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Chapter 24 • Low Back Pain (Acute)
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299
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Acute Low Back Pain—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
POTENTIALLY SERIOUS CAUSES—cont’d
Infection
(vertebral
osteomyelitis)
Diskitis Pain aggravated by movement; more
Herniated disk LBP radiating down the buttock to
Cauda equina
syndrome
SCIATICA PROBLEMS
Sciatica
NONSPECIFIC BACK PROBLEMS
Musculoskeletal
strain
Spondylolisthesis Young person in a sport that demands
Ankylosing
spondylitis
Spinal stenosis Pain worse throughout day; aggravated
Scheuermann
disease
Osteoporosis Chronic, poorly localized back pain;
History of infection, invasive proce-
dure; continuous, dull back pain;
chronic back pain
common in children
below the knee, symptoms present
less than 1 mo
Constant pain in a saddle distribution;
urinary retention, fecal incontinence,
radiculopathy
Acute back pain with radiculopathy;
history of strain or trauma, relief
with sitting
Pain in back, buttocks; history of new
activity or exertion; relief of pain
with sitting
rapid movement between hyperflexion and hyperextension or requires
excess loading in hyperextension
Younger than age 40: insidious onset;
progressive morning back pain relieved
with exercise
by standing, relieved by rest;
pseudoclaudication
Affects mostly adolescent males; mild
to moderately severe pain, worse at
end of day, relieved by rest
postmenopausal; slight build; history
of inactivity or endocrine disorder
Acute onset with fever, dia-
phoresis; tenderness over
affected disk; positive SLR
Tenderness over affected disk ESR
Positive SLR None
Positive SLR, abnormal DTRs,
motor weakness
Paravertebral tenderness and
spasm; positive SLR; sitting
knee extension, sensory
findings
Paravertebral tenderness, scolio-
sis, or loss of lumbar lordosis;
no neurological signs
No neurological signs; pain
localized to low back, just
below level of iliac crest;
tight hamstrings
Painful sacroiliac joints,
reduced spine mobility;
may have uveitis
Signs of osteoarthritis of joints;
may have neurological signs
Normal examination; may
show an exaggerated thoracic kyphosis that is fixed
in attempted hyperextension
Palpable tenderness over area of
compression fracture; kyphosis or lordosis; loss of height
ESR; blood culture;
bone biopsy; CT
scan; MRI
MRI, surgical
emergency
EMG if chronic
None
Lumbar spine
radiographs
ESR; spinal
radiographs
None
Thoracic spine
radiographs
Bone densitometry;
spinal radiograph
to assess fracture
NONSPINAL CAUSES
Aortic aneurysm Severe, acute-onset pain not related to
Gallstones Increased incidence with age; steady,
activity or movement; increased risk
older than age 30; pallor, diaphoresis, anxiety, confusion
intense pain in RUQ with radiation
to right scapula or shoulder; belching, bloating, fatty food intolerance
Intact aneurysm will be a visi-
ble pulsatile midline upper
quadrant abdominal mass;
in a dissected aneurysm,
upper extremity pulse and
pulse pressures are asymmetric; posterior thoracic
pain may be felt
Normal physical examination
or positive Murphy sign on
palpation of abdomen
Emergency surgical
referral
Surgical referral
Continued
300
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Chapter 24 • Low Back Pain (Acute)
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Acute Low Back Pain—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
NONSPINAL CAUSES—cont’d
Pyelonephritis Ill-appearing; sweating, nausea, back
or flank pain, headache
Pleuritis History of recent URI; pleuritic pain Normal examination or crack-
Pelvic inflam-
matory
disease
PSYCHOGENIC CAUSES
Psychological
back pain
CT, Computed tomography; CVA, costovertebral angle; DTRs, deep tendon reflexes; EMG, electromyography; ESR, erythrocyte sedimentation rate;
IUD, intrauterine device; LBP, lower back pain; MRI, magnetic resonance imaging; PPD, purified protein derivative; RUQ, right upper quadrant;
SLR, straight leg raising; URI, upper respiratory tract infection.
Sexually active female; low back and
abdominal pain; history of urinary
or vaginal symptoms, sexually
transmitted disease, IUD, multiple
sex partners
History of psychosocial stressors,
depression, exaggerated expressions
of pain
References and Readings
Balague F, Mannion A, Pellise F, Cedraschi C: Non-specic low
back pain, Lancet 379:482, 2012.
