, Proteus mirabilis, E. coli for acute infections 5, 7

If Drug-Induced Rhinitis:

• Discontinue offending medication if possible after consulting prescribing physician 1
• For rhinitis medicamentosa: suspend topical decongestants immediately 1
• Intranasal corticosteroids to control symptoms during rebound period 1
• Short course of oral corticosteroids may be needed for severe rebound congestion 1

Critical Pitfalls to Avoid

• Do not assume all nasal congestion is infectious—medication-induced rhinitis is commonly overlooked 1
• Do not use topical decongestants beyond 3-5 days—this creates rhinitis medicamentosa with worsening rebound congestion 1
• Do not ignore systemic symptoms—lethargy and malaise in chronic sinusitis indicate significant disease burden requiring aggressive treatment 1, 4
• Do not confuse atrophic rhinitis with hypertrophic rhinitis—they require opposite treatment approaches 1, 5
• Cold feet may represent peripheral vascular symptoms unrelated to rhinosinusitis and warrant separate cardiovascular evaluation if persistent 9

When to Refer

• Failure to respond to initial therapy after 3-5 days or worsening after 48-72 hours 7
• Recurrent episodes despite appropriate treatment 7
• Immunocompromised patients or those who are seriously ill 7
• Suspected anatomic abnormalities requiring surgical correction 1