How should nasal congestion be evaluated?

Evaluation of Nasal Congestion

Begin with a focused history to determine symptom duration, pattern, and laterality, followed by anterior rhinoscopy or nasal endoscopy to identify structural abnormalities, mucosal changes, and purulent drainage—then stratify by duration (<10 days viral, ≥10 days bacterial, ≥12 weeks chronic) and perform allergy testing when indicated. 1

Initial History and Symptom Characterization

The evaluation starts by documenting duration, pattern, laterality, triggers, and associated symptoms to narrow the differential diagnosis 1:

• Duration <10 days without worsening: Presume acute viral rhinosinusitis (98–99.5% of cases), which typically resolves within 7–10 days 1, 2
• Duration ≥10 days without improvement OR worsening after initial improvement ("double sickening") OR severe onset (high fever ≥39°C with purulent discharge for ≥3–4 days): Suspect acute bacterial rhinosinusitis 1, 2
• Duration ≥12 weeks: Evaluate for chronic rhinosinusitis, which requires at least two of four cardinal features: nasal blockage/obstruction, nasal discharge, facial pain/pressure, or reduced/lost sense of smell 1
• Unilateral symptoms: This is a red flag requiring urgent evaluation for neoplasia, inverted papilloma, fungal sinusitis, foreign body, or severe septal deviation 3

Document seasonality (suggests allergic rhinitis), occupational triggers (symptoms worsen at work and improve away from work, suggesting occupational rhinitis), medication use (topical decongestants >3–5 days cause rhinitis medicamentosa), and pregnancy status (rhinitis of pregnancy begins after second month of gestation) 4, 1.

Physical Examination Findings

Perform anterior rhinoscopy or preferably nasal endoscopy to directly visualize the nasal cavity 1, 3:

• Purulent secretions in nasal cavity or posterior pharynx suggest bacterial rhinosinusitis 2
• Mucosal erythema and edema are typical findings in acute bacterial rhinosinusitis 2
• Nasal polyps in adults suggest NSAID sensitivity and asthma; in children, polyps warrant evaluation for cystic fibrosis 1
• Septal deviation, turbinate hypertrophy, or masses indicate anatomic obstruction 1
• Unilateral maxillary sinus tenderness on palpation is particularly predictive of bacterial infection 2

Nasal endoscopy is strongly preferred over anterior rhinoscopy as the primary diagnostic tool, particularly when chronic rhinosinusitis is suspected, because it provides superior visualization of the middle meatus, ostiomeatal complex, and posterior nasal cavity 3.

Differential Diagnosis by Clinical Pattern

Acute Viral Rhinosinusitis (Symptoms <10 Days)

• Accounts for 98–99.5% of all acute rhinosinusitis cases 1
• Symptoms include nasal congestion, clear or cloudy rhinorrhea, post-nasal drainage, facial pressure, and cough 1
• Green nasal mucus alone does NOT indicate bacterial infection—it reflects neutrophils from the normal viral inflammatory response 1
• No imaging or antibiotics indicated; manage with symptomatic therapy 1, 2

Acute Bacterial Rhinosinusitis (Symptoms ≥10 Days or Worsening)

• Only 0.5–2% of viral cases progress to bacterial infection 1, 2
• Requires the triad of purulent nasal discharge, nasal congestion/obstruction, AND facial pain/pressure 1, 2
• Common pathogens: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis 4, 1
• Imaging is NOT indicated for uncomplicated cases meeting clinical criteria; reserve CT for suspected complications (orbital involvement, intracranial extension, facial swelling, immunocompromised state, or failure to respond after 21–28 days of antibiotics) 2

Chronic Rhinosinusitis (Symptoms ≥12 Weeks)

• Requires objective evidence on nasal endoscopy (mucopurulent discharge, edema, obstruction) or CT imaging showing mucosal changes 1
• Microbiology is polymicrobial with anaerobes (Bacteroides, Fusobacterium, Peptostreptococcus), viridans streptococci, and non-encapsulated H. influenzae 4
• Consider non-infectious chronic hyperplastic eosinophilic rhinosinusitis, which does not respond to antibiotics and may require systemic corticosteroids 4

Allergic Rhinitis

• Diagnosis requires positive skin testing or specific IgE antibodies to relevant aeroallergens 1
• Symptoms may be seasonal, perennial, or episodic after specific allergen exposure 1
• Family history of allergic rhinitis, asthma, or atopic dermatitis supports the diagnosis 1

Non-Allergic Rhinitis (NAR)