Chou R, Qaseem A, Snow V, et al: Diagnosis and treatment of low
back pain: A joint clinical practice guideline from the American
College of Physicians and the American Pain Society, Ann Intern
Med 147:478, 2007.
Deyo RA, Rainville J, Kent DL: What can the history and physical
examination tell us about low back pain? JAMA 268:760, 1992.
Deyo RA, Weinstein JN: Low back pain, N Engl J Med 344:363,
2001.
Haus BM, Micheli LJ: Back pain in the pediatric and adolescent
athlete, Clin Sports Med 31:3, 2012.
Fever; cloudy, malodorous
urine; CVA tenderness on
percussion
les and bronchial breath
sounds
Cervical and uterine motion
tenderness, adnexal tenderness; cervicitis, fever
Exaggerated or inconsistent
reactions to testing; normal
examination
Koes BW, van Tulder MW, Ostelo R, et al: Clinical guidelines for the
management of low back pain in primary care: An international
comparison, Spine 26:2504, 2001.
Last AR, Hulbert K: Chronic low back pain: Evaluation and manage-
ment, Am Fam Physician 79:1067, 2009.
Manchikanti L, Singh V, Datta S, et al: American Society of Inter-
ventional Pain Physicians: Comprehensive review of epidemiology, scope, and impact of spinal pain, Pain Physician 12:E35,
2009.
Mills R, Nnadi C, Wilkinson N: Evaluation of back pain, Paediatr
Child Health 21:534, 2011.
Urinalysis; urine
culture
PPD; chest radiograph
Gonorrhea, Chlamydia
cultures; ESR
None
CHAPTER
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Nasal Symptoms and Sinus
25
oncern about symptoms of the “common cold” ac-
C
counts for a signicant proportion of primary care
visits by both children and adults, especially in the winter
months. Viral infections and self-limiting causes of symptoms require the clinician to provide primarily symptom
relief and to avoid overuse of antibiotic treatment. Symptoms include nasal congestion, rhinorrhea, postnasal drip,
sneezing, itchy nose, watery and itchy eyes, and frontal
headache. Severe symptoms are associated with ageusia
(loss of taste) and anosmia (loss of smell).
The nose humidies, warms, and lters inspired air.
The nasal turbinates located in the nasal cavity promote turbulent airow that causes particulate matter to
fall on the mucosa, where it is swept away by ciliated
pseudostratied columnar cells to the nasopharynx
(Figure 25-1). Rhinitis, or inammation of the mucous
membranes, is a frequent nasal symptom that is caused
by bacterial or viral infection, a response to allergens,
or a response to medication or extremes in environmental temperature.
Nasal polyps, septal deviation, or congenital anomaly can cause nasal obstruction. In children, nasal
obstruction is very frequently unilateral and may be
secondary to a foreign body inserted into the nose.
Epistaxis is a common symptom in both adults and
children, with most cases occurring before the age of 10
or between 45 and 65 years of age. Causes are trauma to
the nose, mucosal changes related to uctuations in temperature and humidity, and anticoagulation therapy. Blood
or structural alternations can lead to nasal obstruction.
Respiratory epithelium lines the paranasal sinuses
and creates drainage into the nasal cavity via the superior meatus and middle meatus. The maxillary sinus is
the most frequently involved paranasal sinus because its
ciliated cells carry maxillary sinus drainage against
gravity. When drainage systems become impaired as a
result of mucosal edema, mechanical obstruction, or
impaired ciliary activity, viruses and bacteria proliferate.
The paranasal sinuses include the frontal, ethmoid,
maxillary, and sphenoid (Figure 25-2). Most sinus
Congestion
infections are caused by bacteria common to the nasopharynx that proliferate when local or systemic
defenses are impaired. The most common causative
organisms producing bacterial sinusitis in both adults
and children are Streptococcus pneumoniae and Hae-
mophilus inuenzae. Sinusitis may also be associated
with allergies and asthmatic exacerbations or with
contiguous infection of the mouth or face.
DIAGNOSTIC REASONING: FOCUSED
HISTORY
What symptoms will help me narrow the possibilities?
Key Questions
l
Can you describe your symptoms?
l
Do you have pain? If so, where is the pain located?
l
How long have symptoms been present?
l
Do the symptoms occur at any particular time of the
year? Do you have a history of nasal problems?
l
Is there a family history of allergies or asthma?
