Reasoning GP · Algorithm · 1-page summary
Nasal congestion and rhinorrhoea
For: adults and children with a blocked or runny nose in primary care. Not for: starting immunotherapy or biologics (specialist-led), or managing orbital, intracranial or CSF-leak complications (hospital).
Core rule: bilateral congestion is usually rhinitis or sinusitis; persistent one-sided blockage, blood-stained discharge or clear watery discharge is not. Never keep treating one-sided symptoms as rhinitis.
0Stop — emergency now — before any treatment
- Suspected button battery in the nose → 999; do not attempt removal. Foreign body with respiratory distress or aspiration risk, significant facial swelling or airway compromise → Emergency
- Sinusitis with periorbital swelling, proptosis, painful or restricted eye movements, diplopia or reduced vision; severe headache, meningism, neurological signs or sepsis → Immediate hospital
- One-sided clear watery discharge (possible CSF leak) with fever, severe headache, meningism, confusion or reduced consciousness → Emergency (possible meningitis)
- While waiting: do not delay transfer for imaging, beta-2 transferrin or a set antibiotic; no nasal instrumentation. Antibiotic choice per hospital protocol.
1Triage — one side or both, and how long
| Pattern | Think → action |
|---|---|
| One side, persistent | Structural disease incl. malignancy → Urgent ENT (block 2) |
| One side, clear, watery | CSF leak → Same-day (block 2) |
| Child, one side, smelly | Foreign body; not visible or not removable → Same-day |
| Both sides, <4 weeks | Viral URTI, acute sinusitis or allergic → NG79 10-day rule |
| Both sides, >12 weeks | Rhinitis, suspected CRS ± polyps |
2Screen — one row is enough
- Persistent one-sided obstruction, blood-stained or offensive discharge, recurrent one-sided epistaxis, facial pain or swelling, anosmia, mass or neck nodes → Urgent ENT (local pathway; not an NG12 criterion).
- Suspected CSF leak (after head injury or surgery; salty taste) → Same-day ENT / neurosurgery / ED; testing via hospital.
- Young male: obstruction + epistaxis + headache, cranial-nerve palsies (angiofibroma) → Urgent ENT; never biopsy or manipulate.
- Saddle nose, septal perforation, crusting, auricular chondritis, eye inflammation, lung or kidney signs (GPA, polychondritis, cocaine) → Urgent ENT / rheumatology; consider FBC, U&E, CRP/ESR, urinalysis, ANCA.
3Assess — once blocks 0–2 are answered
☐ Anterior rhinoscopy: side, polyps, crusting, perforation ☐ Visual acuity and eye movements if facial or periorbital symptoms ☐ BP and pulse before a sympathomimetic decongestant
Ask: decongestant sprays, NSAID reactions, cocaine, occupation, pregnancy, asthma. Usually no tests. No routine CT in primary care.
4Classify — only if the screen is negative
- Allergic rhinitis — sneezing, itch, watery discharge, triggers, ± asthma → block 5.
- Acute sinusitis — bacterial more likely if >10 days, one-sided facial pain, fever, double-sickening.
- Suspected CRS ± polyps — >12 weeks, ≥2 of blockage, discharge, facial pain, reduced smell.
- Non-allergic — vasomotor, pregnancy, occupational; rhinitis medicamentosa (spray >5 days → stop, INCS + saline).
- Uncertain or one-sided — not rhinitis; follow block 2.
5Treat today — doses: NICE/SPC, BNF, local formulary
- Allergic: mild intermittent → non-sedating oral or nasal antihistamine. Moderate–severe or persistent → regular intranasal steroid (INCS); teach technique. Not controlled → check adherence, technique; consider INCS + intranasal antihistamine. Ipratropium if watery.
- Acute sinusitis: ≤ about 10 days → no antibiotic, self-care. ≥ about 10 days, not improving → consider 14-day high-dose nasal steroid (≥12 y) and no or back-up antibiotic. Immediate only if systemically very unwell, serious illness or high risk. Phenoxymethylpenicillin; allergy → doxycycline (not pregnancy), clarithromycin or (pregnancy) erythromycin; very unwell or worse on first choice → co-amoxiclav.
- CRS/polyps: mometasone + saline; no routine oral steroid. Decongestant sprays ≤5 consecutive days (MHRA). Pregnancy: saline, INCS; no routine oral decongestant.
6Refer routinely — urgent routes are in blocks 0–2
- Suspected CRS despite INCS + saline, polyps, significant septal deviation → ENT.
- Polyps + asthma + NSAID reactions (AERD) → respiratory/ENT; no aspirin challenge.
- Troublesome allergy despite treatment + confirmed sensitisation → allergy (immunotherapy). Occupational → occupational health or allergy; check for asthma.
7Never reassure by
- Calling persistent one-sided blockage or bloody discharge "rhinitis" or "a polyp".
- Labelling a clear watery drip after head injury or surgery "a cold".
- Discoloured discharge as a reason for antibiotics.
- A "failed" nasal steroid before checking technique, adherence and duration.
- Normal bloods or ANCA as excluding GPA.
- Pregnancy rhinitis when there are red flags or one-sided symptoms.
8Safety-net — say it, then document it
999 “Call 999 for a possible button battery in the nose, confusion or drowsiness, a fit, or rapidly worsening vision.” A&E “Go to A&E now for eye swelling, double or reduced vision, painful eye movements, severe headache, stiff neck, feeling very unwell, or a one-sided clear drip with fever or headache.” Same day: “Contact us today if symptoms worsen quickly, even on antibiotics.” Book a review: “if sinusitis is not better after 3 weeks, a new spray is not working at 4–6 weeks, or one side stays blocked or bleeds.”
✓Safe to leave primary care only if — all five, documented
No block 0–2 feature; symptoms bilateral, or one-sided route arranged
Nose examined; eyes checked if facial symptoms
Decongestant use, drugs, pregnancy and asthma asked
Plan fits the pattern; spray technique taught; NG79 10-day rule applied
Safety-net given; review at 4–6 weeks if new treatment
Summary of the full Reasoning GP nasal congestion algorithm, which holds the history, examination, CRS criteria, immunotherapy, biologics and lifestyle detail. Sources: NICE NG79; NICE CKS allergic rhinitis; BSACI rhinitis guideline (2017); EPOS 2020; MHRA Drug Safety Update (April 2026, nasal decongestants); NICE NG12 (updated April 2026); NICE TA1045, TA1087, TA1134; local formulary. Clinical reference — follow local ENT pathways and check doses: NICE/SPC, BNF.