TABLE 21-2.

Differentiating Among Causes of Nasal Discharge^a

	Viral Nasopharyngitis1, 11, 12, 13, 14, 15	Acute Bacterial Sinusitis16, 17, 24	Streptococcal Nasopharyngitis25	Foreign Body-Related Rhinitis (Bacterial)18	Allergic Rhinitis10
History
Peak age	Peak in first 2 years after “new recruitment” into childcare or school	Any	<3 years	<3 years	>2 years; peak in adolescence
Onset	Dryness, burning in nose or nasopharynx	Insidious, with cough day and night; occasionally, acute, febrile, toxic	Insidious; occasional acute, febrile, toxic	Insidious	Seasonal; precipitants
Associated symptoms	Nasal congestion, sneezing, malaise	Malodorous breath; head or facial pain, edema		Malodorous breath ± hyponasal voice	Sneezing; nasal or palatal pruritus; tearing; snoring
Fever	Yes/no	No/yes	Low/high	No	No
Duration of discharge	3–8 days	≥10 days	>5 days	Chronic	Chronic, recurrent
Physical examination
Associated findings	Red, excoriated nares; sometimes, acute otitis media	Periorbital swelling, facial tenderness; mucopurulent postnasal discharge	Anterior cervical lymphadenitis; impetiginous lesions below nose	Mouth-breathing	Transverse nasal or lower eyelid crease; periorbital hyperpigmentation; cobblestone conjunctivae or posterior pharynx
Character of discharge	Clear or colored, watery or thick	Thick, colored	Thick, colored	Unilateral, purulent, putrid bloodstained	Watery, clear, or white
Rhinoscopy	Hyperemic mucosa; dry or glazed early, edematous later; crusted discharge	Normal mucosa; discharge from middle meatus	Normal, hyperemic, or excoriated mucosa	Identifiable object (button, pit, nut), boggy mass (vegetable), or rhinolith	Pale or blue, edematous turbinates
Diagnostic tests	None; nasal smear shows neutrophils and mononuclear cells ± inclusion bodies, pyknotic epithelial cells	None; sinus radiograph (>6 years of age)	Nasopharyngeal culture for streptococcus only	Rhinoscopy	Nasal smear shows goblet cells and eosinophils; skin test or radioallergosorbent test (RAST)
Cause	Multiple agents, depending on age and seaso	Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis	Streptococcus pyogenes	Normal nasopharyngeal facultative and anaerobic bacteria	Allergens in predisposed individual
Therapy	Saline nasal drops, humidification; amoxicillin if acute otitis media	Amoxicillin; amoxicilin-clavulanate (14:1 formulation)	Penicillin V	Removal of obstruction; amoxicillin-clavulanate if tissue or sinus complication	Avoidance; oral antihistamine/decongestant; or topical corticosteroid; cromolyn

^aSuperscript numbers indicate references.