Acute Symptoms
Acute sinusitis is an abrupt onset of infection of one or
more of the paranasal sinuses, and it occurs when the
sinus ostia become obstructed, usually after an upper
respiratory tract infection. Sinusitis is frequently associated with a sore throat, often irritated by postnasal
discharge, facial or tooth pain, or headache over the
affected sinus, as well as morning periorbital swelling,
fever, and malaise. Other less common causes include
anatomical abnormality, adenoid hypertrophy, and
contiguous infection, such as a dental abscess or
periorbital cellulitis.
Acute symptoms of rhinitis or sinus congestion,
usually lasting 48 to 72 hours, are caused by edematous mucosa obstructing the sinus ostia. Systemic
symptoms such as fever, myalgias, chills, and acute
infectious rhinitis are likely caused by rhinoviruses or
parainuenza virus.
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302
Middle turbinate
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FIGURE 25-2 Anterior and lateral views of the paranasal sinuses.
(From Ball JW, Dains JE, Flynn J, et al: Seidel’s guide to physical
examination, ed. 8, St. Louis, 2015, Elsevier.)
Chapter 25 • Nasal Symptoms and Sinus Congestion
Cribriform plate
of ethmoid bone
Frontal
sinus
Superior
turbinate
Middle
turbinate
Inferior
turbinate
Vestibule
Anterior
naris
Hard palate
FIGURE 25-1 Lateral view of the left nasal cavity. (From Ball JW, Dains JE, Flynn J, et al: Seidel’s guide to
physical examination, ed. 8, St. Louis, 2015, Elsevier.)
Nasal airway
Nasal septum
Floor of nose
Middle meatus
Inferior
turbinate
Inferior
meatus
Soft palate
Acute symptoms of epistaxis may be related to
trauma to the nose, exposure to changes in air temperature or humidity level, or symptoms associated with a
rhinosinusitis infection.
Chronic Symptoms
Chronic symptoms can be caused by prolonged obstruction of the osteomeatal complex, which leads to
dysfunction of ciliary motility and movement of mucus
within the sinuses. Local factors that cause mechanical
Sphenoid
sinus
Uvula
Sella
turcica
Choana
Pharyngeal
tonsil
(Adenoids)
Opening of auditory
(eustachian) tube
obstruction include adenoid hypertrophy, conchae
bullosa, nasal polyps, foreign bodies, and nasal deviations. Adults with symptoms that last more than
3 weeks experience upper molar pain or headache, postnasal drip, and nausea. Chronic rhinitis lasting weeks to
years is rarely infectious; rather it is often associated
with anatomical abnormalities that impair the sinus
drainage system, although the mucociliary clearance
mechanisms are normal.
In children, chronic sinusitis is dened as the pres-
ence of symptoms for longer than 30 days.
Chronic epistaxis can be related to nose picking,
foreign body (especially in children), platelet disorders, and anticoagulation therapy
Location of Pain
An adult with sinusitis most often reports prolonged
symptoms of nasal congestion and facial pain. Children rarely complain of headache or facial pain. The
location of pain may indicate which sinus is involved.
Pain of maxillary sinusitis occurs over the sinuses and
is sometimes perceived as a maxillary toothache.
Frontal sinusitis produces a frontal headache that is
worse on morning wakening. Ethmoid sinusitis causes
pain that refers to the vertex, forehead, or occipital
or temporal region, whereas the pain of sphenoid
sinusitis is perceived on the top of the head.
Seasonal Occurrence of Symptoms
Suspect allergic rhinitis if a person describes seasonal
occurrence of nasal symptoms associated with sneezing,
Chapter 25 • Nasal Symptoms and Sinus Congestion
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303
and itchy or burning eyes. A distinguishing feature of the
allergic individual is the propensity to develop sustained
immunoglobulin E (IgE) response after antigenic stimulation. IgE is an antibody capable of interacting with
target cells that release mediators on contact with specic antigens. This reaction is the manifestation of an
allergy.
People with perennial allergies have an allergen
present in the environment on a year-round basis from
such sources as animal dander, house dust, mold,
feathers, and cockroaches. Seasonal allergies usually
occur in early spring (tree pollens), early summer
(grass pollens), and early fall (weed pollens).
Family History
Family history of asthma or allergies is frequently associated with allergic rhinitis. Other symptoms may
include a sensation of head stufness, ear discomfort,
fatigue, and a scratchy or mild sore throat.
If I suspect sinus problems, what do I need to know?
