Week 15
Rhinorrhea and Congestion
Daniel Anderson, MD & Andrea Rock, MD
Does your nose run, and your feet smell? Then you’re built upside down.
– Unknown
Learning Objectives:
1. Identify the signs and symptoms of an uncomplicated upper respiratory infection, allergic rhinitis
and conjunctivitis, and acute and chronic sinusitis, differentiating these from other causes of
rhinorrhea.
2. Discuss the available modalities for testing, for environmental control, and for treatment of
allergic rhinitis and conjunctivitis.
3. Describe treatment of sinusitis and reasons for referral.
Primary References:
1. Gargiulo KA, Spector ND. Stuffy Nose. Pediatrics in Review. 2010;31: 320-324.
http://pedsinreview.aappublications.org/content/31/8/320.full.pdf+html
2. DeMuri GP and Wald ER. Acute Bacterial Sinusitis in Chlidren. N Engl J Med. 2012;367: 1128-1134
http://www.nejm.org/doi/pdf/10.1056/NEJMcp1106638
PROLOGUE:
It’s early fall and you’re perusing your schedule for the day. You notice that three 5-year-
olds are scheduled back-to-back with complaints of “stuffy nose.” You reflexively start to
think about the reasons why three different parents would be so concerned about stuffy
noses that they would bring it to your attention.
1. What is your differential diagnosis for stuffy nose in a school-aged child?
CASE ONE:
Your first patient, Ry Noria, is a lovely 5-year-old girl whose mother tells you that she has
had a runny nose since spring. “I wish Ry would stop rubbing her nose with her palms and
sleeves!” The rhinorrhea is evident throughout the day, every day. Ry sleeps well at night
and has been breathing through her mouth while asleep. On chart review, Ry has eczema
and is otherwise healthy. An aunt suffers from “sinuses” and others in the family have
“hay fever that comes and goes.” Ry has no siblings, pets or known sick contacts.
2. What is the most likely diagnosis based on history? What other historical points are you likely to
find in children with this diagnosis?
©2013 Yale University School of Medicine Department of Pediatrics
CASE continued:
On exam, Ry is comfortable and talkative with a somewhat nasal voice. She has her mouth
open at rest and an arched palate. Her tympanic membranes are normal in position and
appearance, without effusions. Conjunctivae are clear and moist. The skin over the inferior
orbits is hyperpigmented and there is a transverse crease along her nose. Ry has no facial
tenderness. Her nasal turbinates are pale and swollen and there is clear mucus in both
nares. Respiratory rate and effort are normal, and Ry’s lungs are clear to auscultation. Her
skin is well moisturized and the remainder of the exam is normal for her age.
3. Which physical exam findings support your diagnosis? What, if any, additional testing is
required to confirm your diagnosis?
CASE continued:
On further discussion Mrs. Noria recalls that Ry’s nose runs and her eyes itch whenever
they sweep or dust, and when Ry sleeps at her aunt’s house which is carpeted and full of
old furniture. She occasionally gives Ry acetaminophen or diphenhydramine for the
symptoms, but neither seems terribly effective.
4. What is your approach to treatment?
CASE TWO:
Stu Phenos is a veritable rapscallion with a nasty habit of trying to dismantle your exam
room at every visit. His parents report two days of thick yellow-white discharge from his
left nostril only, with occasional blood streaking and a bad odor. He has been afebrile and
otherwise acting like his usual self, you note as he tries to wrap his foot in the cord of your
otoscope. On exam he is well-appearing, with normal tympanic membranes, no facial
tenderness, and a normal oropharynx.
5. What do you suspect is the cause of Stu’s rhinitis? What do you expect to see on your nasal
exam?
©2013 Yale University School of Medicine Department of Pediatrics
CASE THREE:
Your next patient, Symon Nositis arrives with a low-grade fever. His parents describe 12
days of bilateral, thick nasal discharge and cough, and three days now of low-grade fevers
and decreased energy. They initially thought that it was a typical cold, but have come to
see you because the duration and continued worsening do not seem normal to them. You
immediately suspect that Sy has sinusitis, and frankly because of his name have always
wondered when he would come to you with this problem.
