Family medicine
Nasal Drip (rhinorrhoea) / Nasal Congestion
Rhinorrhoea is the discharge of mucus from the nasal passages, while nasal congestion is the obstruction of airflow due to mucosal swelling and secretions, both commonly resulting from inflammation, infection, or allergic processes.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Allergic rhinitis | Sneezing, itchy nose, clear watery discharge, atopic Hx, trigger-related [3] | 「鼻有冇痕？打乞嚏多唔多？有冇濕疹或者哮喘？」 |
| Acute viral rhinosinusitis (common cold) | Acute onset < 10d, self-limiting, coryzal symptoms [2] | 「係咪最近先開始？有冇喉嚨痛、周身唔舒服？」 | |
| Chronic rhinosinusitis ± nasal polyps | > 12w duration, purulent PND, ↓ smell, polyps on rhinoscopy [1][3] | 「鼻塞超過三個月未？聞嘢有冇差咗？」 | |
| Serious Not To Miss | Nasopharyngeal carcinoma (NPC) | Blood-stained PND, unilateral ear symptoms, upper neck mass, CN palsy; Southern Chinese [4] | 「有冇流鼻血或者痰有血絲？耳仔有冇塞住？頸有冇粒嘢？」 |
| Complications of sinusitis (orbital cellulitis, intracranial abscess) | Periorbital swelling/erythema, proptosis, high fever, severe headache, altered consciousness [1] | 「眼有冇腫？有冇好嚴重嘅頭痛或者發高燒？」 | |
| Foreign body (children) | Unilateral foul-smelling purulent discharge in a child [3] | 「細路仔一邊鼻有冇好臭嘅鼻水？」 | |
| Pitfalls | Rhinitis medicamentosa | Rebound congestion from topical decongestant overuse > 5–7 days [3] | 「你有冇用通鼻噴劑？用咗幾耐？」 |
| Vasomotor (non-allergic) rhinitis | Congestion/rhinorrhoea triggered by cold air, strong smells, stress; NO itch/sneezing; no atopic Hx | 「凍嘅天氣或者濃味嘢會唔會引發？有冇鼻痕？」 | |
| CSF rhinorrhoea | Clear watery unilateral discharge, Hx of head trauma or surgery; ↑ glucose in fluid | 「有冇撞過頭？一邊鼻成日流清水？」 | |
| Masquerades | Drug-induced rhinitis (ACEI, β-blockers, OCP, antihypertensives) | Temporal correlation with drug initiation | 「最近有冇開始食新藥？」 |
| Hypothyroidism | Nasal congestion + weight gain, cold intolerance, constipation, fatigue | 「有冇肥咗？怕唔怕凍？有冇便秘？」 | |
| Depression | Chronic fatigue, poor sleep, low mood presenting as somatic nasal complaints | 「心情點？瞓得好唔好？」 | |
| Pregnancy rhinitis | Nasal congestion in pregnant woman, resolves post-delivery [5] | 「你有冇懷孕嘅可能？」 | |
| Trying to Tell Me Something? | Fear of NPC | Southern Chinese + family/friend diagnosed with NPC → health anxiety | 「你最擔心係咩？有冇擔心係鼻咽癌？」 |
| Work/school impairment | Chronic congestion → poor sleep → daytime dysfunction | 「返工/返學有冇受影響？」 | |
| Relationship/social impact | Snoring, mouth-breathing affecting partner | 「枕邊人有冇投訴你鼻鼾大？」 |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport, agenda setting | 「你好呀，我係X醫生，今日由我同你傾吓。你點稱呼呀？」「你今日想睇咩問題呀？」 | Builds rapport; scores interpersonal marks from the start |
| 0:30–1:30 | Chief complaint + HPI (symptom analysis) | 「你鼻水/鼻塞幾耐喇？」「鼻水係清嘅定黃綠色嘅？」「邊邊鼻塞呀？兩邊定一邊？」「有冇面痛或者頭痛呀？」「有冇聞嘢唔到呀？」 | Establishes CC duration, character, laterality; key discriminators for DDx |
| 1:30–2:30 | Red flags + systems review | 「有冇流鼻血呀？」「個耳仔有冇塞住或者聽嘢唔清楚？」「頸有冇摸到粒嘢？」「有冇眼腫或者睇嘢矇咗？」「有冇發燒、周身骨痛？」 | Rules out NPC, complications of sinusitis, orbital cellulitis |
| 2:30–3:30 | Allergic/atopic Hx, PMH, DHx, FHx, SHx | 「你有冇濕疹、哮喘、或者鼻敏感嘅病史？」「屋企人有冇鼻敏感？」「你食緊咩藥？有冇藥物敏感？」「你有冇食煙飲酒？做咩工嘅？」 | Atopy Hx is key for allergic rhinitis; smoking/occupation for vasomotor; drugs for rhinitis medicamentosa |
| 3:30–4:30 | ICE + hidden agenda | 「你自己覺得鼻塞係咩原因呢？」(Idea) 「你最擔心咩嘢？」(Concern) 「你今日嚟最想我幫到你啲咩？」(Expectation) 「點解今日先嚟睇呢？」(Hidden agenda) | ICE is directly examined on the Case Report Form; hidden agenda often = fear of NPC or impact on sleep/work |
| 4:30–5:15 | Functional impact + psychosocial | 「瞓覺有冇受影響？」「返工/返學有冇影響到？」「心情方面點呀？有冇因為呢個問題覺得好煩？」 | Scores biopsychosocial problem marks |
| 5:15–6:00 | Summarise, check understanding, signpost, close | 「等我總結吓，你嘅情況係…你覺得啱唔啱？」「我會幫你檢查吓，之後再同你解釋。有冇其他嘢想問？」 | Summarising + checking = high interpersonal marks; safe close |