Key Questions
l
Do your symptoms change with position changes?
l
Do you have a history of sinus problems?
Position Change
Maxillary sinusitis produces pain that worsens with
bending or leaning forward. The postnasal discharge
associated with sinusitis produces a cough that worsens while lying down.
Does the presence of other symptoms provide any clues?
are pressure and/or pain of the cheeks, forehead, or
behind the eyes.
Acute sinusitis in children involves the presence of
symptoms for less than 30 days, a persistent cough,
fever with a temperature greater than 39° C (102.2° F)
for more than 3 days, and malodorous breath. The
maxillary and ethmoid sinuses are most commonly
affected, the frontal sinus is occasionally affected, and
the sphenoid sinus is rarely affected.
Other Chronic Symptoms
Chronic sinusitis involves long episodes of inammation or repeated infections that lead to anatomical
destruction. The recurrent symptoms interfere with
daily activities and are not relieved with nonpharmacological measures or over-the-counter medications.
Patients often report a cold that does not go away, eye
pain, halitosis, chronic cough, fatigue, anorexia, and
malaise.
Is the cause viral, bacterial, or allergic?
Key Question
l
What color is your nasal drainage?
Acute rhinitis is caused by a bacterial or viral infection that produces a watery, profuse nasal discharge
early in the onset, and later becomes more mucoid
and purulent. Purulent discharge may be the result
of a primary viral infection or a secondary bacterial
infection. The color of the nasal discharge is not diagnostic. Watery or clear discharge occurs with allergic
reactions and is usually persistent or seasonal.
Key Questions
l
Do you have other acute symptoms, such as cough,
fever, or muscle aches?
l
Do you have other chronic symptoms, such as eye
pain, bad breath, or fatigue?
Other Acute Symptoms
Seropurulent nasal discharge is often present with
acute bacterial infection of the nasal and sinus mucosa.
Acute rhinitis caused by a bacterial or viral infection
produces systemic symptoms such as fever, myalgia,
and chills. Allergic rhinitis is associated with sneezing,
nasal congestion, clear and profuse rhinorrhea, as well
as pruritus of the nose, palate, pharynx, and middle ear.
Eye symptoms include conjunctival irritation, itching,
erythema, and tearing. Ear symptoms involve a feeling
of fullness in the ears with popping. Sinus symptoms
Are symptoms unilateral or bilateral?
Key Question
l
Is the symptom on one side or both sides?
Infectious rhinitis and allergic rhinitis are usually
bilateral. Unilateral symptoms are more indicative
of an anatomical cause such as nasal polyps, septal
deviation, unilateral choanal atresia, or a foreign
body (typically occurs in children).
Are there risk factors that will narrow the diagnosis?
Key Questions
l
Do you smoke?
l
Are you exposed to others who smoke?
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Chapter 25 • Nasal Symptoms and Sinus Congestion
EVIDENCE-BASED PRACTICE
Do Symptoms Distinguish Between Viral or Bacterial
Acute Sinusitis?
This systematic literature search was performed to assess the
diagnostic value of fever and facial and dental pain in adults
suspected of acute bacterial rhinosinusitis (ABRS). Prevalence of positive predictive values and negative predictive
values were extracted from 3171 records where the diagnosis
was confirmed by culture from either sinus puncture or
endoscopically obtained antral aspirate. Only one study was
deemed to be of good quality. The study reported an odds
Data from Hauer AJ, Luiten EL, van Erp NF, et al: No evidence for distinguishing bacterial from viral acute rhinosinusitis using fever and facial/
dental pain: A systematic review of the evidence base, Otolaryngol Head Neck Surg, 150:28, 2014.
l
Have you had a recent history of head or facial
trauma?
l
Have you been diving or swimming?
l
Have you been exposed to infections in day care,
school, or work settings?
l
Are you pregnant?
Smoking History
Smokers have an increased risk of sinusitis. Smoking
can lead to the production of more tenacious mucus
and to temporary paralysis of the nasal cilia. Exposure
to passive smoke causes an increased risk of upper and
lower respiratory tract infections.
Trauma History
Nasal trauma or fracture may lead to nasal congestion.
A rare but serious posttrauma cerebrospinal uid rhinorrhea can be present. Up to 80% of head injuries
involve the paranasal sinuses.