• Diagnosed by negative or irrelevant skin test responses combined with symptoms triggered by environmental irritants 4
• Subtypes include NARES (non-allergic rhinitis with eosinophilia syndrome), gustatory rhinitis, senile rhinitis, and idiopathic vasomotor rhinitis 1
• NAR affects approximately 40 million Americans and is present in 23% of rhinitis patients as pure NAR and 34% as mixed rhinitis 4

Rhinitis Medicamentosa

• Results from overuse of intranasal α-adrenergic decongestants (e.g., oxymetazoline) or cocaine for more than 3–5 days 4, 1
• Causes rebound nasal edema and congestion that can only be terminated with cessation of the topical vasoconstrictor 4
• Review all medications: ACE inhibitors, β-blockers, phosphodiesterase-5 inhibitors, α-adrenergic antagonists, aspirin, and NSAIDs can all cause drug-induced rhinitis 1

Occupational Rhinitis

• Symptoms are temporally linked to workplace exposure and improve when away from work 4, 1
• Prevalence approaches 100% among workers with occupational asthma sensitized to high-molecular-weight protein allergens 1
• May require industrial hygienist evaluation to identify the source 4

Diagnostic Algorithm

Step 1: Determine Duration and Pattern

• <10 days without worsening → Viral rhinosinusitis, symptomatic therapy only 1, 2
• ≥10 days, worsening after improvement, or severe onset → Bacterial rhinosinusitis, consider antibiotics 1, 2
• ≥12 weeks → Chronic rhinosinusitis, proceed to endoscopy or CT 1

Step 2: Assess Laterality

• Unilateral symptoms → Urgent evaluation with endoscopy and imaging (CT or MRI with contrast) to exclude neoplasia, fungal infection, or foreign body 3
• Bilateral symptoms → Proceed with standard evaluation 1

Step 3: Perform Physical Examination

• Nasal endoscopy (preferred) or anterior rhinoscopy to document purulent drainage, polyps, septal deviation, masses, or mucosal changes 1, 3
• Palpate sinuses for tenderness 2

Step 4: Allergy Testing When Indicated

• Perform skin testing or specific IgE testing in patients with recurrent or chronic rhinosinusitis, environmental triggers, clear rhinorrhea with sneezing/ocular symptoms, or treatment failure 3
• Skin testing is preferred over serum IgE due to higher sensitivity, lower cost, and immediate results 3

Step 5: Reserve Imaging for Specific Indications

• Do NOT routinely order imaging for uncomplicated acute rhinosinusitis; clinical criteria have comparable diagnostic accuracy to radiography 2
• Order CT only for suspected complications, immunocompromised state, treatment failure after 21–28 days, or suspected alternative diagnosis (malignancy, fungal infection) 2

Step 6: Consider Specialized Testing in Refractory Cases

• Acoustic rhinometry or rhinomanometry to objectively measure nasal obstruction 3
• Nasal cytology in skin test-negative patients to diagnose NARES (>10% eosinophils) 3
• Quantitative immunoglobulin levels (IgG, IgA, IgM) and specific antibody response testing in patients with recurrent sinusitis (≥3 episodes/year) to assess for immunodeficiency 4

Referral Indications

Refer to Allergist/Immunologist for:

• Prolonged rhinitis with complications (sinusitis, polyposis, comorbid asthma) 1
• Need for systemic corticosteroids or significant quality-of-life impact 1
• Treatment failure, adverse effects, or rhinitis medicamentosa 1
• Allergen identification or immunotherapy consideration 1

Refer to Otolaryngologist (ENT) for:

• Symptoms persisting despite optimal medical therapy 1
• ≥3–4 episodes of acute bacterial sinusitis per year 4
• Suspected complications (orbital cellulitis, periorbital edema/erythema, visual changes, severe headache with neck stiffness, altered mental status, facial swelling suggesting frontal bone involvement) 1, 2
• Consideration for functional endoscopic sinus surgery 4

Critical Pitfalls to Avoid

• Do NOT assume green nasal mucus mandates antibiotics—color reflects neutrophils, not necessarily bacterial infection 1
• Do NOT routinely order imaging for uncomplicated acute rhinosinusitis; plain radiographs have high false-positive/negative rates, and up to 87% of young adults recovering from a common cold show maxillary sinus abnormalities on CT 2
• Do NOT overlook rhinitis medicamentosa in patients using topical decongestants for more than 3–5 days 1
• Do NOT miss nasal polyps in children—their presence should trigger evaluation for cystic fibrosis 1
• Do NOT ignore red-flag signs (periorbital edema/erythema, visual changes, severe headache with neck stiffness, altered mental status, unilateral symptoms)—these require urgent evaluation 1, 3
• Do NOT diagnose acute bacterial rhinosinusitis solely on purulent nasal discharge; the triad of purulent discharge, nasal obstruction, AND facial pain/pressure is required 2