Uncovering the hidden agenda: Ask 「點解今日先嚟睇呢？」(Why come today specifically?). Common hidden agendas: fear of NPC (esp. if family/friend diagnosed), chronic sleep disturbance affecting work, concern about long-term steroid use, or child's poor school performance due to mouth-breathing.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset/Duration | How long? Acute or chronic? | 「鼻塞/鼻水幾耐喇？突然定慢慢嚟？」 | Acute < 4w → URTI/acute sinusitis; Chronic ≥ 12w → AR/CRS [1] | Acute rhinosinusitis vs chronic rhinosinusitis |
| Character of discharge | Clear/watery or thick/coloured? | 「鼻水係清嘅定黃綠色嘅？」 | Clear watery → allergic/vasomotor; purulent → bacterial sinusitis [2] | AR if clear; bacterial sinusitis if purulent with double sickening |
| Laterality | One side or both? | 「一邊定兩邊？」 | Unilateral symptoms are a red flag for NPC, nasal polyp, FB, tumour [3] | NPC, unilateral polyp, foreign body (children) |
| Nasal itch/sneezing | Itchy nose? Frequent sneezing? | 「鼻有冇痕？有冇成日打乞嚏？」 | Classic early allergic rhinitis triad [3] | Allergic rhinitis |
| Facial pain/pressure | Facial pain worse bending forward? | 「面有冇痛？低頭會唔會痛啲？」 | Facial pain ↑ on bending → sinusitis [1][2] | Acute/chronic rhinosinusitis |
| Smell | Any change in sense of smell? | 「聞嘢有冇唔同咗？聞唔聞到嘢？」 | Hyposmia/anosmia → CRS with polyps, NPC [1][3] | CRSwNP, NPC |
| Epistaxis/blood in PND | Any nosebleed or blood in postnasal drip? | 「有冇流鼻血？痰入面有冇血絲？」 | Blood-stained postnasal drip is significant for early NPC diagnosis [4] | NPC |
| Ear symptoms | Ear blockage, hearing loss, tinnitus? | 「耳仔有冇塞住？有冇耳鳴或者聽嘢唔清楚？」 | Eustachian tube dysfunction → sinusitis complication; unilateral serous OM → NPC [3][4] | NPC, sinusitis complication |
| Neck mass | Any neck lump? | 「頸有冇摸到粒嘢？」 | Upper neck lymphadenopathy is the MOST common initial presenting symptom of NPC [4] | NPC |
| Fever | Any fever? | 「有冇發燒？」 | Fever → viral URTI, bacterial sinusitis; recurrent fever after initial improvement = double sickening [2] | Bacterial rhinosinusitis |
| Eye symptoms | Swelling around eye? Double vision? | 「眼有冇腫？有冇睇嘢有重影？」 | Orbital/periorbital signs → sinusitis complications (orbital cellulitis); diplopia → NPC skull base invasion [1][4] | Sinusitis complication, NPC |
| Triggers | Worse with dust/pollen/cold air/seasons? | 「有冇啲嘢會特別引發？例如塵、花粉、凍嘅天氣？邊個季節特別差？」 | Trigger-related → allergic rhinitis [3] | Allergic rhinitis (seasonal vs perennial) |
| Atopic Hx | Eczema, asthma, allergic conjunctivitis? | 「你有冇濕疹、哮喘、或者眼敏感？」 | Atopic triad supports allergic rhinitis [3] | Allergic rhinitis |
| PMH | Any chronic illness? | 「有冇長期病患？」 | Immunocompromised → complicated sinusitis; DM, hypothyroid | Underlying chronic disease |
| Drug Hx | Any medications? Nasal sprays? | 「食緊咩藥？有冇用鼻噴劑？用咗幾耐？」 | Overuse of topical decongestants ( > 5–7 days) → rhinitis medicamentosa [3]; ACEI → cough/PND | Rhinitis medicamentosa, drug-induced rhinitis |
| Allergy | Drug allergies? | 「有冇藥物敏感？」 | Safety; aspirin sensitivity → Samter's triad [1] | CRSwNP + asthma + aspirin sensitivity |
| FHx | Family Hx of NPC, atopy? | 「屋企人有冇鼻咽癌？有冇鼻敏感？」 | NPC has familial clustering (Southern Chinese); atopy runs in families [4] | NPC, allergic rhinitis |
| Smoking/Occupation | Smoke? Occupation with irritants? | 「有冇食煙？做咩工嘅？有冇接觸化學品或者塵？」 | Smoking = RF for URTI severity, CRS; occupational irritants → vasomotor rhinitis [2] | CRS, vasomotor rhinitis |
| Functional impact | Sleep, work, daily life? | 「瞓覺點？有冇影響返工/返學？」 | Biopsychosocial marks; mouth-breathing/snoring → OSA in chronic congestion | Sleep disturbance, functional impairment |
| Mood | Feeling low or anxious? | 「心情方面點呀？有冇覺得好煩或者低落？」 | Depression as masquerade; also chronic symptoms → frustration | Depression, health anxiety |
Case Report Form Answer Builder