Diving and Swimming
Sinusitis from diving or swimming is secondary to
barotrauma, infection from contaminated water, or an
allergic response to chlorine. Chlorine exposure can
cause inammation of the sinus mucosa, restricting
nasal discharge.
ratio for fever of 1.02 (0.52 to 2.00) and 1.65 (0.83 to 3.28)
for facial and dental pain. The authors concluded that
evidence is inadequate to support the value of fever and facial
and dental pain to differentiate viral or bacterial causes
of ABRS in adults. These symptoms should not be used
in clinical practice for decision making about prescribing
antibiotic treatment.
Is the patient using any drugs that would cause nasal
congestion?
Key Questions
l
Are you using nasal sprays or drops?
l
Do you use cocaine or other recreational drugs?
l
What other medications are you taking?
Nasal Spray
The use of topical sympathomimetic sprays or drops
for more than 1 week can lead to rebound nasal congestion or vasodilation after short periods of vasoconstriction. The use of decongestants and antihistamines
with low ambient humidity leads to excessive dryness
and impaired ciliary function.
Recreational Drug Use
Chronic or acute cocaine use can cause rebound nasal
congestion. Nasal congestion associated with conjunctivitis and irritation of the eyes may be seen in people
who abuse drugs by inhalation.
Medications
Oral contraceptives, phenothiazines, angiotensinconverting enzyme (ACE) inhibitors, and b-blockers
may cause nasal congestion.
Exposure
Exposure to viral infections increases when children
are exposed to other children. The spread of a virus
occurs by direct secretion of droplets or contact with
contaminated objects.
Pregnancy
The hormonal changes of pregnancy can cause nasal
congestion.
Is there systemic disease present?
Key Questions
l
Have you noticed any other body symptoms?
l
Do you have any chronic health problems?
Systemic Disorders and Chronic Health Problems
Systemic causes of decreased mucociliary clearance
include cystic brosis, ciliary dyskinesia syndrome,
Chapter 25 • Nasal Symptoms and Sinus Congestion
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and immunoglobulin deciency. Individuals with
congenital or acquired immune deciencies, such as
diabetes mellitus, leukemia, acquired immunodeciency syndrome, and cystic brosis have an increased
risk of developing acute and chronic sinusitis. Hypothyroidism, acromegaly, Horner syndrome, neoplasm,
and granulomatosis disorder can cause nasal symptoms.
DIAGNOSTIC REASONING: FOCUSED
PHYSICAL EXAMINATION
Perform a General Inspection
Note the patient’s general appearance. Observe for
signs of impaired mental status. A severe, unremitting,
or new-onset headache, vomiting, or alteration in
consciousness requires consideration for immediate
referral.
Take Vital Signs
Patients with acute viral rhinitis or acute sinusitis may
be afebrile or have a low-grade fever. Patients with
allergic rhinitis are afebrile. The presence of mouth
breathing suggests chronic nasal obstruction caused by
hypertrophied pharyngeal lymphoid tissues.
Inspect the Face
Children with chronic allergic conditions have an
allergic “salute”; this is a crease on the nose from
continued wiping up of nasal drainage. Allergic “shiners”
are dark circles under the eyes suggestive of venous
congestion and stasis. Observe for allergic facies from
chronic mouth breathing: open mouth, receding
chin, overbite, elongated face, and arched hard palate.
Observe for facial symmetry and signs of periorbital
edema. Periorbital cellulitis is the most common serious complication of severe bacterial sinusitis.
Perform a Regional Examination of the Head
and Neck
Examine the eyes (including visual acuity), ears, and
cervicofacial lymph nodes. Complications of severe
fulminant sinusitis are rare and are caused by the direct
spread of infection, secondary to destruction of the
wall between the sinuses and the orbit. Symptoms can
include a sudden increase in pain, acute edema of the
eyelids, periorbital edema and erythema, decreased
visual acuity, diplopia, and displacement of the eye
laterally. The patient may experience pain on testing of
extraocular muscles. These symptoms mandate immediate referral.
Observe for symptoms of coryza (acute rhinitis) as
well as ear and eye drainage. Erythematous tympanic
membranes are seen in acute viral rhinitis.
Examine the Mouth and Teeth
Examine the teeth for the presence of abscesses, especially the rst and secondary maxillary molars and the
alveolar margin of the teeth. Tenderness elicited by
tapping on the maxillary teeth with a tongue blade may
indicate dental root infection or maxillary sinusitis.
Lymphoid hyperplasia, “cobblestoning,” may be seen
on the posterior pharynx with chronic allergies. Mouth
breathing is associated with hypertrophied gingival
mucosa and halitosis. Halitosis can also be a sign of
dental abscess or sinusitis.