6. You recall that the paranasal sinuses develop throughout childhood. When do each of the sinus
spaces become clinically significant?
7. How is the diagnosis of sinusitis made in school-aged children?
CASE continued:
Sy’s mother watches you point to where his ethmoid sinuses are and listens to your
explanation of the infection. When you pause, she looks slightly disturbed and blurts out,
“but isn’t that his brain?!” You reassure her that Sy does not currently have an infection of
his brain. Meanwhile, you remind yourself to keep on the lookout for complications of
acute bacterial sinusitis.
8. What are these potential complications?
9. How will you treat Sy’s sinusitis?
©2013 Yale University School of Medicine Department of Pediatrics
Additional References:
1. Bielory L, Lien KW, Bigelsen S. Efficacy and tolerability of newer antihistamines in the treatment of
allergic conjunctivitis. Drugs. 2005;65(2): 215-228.
2. Botma M, Bader R, Kubba H. ‘A Parent’s Kiss’: evaluating an unusual method for removing nasal
foreign bodies in children. J Laryngol Otol. 2000;114: 598-600.
3. Calderon MA, et al. Allergen injection immunotherapy for seasonal allergic rhinitis. Cochrane
Database of Systematic Reviews. 2007, Issue 1. Art No: CD001936. DOI:
10.1002/14651858.CD001936.pub2.
4. Chan TC, et al. Nasal foreign body removal. J Emerg Med. 2004;26(4): 441-445.
5. Chow AW, et al. IDSA Clinical Practice Guidelines for acute bacterial rhinosinusitis in children and
adults. Clin Infect Dis. 2012; 54(8): e72-e112.
6. Cook SC, et al. Efficacy and saftety of the “mother’s kiss” technique: a systemic review of case
reports and case series. CMAJ. 2012, 184(17): E904-E912.
7. Custovic A, van Wijk RG. The effectiveness of measures to change the indoor environment in the
treatment of allergic rhinitis and asthma: ARIA update. Allergy. 2005;60: 1112-1115.
8. Holgate S. The epithelium takes centre stage in asthma and atopic dermatitis. Trends in
Immunology. 2007;28(6): 248-251.
9. Mitra A, et al. The natural history of acute upper respiratory tract infections in children. Primary
Health Care Research and Development. 2011;12: 329-334.
10. Navitsky RC, Beamsley A, McLaughlin S. Nasal positive-pressure technique for nasal foreign body
removal in children. Am J Emerg Med. 2002;20(2): 103-104.
11. Quillen DM, Feller DB. Diagnosing rhinitis: allergic vs. non-allergic. Am Fam Physician. 2006;73(9):
1583-1590.
12. Radulovic S, et al. Sublingual immunotherapy for allergic rhinitis. Cochrane Database of Systematic
Reviews, 2010, Issue 12. Art No: CD002893. DOI: 10.1002/14651858.CD002893.pub2.
13. Sicherer SH, Wood RA, AAP Section on Allergy and Immunology. Allergy testing in childhood: using
allergen-specific IgE tests. Pediatrics. 2012;129(1): 193-197.
14. Slavin RG, et al. The diagnosis and management of sinusitis: a practice parameter update. J Allergy
Clin Immunol. 2005;116: S13-47.
15. Sublet JL, et al. Air filters and air cleaners: rostrum by the American Academy of Allergy, Asthma,
& Immunology Indoor Allergen Committee. J Allergy Clin Immunol. 2010;125: 32-38.
16. Terreehorst I, et al. Evaluation of impermeable covers for bedding in patients with allergic rhinitis.
New England Journal of Medicine. 2003;349(3): 237-246.
Resources:
1. American Academy of Allergy, Asthma and Immunology. www.aaaai.org
2. Healthy Children Guidelines for Referral to Pediatric Surgical Specialists.
http://www.healthychildren.org/English/family-life/health-management/Pages/Guidelines-for-
Referral-to-Pediatric-Surgical-Specialists.aspx
3. Healthy Children information on Ear Nose and Throat conditions – includes parent information on
colds, allergic rhinitis, and sinusitis. www.healthychildren.org/English/health-
issues/conditions/ear-nose-throat/Pages/default.aspx
©2013 Yale University School of Medicine Department of Pediatrics
