What are the typical physical examination findings in patients with post nasal drip syndrome?

Physical Examination Findings in Post Nasal Drip Syndrome

The physical examination in post nasal drip syndrome (now termed Upper Airway Cough Syndrome) typically reveals mucoid or mucopurulent secretions in the nasopharynx or oropharynx, and cobblestoning of the posterior pharyngeal mucosa, though approximately 20% of patients may have completely normal examinations despite active symptoms. 1

Key Oropharyngeal Findings

The most characteristic finding is cobblestoning of the posterior pharyngeal wall, which appears as raised lymphoid tissue creating a bumpy, pebbled appearance of the mucosa. 1 This finding is highly suggestive of chronic postnasal drainage irritating the pharyngeal tissues.

Visible mucoid or mucopurulent secretions may be observed draining down the posterior pharyngeal wall or pooling in the oropharynx. 1 However, the absence of visible secretions does not exclude the diagnosis, as the American College of Chest Physicians emphasizes that approximately 20% of patients have "silent" postnasal drip with no obvious drainage visible on examination. 1, 2

Nasal Examination Findings

The nasal examination findings vary depending on the underlying cause:

For allergic rhinitis-related postnasal drip:

• Pale, bluish, or edematous nasal turbinates 1, 3, 4
• Clear, watery nasal discharge 1, 3
• Nasal mucosal edema and swelling 1

For chronic rhinosinusitis-related postnasal drip:

• Erythematous and inflamed turbinates 4
• Purulent nasal discharge 1
• Nasal polyps may be present 1

For vasomotor rhinitis:

• Often normal nasal examination or minimal findings 1
• Turbinate hypertrophy without specific color changes 1

Associated Physical Findings

Ocular findings may include:

• Allergic shiners (dark circles under eyes from venous stasis) 1, 3
• Conjunctival erythema and swelling 1, 3
• Excessive lacrimation 1

Facial findings may include:

• Transverse nasal crease from chronic nose rubbing ("allergic salute") 1, 3
• Mouth breathing preference 1

Ear findings may include:

• Tympanic membrane dullness or retraction from eustachian tube dysfunction 1
• Reduced tympanic membrane mobility 1

Critical Diagnostic Pitfalls

The absence of visible postnasal drainage does NOT rule out the diagnosis. The American College of Chest Physicians specifically notes that 20% of patients with confirmed upper airway cough syndrome are completely unaware of postnasal drainage and have no visible secretions on examination, yet still respond to treatment. 1, 2 This "silent postnasal drip" is a common diagnostic trap.

Physical examination provides limited diagnostic information overall. 1 The diagnosis of postnasal drip syndrome is primarily clinical, based on the combination of symptoms (sensation of drainage, throat clearing, cough), physical findings when present, and most importantly, response to empiric therapy. 1

If the patient is asymptomatic at the time of examination, findings may be minimal or absent even with a strong history suggestive of the condition. 1 This emphasizes the importance of not relying solely on physical examination to make or exclude the diagnosis.

Examination Technique

Anterior rhinoscopy with a nasal speculum and appropriate lighting allows visualization of the anterior nasal cavity, turbinates, septum, and anterior secretions. 1

Fiberoptic nasopharyngoscopy provides superior visualization of the middle meatus, posterior nasal cavity, and nasopharynx, allowing direct observation of secretions and mucosal changes. 1

Application of topical decongestant during examination can help differentiate mucosal edema from bony hypertrophy and distinguish severely edematous mucosa from nasal polyps. 1