Children with acute viral rhinitis have mild erythema of the tonsils and posterior pharynx. If there is
vasomotor rhinitis, mucus is present in the posterior
pharynx.
Test for Smell
Test for smell by asking the patient to close their eyes
and identify simple odors (e.g., coffee, vinegar, chocolate) presented to each naris separately. Severe nasal
congestion or ethmoid sinusitis causes anosmia.
Inspect Condition of Nasal Mucosa and Turbinates
Use a nasal speculum and pen light or head mirror to
optimally visualize the condition of the nasal mucosa
and turbinates. A topical vasoconstrictive agent may be
needed to shrink the swollen mucosa to visualize the
middle meatus.
In infants and young children, the nares tend to
open forward, and tilting the tip of the nose up with the
thumb and directing the light into the nares will allow
inspection of the nasal cavities.
Pale, swollen, and wet turbinates are seen with
allergic rhinitis. Inamed mucous membranes are
seen with acute coryza or hay fever. Allergic rhinitis
may also produce a violet-colored mucous membrane.
Ulceration of the nasal mucosa may be found in
individuals who abuse drugs by inhalation.
Inspect for Masses
Observe for the presence of nasal polyps, which look
like skinned grapes and are usually bilateral and hang
from the middle turbinate into the lumen of the nose.
Septal deviation or anatomical anomalies may predispose to infection. Nasal septum deviation can also lead
to nasal obstruction. Squamous cell carcinoma usually
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Chapter 25 • Nasal Symptoms and Sinus Congestion
occurs unilaterally. Masses that increase in size
and pulsate on Valsalva maneuver may indicate a
meningocele.
Note the Presence and Color of Any Discharge
Pus in the ostium of the middle turbinate suggests a
bacterial sinusitis. Cerebrospinal uid (CSF) drainage
will increase in a forward position. Identify CSF by
testing nasal drainage for glucose and protein levels
comparable to those of CSF. Foul-smelling nasal discharge is a characteristic feature of sinusitis of dental
origin. Foul-smelling unilateral purulent discharge
may indicate a foreign body in the nasal cavity.
Transilluminate the Sinuses
Frontal sinuses can be transilluminated by placing a
light source below the supraorbital rim. Transillumination of maxillary sinuses can be done in two ways.
Place a transilluminator over the infraorbital rim,
blocking light from the examiner’s vision with the free
hand, and judge the amount of light transmission
(opaque, dull, normal) through the hard palate. This
should be performed in a completely darkened room.
Dentures must be removed. A second method is to
place the transilluminator in the patient’s mouth, sealing the lips, and observe the amount of light transmitted through the maxillary sinuses.
Light will pass through air-lled sinuses. Transillumination is used to assess the presence of uid in the
frontal and maxillary sinuses and cannot be used to
examine the ethmoid or sphenoid sinuses. Normal
transillumination of the frontal sinus rules out frontal
sinusitis in 90% of cases. Complete opacity of sinuses
suggests infection. However, the results of transillumination are often nonspecic, and reduced illumination
does not lead to a diagnosis.
Palpate and Percuss Frontal and Maxillary
Sinuses for Tenderness
Percuss and palpate the cheeks for tenderness and
swelling, indicating maxillary sinusitis of dental origin. To assess for tenderness in the frontal sinuses,
exert pressure over the eyebrow or slightly upward
pressure under the brow. Direct percussion may elicit
tenderness over the affected sinus.
Test for Facial Fullness and Pressure
Bending forward from the waist (with head dropping
downward) or performing a Valsalva maneuver will
worsen the symptoms if a partial or complete sinus
obstruction is present.
Examine the Lungs
Auscultate the lungs for signs of wheezing, rales, and
loudness of breath sounds. Peak ow volume or PO2
saturation as measured using a pulse oximeter will
detect the presence of reactive upper airway disease
that may be associated with nasal symptoms.
Perform Neurological Testing If Indicated
To detect any complications from sinusitis, assess
neurological and cranial nerve function if the patient
appears severely ill. A rare but severe complication
of sinusitis is cavernous sinus thrombosis. Cavernous
sinuses are trabeculated sinuses located at the base of
the skull that drain venous blood from facial veins.
Cranial nerves III, IV, V, and VI are commonly affected
because they are adjacent to the cavernous sinuses.