- CC: Rhinorrhoea / nasal congestion × [duration]
- HPI high-yield points:
- Onset, duration (acute < 4w vs chronic ≥ 12w)
- Character of discharge (clear watery vs purulent vs blood-stained)
- Laterality (bilateral vs unilateral)
- Associated: sneezing, nasal itch, facial pain/pressure, ↓ smell, epistaxis, PND, ear symptoms
- Triggers/seasonality
- Aggravating/relieving factors
- Systemic: fever, weight loss, malaise
- Impact on sleep, work, daily function
- Previous treatment and response (esp. topical decongestants)
- Examples: "Persistent nasal congestion affecting sleep, wants relief" / "Worried about cause of blood-stained nasal discharge" / "Wants to know if this is allergy or something more serious"
- Phrasing tip: Combine the symptom + the patient's concern/trigger for attendance into one sentence. E.g., "Chronic nasal congestion for 3 months with poor sleep, concerned about NPC given family history."
| Likely Content | Exact Wording Example | |
|---|---|---|
| Idea | "I think it's just allergy/sinus" or "I'm worried it could be nose cancer" | Patient believes the nasal congestion is due to allergic rhinitis / sinusitis |
| Concern | Fear of NPC (very common in HK); fear of needing surgery; worry about drug side effects | Patient is worried this could be nasopharyngeal carcinoma, especially as a relative was diagnosed |
| Expectation | Wants medication / referral to ENT / investigation (endoscopy) / reassurance | Patient hopes to get a nasal spray prescription and be referred for nasal endoscopy to rule out NPC |
- Allergic rhinitis if: bilateral, clear watery discharge, sneezing, nasal itch, atopic history, trigger-related, ± allergic salute/shiners
- Acute viral rhinosinusitis if: acute onset < 10 days, coryzal symptoms, self-limiting
- Chronic rhinosinusitis if: > 12 weeks, purulent PND, ↓ smell, facial pressure
- Minimum supporting evidence: Duration + character of discharge + presence/absence of itch-sneeze + atopy + trigger pattern
| DDx | One Key Discriminator |
|---|---|
| Acute/Chronic rhinosinusitis | Facial pain/pressure ↑ on bending, purulent discharge, double sickening (bacterial), > 12w (chronic) [1] |
| Vasomotor (non-allergic) rhinitis | Congestion without itch/sneezing, triggered by cold air/irritants, no atopic Hx |
| Nasopharyngeal carcinoma | Blood-stained PND, unilateral serous otitis media, upper neck mass, cranial nerve palsy [4] |
| Domain | Problem |
|---|---|
| Biological | Chronic nasal congestion leading to mouth-breathing and recurrent sinusitis |
| Psychological | Health anxiety / fear of NPC; frustration from chronic symptoms; poor sleep → low mood |
| Social/Functional | Sleep disturbance → daytime fatigue → impaired work/school performance; snoring affecting partner |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit It | Why It Supports This Diagnosis |
|---|---|---|---|
| Allergic rhinitis (most likely Dx) | Pale, boggy (bluish-grey), oedematous inferior turbinates on anterior rhinoscopy [3] | Anterior rhinoscopy with nasal speculum + headlight; also look for allergic salute crease, allergic shiners | Mucosal pallor/oedema indicates chronic allergic inflammation, distinct from erythema of infection |
| Acute rhinosinusitis | Tenderness on palpation/percussion over maxillary/frontal sinuses | Press firmly over cheekbone and brow; tap with finger | Localised sinus tenderness + purulent anterior discharge supports acute sinusitis [1][2] |
| Chronic rhinosinusitis with nasal polyps | Grey-white, mobile, painless polyps visible on anterior rhinoscopy | Anterior rhinoscopy; polyps are insensitive to touch cf. swollen turbinate which is painful/bleeds [1] | Polyps are pathognomonic of CRSwNP |
