Differentials
Allergic rhinitis (seasonal, perennial, mixed)
SIGNS / SYMPTOMS
May have positive family history, symptoms around cats/dogs/furry pets, seasonality. More likely to present early in life, before age 35.
INVESTIGATIONS
Skin prick testing or specific IgE testing to aeroallergens will be positive; eosinophils will be elevated in peripheral blood.
Nasal polyposis
SIGNS / SYMPTOMS
Loss of olfaction. Polyps may be evident on physical exam.
INVESTIGATIONS
CT scan of sinuses reveals polyps.
Deviated septum
SIGNS / SYMPTOMS
Unresponsive to medications. Possibly evident on physical exam.
INVESTIGATIONS
Seen on CT scan of sinuses or on nasal endoscopy.
Hypertrophic turbinates
SIGNS / SYMPTOMS
Unresponsive to medications.
INVESTIGATIONS
Seen on CT scan of sinuses.
Adenoidal hypertrophy
SIGNS / SYMPTOMS
Unresponsive to medications.
INVESTIGATIONS
Seen on CT scan of sinuses.
Anatomic variants in osteomeatal complex
SIGNS / SYMPTOMS
Unresponsive to medications. May have history of numerous sinus infections.
INVESTIGATIONS
Seen on CT scan of sinuses.
Foreign body
SIGNS / SYMPTOMS
Unresponsive to medications, possibly history of inserting object into nares. Might be visible on physical exam.
INVESTIGATIONS
Seen on CT scan or nasal endoscopy.
Choanal atresia
SIGNS / SYMPTOMS
Unresponsive to medications. History of syndrome (where the choanal openings are not developed and are blocked).
INVESTIGATIONS
Seen on CT scan.
Nasal tumor
SIGNS / SYMPTOMS
Possible to have headaches, anosmia, and other constitutional symptoms (e.g., cachexia, weight loss, lymphadenopathy), or patients can be refractory to medications with persistent symptoms. May have mass and/or lymphadenopathy on physical exam.
INVESTIGATIONS
Mass seen on CT scan of sinuses; nasal endoscopy.
Granulomatosis with polyangiitis (Wegener)
SIGNS / SYMPTOMS
May rarely cause prolonged and progressive sinusitis, leading to loss of cartilage in nose and a typical pug-nosed appearance.
INVESTIGATIONS
Biopsy lesion.
Sarcoidosis
SIGNS / SYMPTOMS
20% will have upper airway involvement, primarily in the nasal cavity.
INVESTIGATIONS
Biopsy shows granuloma.
Upper respiratory infection
SIGNS / SYMPTOMS
May have fever, chills, cough, and shortness of breath.
INVESTIGATIONS
Most often caused by respiratory viruses; influenza antigen testing may be appropriate in season, otherwise diagnosis is clinical.
Cerebrospinal fluid (CSF) rhinorrhea
SIGNS / SYMPTOMS
Clear rhinorrhea.
INVESTIGATIONS
Sample of nasal discharge for beta-2 transferrin and beta-trace protein tests. CT scan will usually reveal the source of the leak and would be indicated if CSF rhinorrhea was suspected.
Sinusitis, acute
SIGNS / SYMPTOMS
May have fever, chills, headache, and sinus pressure.
INVESTIGATIONS
Sinus CT reveals inflammation, opacification of sinuses.
Sinusitis, chronic
SIGNS / SYMPTOMS
May have fever, chills, headache, and sinus pressure.
INVESTIGATIONS
Sinus CT reveals inflammation, opacification of sinuses.
Intranasal drug abuse-induced rhinorrhea
SIGNS / SYMPTOMS
History of intranasal drug abuse. Patient may have septal perforation, atrophy of the nasal mucosa, or mucosal ulcerations.
INVESTIGATIONS
Urine drug testing.
Estrogen related
SIGNS / SYMPTOMS
Pregnancy or estrogen supplementation (including oral contraceptives) may be present in history.
INVESTIGATIONS
Pregnancy test if applicable.
Hyperthyroidism
SIGNS / SYMPTOMS
May have no symptoms or may have palpitations, unexplained weight loss, increased appetite. Eye bulging (compared with raccoon eyes in NAR).
INVESTIGATIONS
Thyroid-stimulating hormone low, free T4 high.
Hypothyroidism
SIGNS / SYMPTOMS
May have no symptoms or may have unexplained weight gain, low energy, changes in hair and skin texture.
INVESTIGATIONS
Thyroid-stimulating hormone high, free T4 low.
Side effect of beta-blockers
SIGNS / SYMPTOMS
History of beta-blocker use.
INVESTIGATIONS
Resolves with cessation of beta-blockers.
Adverse reaction to aspirin
SIGNS / SYMPTOMS
History of aspirin use.
INVESTIGATIONS
Resolves with cessation of aspirin.
Topical decongestant rebound effect
SIGNS / SYMPTOMS
History of recent discontinuation or irregular usage of topical decongestants.
INVESTIGATIONS
Resolves with consistent decongestant use or complete cessation.
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