LABORATORY AND DIAGNOSTIC STUDIES
Nasal Smear
A nasal smear performed to look for eosinophils conrms the diagnosis of allergic rhinitis. Nasal scraping
of the surface epithelium and a sample of secretions
are more reliable in detecting the presence of eosinophils than is the sampling of secretions alone. Either
method can be used to detect the presence of neutrophils. Specimens are graded using a scale of 0 to 41,
based on the concentration of cells.
Sinus Radiographs
Radiographs are not routinely indicated, but may be
obtained in patients who have severe symptoms and
fail to respond to treatment. Severe symptoms may
indicate complications of sinusitis such as orbital cellulitis, brain abscess, osteomyelitis, or cavernous sinus
thrombosis. A sinus radiographic series consists of four
views: an anteroposterior (Caldwell) view of the ethmoid sinus, a view (Chamberlain) of the frontal sinus,
a lateral view of the sphenoid and frontal sinuses, and
an occipitomental (Waters) view of the maxillary
sinuses.
Computed Tomography Scan
A computed tomography (CT) scan shows air, bone,
and soft tissue and optimally facilitates denition of
regional anatomy and the extent of disease. A CT scan
is done when sinusitis becomes chronic and does not
respond to symptomatic or antibiotic treatment. A CT
scan may also show causes for chronic sinusitis by visualizing disorders not detected by plain lms such as
facial fractures, nasal polyps, cysts, chronic mucosal
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thickening, temporomandibular joint (TMJ) disorders,
foreign bodies, and tumors.
Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) is used to image
soft tissue pathology of the face and neck, especially
neoplastic conditions. CT does not delineate soft tissue
pathology as well as MRI.
Sinus Aspiration
Sinus aspiration is the only way to conrm the diagno-
sis of bacterial sinusitis and is performed by an otolar-
yngologist. A trocar is introduced into the maxillary
sinus through the upper gingival recess.
Nasal Endoscopy
Nasal endoscopy allows direct observation of the nasal
passages, larynx, pharynx, and surrounding tissue, and
aids in the diagnosis of nasal polyps, chronic sinusitis,
or laryngeal trauma. Before a exible beroptic scope
is threaded through the nasal passages, an anesthetic
spray is applied to the nasal tissue while the patient
is in a sitting position. This procedure is generally
performed by an otolaryngologist.
Allergy Skin Testing
Results of skin testing can conrm immunological
disease and identify specic antigens responsible for
allergic rhinitis, which may come from exposure to
irritants in the patient’s environment. The presence of
serum IgE antibody suggests an allergic response.
DIFFERENTIAL DIAGNOSIS
Seasonal allergies are associated with short bursts
of intense exposure to an allergen that creates symptoms consistent with a histamine-mediated response
such as pruritus, swelling, sneezing, and rhinorrhea.
Perennial allergies are caused by continuous exposure
to allergens associated with chronic congestion. Common indoor allergens are animal dander, dust mites,
and cockroaches. Outdoor allergens include grasses,
trees, pollens, and weeds. A history or pattern of symptoms and exposure is critical in diagnosis.
Nonallergic Rhinitis
Nonallergic rhinitis may be associated with eosinophilia on a nasal smear. Nonallergic rhinitis with
eosinophilia syndrome (NARES) is a diagnosis based
on nasal cytology and involves symptoms similar to
allergic rhinitis without an identiable allergen cause.
A history will reveal aspirin or nonsteroidal antiinammatory drug intolerance and rhinorrhea. Noneosinophilia is associated with any other nonallergic
cause of rhinitis.
Rhinitis Medicamentosa
Drug-induced rebound congestion can follow the longterm use of topical nasal decongestants. Rhinitis medicamentosa is also used to describe nasal symptoms
secondary to other medications, such as nasal congestion associated with hormone changes of pregnancy.
Other drugs that have vasodilative effects include antihypertensives that interfere with adrenergic neuronal
function and hormones in oral contraceptives. Nasal
vasoconstriction response is completely abolished after
the administration of reserpine.
Infectious Rhinitis
Infectious rhinitis is an acute condition frequently
associated with a history of recent upper respiratory
tract infection. A denitive sign of this condition is the
presence of yellow or green purulent discharge and red
nasal mucosa.
Allergic Rhinitis
Allergic rhinitis is distinguished by a recurrent rhinorrhea with clear watery mucus, sneezing, and pruritus.