| Vasomotor rhinitis | Normal-appearing or engorged (erythematous) turbinates, no pallor | Anterior rhinoscopy; no pale/boggy mucosa, no polyps, no purulent discharge | Exclusion of allergic and infective signs supports vasomotor |
| NPC | Firm, non-tender, upper cervical (Level II) lymphadenopathy | Palpate neck systematically; inspect postnasal space (in real practice via nasendoscopy) | Upper neck mass is the most common initial presenting symptom of NPC [4]; any suspicious node → urgent ENT referral |
Must-Not-Miss Red Flags — Urgent Referral
- Unilateral blood-stained postnasal drip / epistaxis → NPC until proven otherwise [4]
- Unilateral serous otitis media in an adult → NPC
- Upper cervical lymphadenopathy → NPC
- Cranial nerve palsy (diplopia, facial numbness, trismus) → NPC with skull base invasion [4]
- Periorbital swelling / proptosis / decreased vision → orbital complication of sinusitis → emergency referral [1]
- Severe headache + high fever + altered consciousness → intracranial complication of sinusitis → emergency referral
- Unilateral foul-smelling discharge in a child → nasal foreign body
Top Traps That Lose Marks:
- Assuming purulent discharge = bacterial infection requiring antibiotics. Coloured nasal discharge is a normal phase of an uncomplicated common cold; purulence alone does NOT distinguish between a cold and a sinus infection [2]. Don't write antibiotics for viral rhinosinusitis.
- Forgetting to ask about nasal spray overuse → missing rhinitis medicamentosa (topical decongestant > 5–7 days).
- Not asking about blood in postnasal drip → missing early NPC. This is especially high yield in a Hong Kong/Southern Chinese patient population.
- Diagnosing allergic rhinitis without asking about itch/sneezing — the itch-sneeze component is the key discriminator from vasomotor rhinitis.
- Not asking ICE — this is directly scored on the Case Report Form.
- Forgetting to ask about ear symptoms — Eustachian tube dysfunction is commonly associated with both sinusitis and NPC.
- Not asking functional impact — needed for the biopsychosocial problem.
Shortest Safe Management / Safety-Net Line (for consultation close):
- 「如果你嘅鼻水/鼻塞持續唔好，或者出現流鼻血、耳仔塞住、頸有粒嘢，一定要即刻返嚟睇。」
- (English: "If symptoms persist or you develop nosebleed, ear blockage, or a neck lump, please come back immediately.")
High Yield Summary
What to ASK: Duration, character (clear vs purulent vs blood-stained), laterality, itch/sneezing, facial pain, smell, epistaxis, ear symptoms, neck lump, triggers, atopic Hx, drug Hx (nasal sprays!), FHx (NPC/atopy), functional impact, ICE, hidden agenda (NPC fear).
What to WRITE: CC with duration → HPI with clear discriminators → One main RFC (symptom + why today) → ICE → Most likely Dx with evidence → 3 DDx each with one discriminator → 3 biopsychosocial problems → One physical sign (pale boggy turbinates for AR; sinus tenderness for sinusitis; neck node for NPC).
What NOT to MISS: Blood-stained PND in a Southern Chinese patient = NPC until proven otherwise. Unilateral symptoms always need explanation. Rhinitis medicamentosa from decongestant overuse. Coloured discharge ≠ automatic antibiotics.
Active Recall - Family Medicine Clinical Test
[1] Ryan Ho Respiratory.pdf (Section 3.1.1.4 Rhinosinusitis, p.54); Adrian Lui Pediatrics Notes.pdf (p.159) [2] MBBS Final MB (Medicine) (Felix PY Lai).pdf (p.119, 136–137); MBBS Final MB (Pediatrics) (Felix PY Lai).pdf (p.95, 112–113) [3] GC 215. Common nasal conditions and nasopharyngeal carcinoma.pdf (p.32 — Allergic Rhinitis); CFB WCS29_Common ENT conditions 2023.pdf (p.14 — Sinusitis definition) [4] MBBS Final MB (Surgery) (Felix PY Lai).pdf (p.251 — NPC clinical manifestation and diagnosis) [5] CFB (OG01) Physiology of Pregnancy and Minor Ailments.pdf
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