What is the differential diagnosis and initial management for nasal congestion?

Differential Diagnosis for Nasal Congestion

The differential diagnosis for nasal congestion includes allergic rhinitis, nonallergic rhinitis (vasomotor/idiopathic), acute viral rhinosinusitis, acute bacterial rhinosinusitis, chronic rhinosinusitis, drug-induced rhinitis (including rhinitis medicamentosa), hormonal rhinitis, occupational rhinitis, infectious rhinitis, nasal polyps, and anatomic abnormalities. 1, 2

Primary Diagnostic Categories

Allergic Rhinitis

• Presents with nasal congestion (94% of cases), rhinorrhea (90%), sneezing, and nasal/ocular itching 3
• Physical examination reveals pale, edematous turbinates in seasonal allergic rhinitis or erythematous, inflamed turbinates with serous secretions in perennial allergic rhinitis 3
• Diagnosis requires positive skin testing or specific IgE antibodies to aeroallergens 1
• Symptoms occur seasonally, perennially, or episodically after specific allergen exposures 1
• Family history of allergic rhinitis, asthma, or atopic dermatitis supports the diagnosis 1

Nonallergic Rhinitis (NAR)

• Comprises approximately 7% of the U.S. population (22 million people), with idiopathic NAR being the most common subtype 2
• Presents primarily with nasal congestion and postnasal drainage, with less sneezing and itching compared to allergic rhinitis 3
• Diagnosis requires negative skin testing or specific IgE testing to rule out allergic causes 2, 3
• Triggers include perfume, strong odors, temperature/humidity changes, and tobacco smoke, though may occur without defined triggers 2
• Subtypes include NARES (nonallergic rhinitis with eosinophilia syndrome), gustatory rhinitis, senile rhinitis, and idiopathic vasomotor rhinitis 1, 2

Acute Viral Rhinosinusitis

• Accounts for 98-99.5% of acute rhinosinusitis cases 4
• Symptoms include nasal congestion, purulent rhinorrhea, postnasal drainage, facial pain/pressure, and cough 1
• Typically resolves within 7-10 days; symptoms lasting <10 days without worsening suggest viral etiology 5, 4
• Green mucus alone does not indicate bacterial infection—it represents white blood cells from normal viral inflammatory response 5, 4

Acute Bacterial Rhinosinusitis (ABRS)

• Diagnosed when symptoms persist ≥10 days without improvement, worsen after initial improvement ("double sickening"), or are particularly severe in the first 3-4 days 1, 4
• Requires the triad of purulent nasal discharge, nasal congestion/obstruction, and facial pain/pressure 1, 4
• Only 0.5-2% of acute rhinosinusitis cases are bacterial 4
• Common pathogens include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 5, 4

Chronic Rhinosinusitis

• Requires symptoms persisting ≥12 weeks with at least 2 of 4 cardinal symptoms: nasal blockage/obstruction, nasal discharge, facial pain/pressure, or reduction/loss of smell 6
• Definitive diagnosis requires objective evidence via nasal endoscopy (showing mucopurulent discharge, edema, or mucosal obstruction) or CT imaging (demonstrating mucosal changes) 6
• May involve anaerobic bacteria, gram-positive streptococcus, bacteroides, Fusobacterium species, or S. aureus 6

Drug-Induced Rhinitis

• Caused by ACE inhibitors, phosphodiesterase-5 inhibitors, α-receptor antagonists, β-blockers, aspirin, and NSAIDs 1
• Rhinitis medicamentosa results from overuse of intranasal α-adrenergic decongestants or cocaine, causing rebound nasal congestion 1

Hormonal Rhinitis

• Pregnancy rhinitis starts after the second month of pregnancy and resolves within 2 weeks after delivery 1
• Menstrual cycle-related rhinitis also occurs 1

Occupational Rhinitis

• Symptoms temporally related to workplace exposure, improving away from work 1
• Prevalence approaches 100% among workers with occupational asthma sensitized to high-molecular-weight protein allergens 1
• Reactive upper-airways dysfunction syndrome (RUDS) occurs after acute high-level irritant exposure 1

Nasal Polyps

• Should be considered in patients with invariant nasal congestion and/or anosmia 1
• In adults, may be associated with NSAID sensitivity and asthma 1
• In children, their presence should prompt evaluation for cystic fibrosis 1

Anatomic Abnormalities

• Include nasal septal deviation, turbinate hypertrophy, tumors, cleft palate, and adenoidal hypertrophy 1
• In infants, consider laryngopharyngeal reflux as a functional cause 1

Initial Management Algorithm

Step 1: History and Physical Examination

• Document pattern, chronicity, seasonality, triggers, response to medications, occupational exposures, and quality of life impact 1
• Examine nasal mucosa appearance, patency, unilaterality vs. bilaterality, anatomic obstruction, and discharge quality/quantity 1
• Assess for complications (sinusitis, otitis media) and comorbidities (asthma) 1

Step 2: Differentiate Allergic from Nonallergic

• Perform skin testing or specific IgE testing to confirm or exclude allergic rhinitis 1
• Presence of sneezing, itching, and pale turbinates favors allergic rhinitis 3
• Predominant congestion without itching and negative allergy testing indicates nonallergic rhinitis 2, 3

Step 3: Rule Out Infectious Causes

• Symptoms <10 days without worsening: treat as viral rhinosinusitis with symptomatic management 5, 4
• Symptoms ≥10 days, worsening after improvement, or severe onset: consider ABRS and initiate antibiotics 5, 4
• Symptoms ≥12 weeks: evaluate for chronic rhinosinusitis with objective testing 6

Step 4: Identify Medication-Related Causes

• Review all medications including ACE inhibitors, β-blockers, and intranasal decongestant use 1
• If overusing topical decongestants, diagnose rhinitis medicamentosa 1

Step 5: Consider Specialist Referral

Refer to allergist/immunologist when: 1

• Prolonged manifestations of rhinitis
• Complications (otitis media, sinusitis, nasal polyposis)
• Comorbid asthma
• Required systemic corticosteroids
• Symptoms interfere with function or significantly decrease quality of life
• Treatment ineffective or produces adverse events
• Rhinitis medicamentosa diagnosed
• Need for allergen identification or immunotherapy education

Refer to ENT when: 6, 4

• Symptoms persist despite appropriate medical therapy
• Recurrent acute bacterial sinusitis (≥3-4 episodes/year)
• Suspected complications (orbital cellulitis, neurological symptoms)
• Consideration for functional endoscopic sinus surgery

Critical Pitfalls to Avoid

• Do not assume green mucus mandates antibiotics—color relates to neutrophils, not necessarily bacteria 5, 4
• Do not routinely order imaging for uncomplicated acute rhinosinusitis—plain radiographs have significant false-positive/negative results 1
• Do not overlook rhinitis medicamentosa in patients using topical decongestants >3-5 days 1
• Do not miss nasal polyps in children—their presence warrants cystic fibrosis evaluation 1
• Do not ignore red flags: periorbital edema/erythema, vision changes, severe headache with neck stiffness, or mental status changes require urgent evaluation 1, 5