Nasal turbinates are pale and swollen. There is often a
family history of allergies. About 25% of the population
has some type of allergy. Diagnosis of IgE-mediated
reactions to aeroallergens are based on a combination of
history, physical examination, and skin tests. Nasal
smears can be tested for the presence of eosinophils to
conrm an allergenic response.
Acute Sinusitis
Acute sinusitis is characterized by purulent nasal
discharge, postnasal drip, and localized facial pain
over the sinus involved. It often follows a viral upper
respiratory tract infection. However, symptoms such as
halitosis, reduced sense of smell, or morning cough
have been reported in children in the absence of facial
pain. Physical examination will elicit localized tenderness to palpation or percussion over the affected sinus.
Pressure and pain will increase in a forward-bending
position. Purulent discharge may be visible in the posterior pharynx or may be seen emerging from the ostia
of the middle turbinate. Transillumination will indicate
unilateral or bilateral obstruction. Ciliary function is
impaired with infection and may not be completely
restored for 2 to 6 weeks. The diagnosis of sinusitis in
children requires two of three major criteria (cough,
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Chapter 25 • Nasal Symptoms and Sinus Congestion
purulent nasal discharge, purulent pharyngeal drainage), or one major and two minor criteria (sore throat,
wheezing, foul breath, facial pain, periorbital edema,
headache, earache, fever, toothache).
Chronic Sinusitis
An incompletely treated acute sinusitis can lead to a
chronic condition. The patient has persistent symptoms
of low-grade infection and intermittent acute exacerbations typical of acute sinusitis. Symptoms are recurrent
and not controlled with over-the-counter or nonpharmacological remedies. Multiple pathogens may be
causative organisms, with the most common being
Moraxella catarrhalis, H. inuenzae, and S. pneumoniae. A diagnosis of chronic sinusitis requires sinus
radiographs or a CT scan that reveals mucosal thickening of 5 mm or greater. Allergy testing may reveal a
perennial allergy that creates chronic inammation.
Nasal or Sinus Obstruction
A history of aspirin intolerance or asthma with polyps
is associated with obstruction. Acute obstruction
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Nasal Symptoms and
Sinus Congestion
suggests edema secondary to infection, allergic response,
exposure to irritants, or foreign body (in children).
Chronic obstruction may be secondary to congenital deformity, nasal polyps, or septal deviation. In infants,
congenital choanal atresia can cause obstruction.
Nasal Polyposis
This syndrome has multiple causative factors, including
a history of asthma and aspirin intolerance. The polyps
are translucent, grapelike growths that are mobile, rarely
bleed, and prolapse into the nasal cavity. The resulting
obstruction can be associated with chronic sinusitis. Any
suspicious polyps should be biopsied.
Osteomyelitis of the Frontal Bone
Osteomyelitis can occur as a complication of sinusitis.
Osteomyelitis occurs in children and young adults and
may follow head trauma or scuba diving. Staphylococcus
pyogenes or anaerobic streptococci are the causative organisms. Patients appear severely ill and may have edema
of the upper eyelid and puffy swelling over the frontal
bone. Diagnosis is by radiography and blood culture.
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Infectious rhinitis Perennial, but more common in
winter months; recent URI
Allergic rhinitis Family history of allergies;
Nonallergic rhinitis No allergenic cause identified Similar to allergic rhinitis Absence of eosinophilia
Rhinitis medicamen-
tosa
Acute sinusitis Smoker; recent URI; winter
Chronic sinusitis History of previous sinus
sneezing; recurrent pattern;
more common in children
and young adults
History of medication use: oral
contraceptives, nasal sprays,
antihypertensives; nasal
congestion
months; frontal headaches
made worse with forward
bending; sensation of
fullness or pressure
In children nasal discharge,
cough, for .10 days, fever
.38° C with purulent
rhinorrhea for 3 days
infections; dull ache or no
pain; persistent symptoms
Red, swollen mucosa; purulent
discharge
Pale, boggy mucosa;
rhinorrhea with clear,
watery mucus
Swollen mucosa; clear mucus
or dry mucosa
Purulent discharge; maxillary
toothache on percussion;
postnasal drainage; decreased transillumination;
fever
Same as in acute sinusitis;
decreased or no transillumination; obstruction such as
deviated septum, polyps
Nasal smear
for neutrophils,
intracellular bacteria
Nasal smear for eosino-
phils; allergy testing
on nasal cytology
None
None
CT scan; nasal endoscopy;
allergy testing
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