49. Nasal Congestion 2025

What is nasal congestion?

Symptom of acute or chronic disorders causing nasal blockage

How long does acute nasal congestion usually last?

Days to weeks

How long does chronic nasal congestion last?

Months to years

What are common anatomical causes of nasal congestion?

Septal deviation, nasal fracture

What are inflammatory causes of nasal congestion?

Infectious, allergic, autoimmune disorders

What rare congenital conditions can cause nasal blockage?

Choanal atresia, vestibular stenosis, nasolacrimal cyst, encephalocele

What rare pathologies can cause nasal congestion besides infection/inflammation?

Sinonasal tumors (benign or malignant)

How is acute rhinosinusitis defined?

Symptomatic inflammation of nasal cavity and paranasal sinuses lasting <4 weeks

What typically causes acute rhinosinusitis?

Viral URI or allergy → mucosal edema → obstruction → possible bacterial overgrowth

What viral pathogens most often cause acute rhinosinusitis?

Rhinovirus, adenovirus, influenza, parainfluenza

What bacteria most often cause acute bacterial rhinosinusitis (ABRS)?

Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis

What fungi can cause acute invasive rhinosinusitis in immunosuppressed patients?

Mucor, Rhizopus, Rhizomucor, Aspergillus

Clinical manifestations & diagnosis of acute rhinosinusitis

What are the three cardinal symptoms of acute rhinosinusitis?

Purulent nasal drainage + nasal obstruction or facial pain/pressure/fullness

When do symptoms suggest ABRS instead of viral rhinosinusitis?

Persist >10 days, high fever with purulent discharge/facial pain for 3–4 days, or double worsening

What is “double worsening” in rhinosinusitis?

Initial improvement followed by worsening symptoms → suggests bacterial superinfection

What are the two main treatment approaches for ABRS?

Antibiotics or watchful waiting with symptomatic treatment

What is the first-line antibiotic for ABRS per IDSA guidelines?

Amoxicillin/clavulanate

How long should children be treated with antibiotics for ABRS?

10–14 days

How long should adults be treated with antibiotics for ABRS?

5–7 days

When is sinusitis considered chronic?

Lasts more than 3 months

What are the hallmark symptoms of chronic rhinosinusitis?

Nasal congestion, facial pressure, abnormal drainage, decreased smell

Are all four hallmark symptoms required for diagnosis of chronic rhinosinusitis?

No

What additional symptoms may occur in chronic rhinosinusitis?

Cough, sleep disruption, ear symptoms

What type of inflammation is associated with chronic rhinosinusitis with polyps?

Type 2 inflammation with eosinophils

What type of inflammation is associated with chronic rhinosinusitis without polyps?

Type 1 inflammation with bacteria or autoimmune disease

What leads to mucus stasis and bacterial overgrowth in chronic rhinosinusitis?

Loss of mucociliary function

What type of illness is allergic rhinitis?

Chronic IgE-mediated respiratory illness

How does allergic rhinitis affect patients?

Impairs quality of life and productivity, can exacerbate asthma

What should treatment be based on in allergic rhinitis?

Patient’s age and symptom severity

What should patients with allergic rhinitis be advised to do?

Avoid known allergens

What is the most effective first-line treatment for persistent allergic rhinitis?

Intranasal corticosteroids

What are second-line therapies for allergic rhinitis?

Antihistamines, decongestants, cromolyn, leukotriene receptor antagonists, nasal irrigation

What advanced therapy may be considered if allergic rhinitis is uncontrolled?

Subcutaneous or sublingual immunotherapy (esp. with allergic asthma)

What is an antrochoanal polyp?

Single polyp from maxillary sinus into nasopharynx causing obstruction

What is the treatment for an antrochoanal polyp?

Surgical excision (curative)

What is a deviated septum?

Shift of septal cartilage/bone obstructing nasal cavities

What procedure treats a deviated septum?

Septoplasty

What benign sinonasal tumor can mimic chronic sinusitis?

Inverted papilloma

What vascular nasal tumor presents with severe posterior epistaxis in adolescent boys?

Juvenile nasopharyngeal angiofibroma (JNA)

What virus is linked to endemic nasopharyngeal carcinoma in Southeast Asia?

Epstein–Barr virus (EBV)

What autoimmune diseases may cause chronic rhinosinusitis?

GPA, eGPA, sarcoidosis, other autoimmune disorders

What finding should prompt evaluation for autoimmune disease in chronic rhinosinusitis?

Unexplained septal/turbinate tissue loss (septal perforation)

What genetic diseases can cause chronic rhinosinusitis?

Cystic fibrosis, primary ciliary dyskinesia

How does cystic fibrosis affect the airways?

Causes upper and lower airway disease, variable severity

What therapy has reversed disease process in many CF patients?

Triple therapy (CFTR modulators)

What organs are affected by primary ciliary dyskinesia?

Sinuses, lungs, reproductive organs (all cilia-dependent)

What rare infectious causes can lead to rhinosinusitis?

Rhinosporidiosis, tuberculosis, rhinoscleroma, atrophic rhinitis (Klebsiella ozaenae)

How are rare infectious causes of rhinosinusitis diagnosed?

Culture and biopsy

What congenital anomalies can obstruct nasal cavities?

Encephalocele, choanal atresia, vestibular stenosis, lacrimal duct anomalies

What are the three main types of fungal sinusitis?

Allergic fungal sinusitis, fungal ball (mycetoma), invasive fungal sinusitis