7 Colds, Flu, and Stuffy Nose
The differential diagnosis of colds, flu, and stuffy nose might appear unimportant, because most of these conditions have no specific cures. However, because upper respiratory infections (URIs) are the most common affliction of adults and children, the sheer case volume requires the physician to be particularly expert in the diagnosis and symptomatic treatment of these conditions.
Many different viruses are responsible for causing colds, URIs, and flu. The physician must be able to differentiate these viral infections from allergic rhinitis (both perennial and seasonal), chronic rhinitis, and the common complications of these viral infections, which include sinusitis, otitis media, bronchitis, and pneumonia. These last four complications are usually secondary to superimposed bacterial infections, which will respond to appropriate antibiotic therapy. The constitutional complaints often associated with URI may also represent the prodrome of other viral infections, such as infectious mononucleosis, measles, and mumps.
Children typically experience more severe constitutional symptoms with URIs or colds than adults do. After a common cold, adults with a history of bronchitis, allergies, asthma, heavy cigarette smoking, or immune incompetence and children with a history of recurrent bronchitis, allergies, or cystic fibrosis develop lower respiratory tract infections more frequently than other people. Pregnancy is occasionally the cause of rhinitis.
Influenza tends to be milder in neonates and children; severity increases with age. Many elderly patients develop superimposed bacterial pneumonia. More than 70% of deaths recorded during known influenza epidemics have occurred in patients over age 65. Other high-risk groups include patients with acquired immunodeficiency syndrome (AIDS), chronic cardiorespiratory disease, chronic renal disease, diabetes, and third-trimester pregnancies. Rhinitis medicamentosa should be suspected in patients who frequently use nasal drops, sprays, or inhalers.
The physician must be especially alert for the development of complications of common URIs. Sinusitis is more likely to occur in a patient with a history of recurrent sinusitis. Otitis media is more common in young children, bronchitis in smokers and patients with underlying pulmonary disease, and pneumonia in older and diabetic patients.
Symptoms of common viral URIs are well known. These symptoms largely depend on the particular infective viral agent, the patient’s age, and the underlying medical conditions. The incubation period is 1 to 3 days. Patients usually have profuse nasal discharge and congestion and complain of stuffy nose, sneezing, postnasal drip, cough, and sore throat. They may also complain of headache, fever, malaise, and hoarseness and may note pharyngeal exudates, oropharyngeal vesicles, and lymphadenopathy. It is notable that colds in adults are rarely associated with a substantial fever. Acute bacterial rhinosinusitis is characterized by purulent rhinorrhea, facial pain or pressure, nasal obstruction, and often a worsening of symptoms after an initial improvement. Children may experience vomiting, diarrhea, abdominal pain, and wheezing.
Although a URI is the most frequent cause of nasal airway obstruction, other causes must be considered, including polyps, foreign bodies, herpes simplex, furuncles (folliculitis of nasal vibrissae), and less common infections. In neonates, unilateral nasal obstruction may be caused by a congenital abnormality (e.g., choanal atresia). In a child with unilateral nasal obstruction as the presenting symptom, the physician should consider a foreign body.
Although the symptoms of influenza and common URI may be similar, influenza viral infections can often be differentiated from the symptoms of a common cold by the sudden onset of typical signs of flu: shivering, chills, malaise, insomnia, marked aching of the limb and back muscles, dry cough, retrosternal pain, loss of appetite, and especially the coexistence of cough and fever greater than 37.8° C within 48 hours of the onset of symptoms. The sudden onset of fever and cough is highly predictive of influenza. A patient with type A influenza may not have coryza (profuse nasal discharge).
In addition to acute stuffy nose, chronic stuffy nose is a common complaint. Chronic rhinitis is most frequently caused by allergy (both seasonal and perennial), nonallergic rhinitis with eosinophilia (NARES), drugs (topical and systemic), and vasomotor rhinitis (nonallergic rhinitis). Chronic rhinitis is characterized by nasal congestion, postnasal drip, rhinorrhea, sneezing, and nasal itchiness. It is difficult to determine the specific cause on the basis of the symptoms alone.
The physician must especially recognize allergic rhinitis and chronic rhinitis as causes of nasal stuffiness. The two types of allergic rhinitis are perennial and seasonal. Patients with perennial rhinitis usually complain of nasal airway blockage with a persistent watery mucoid drainage. Their nasal turbinates are pale and boggy. Patients with seasonal rhinitis usually complain of sneezing, itchy eyes, lacrimation, and a watery nasal discharge. Their symptoms have a seasonal variation, unlike those of patients with the perennial type.
Chronic, or idiopathic, rhinitis is not known to have a specific cause. Most patients have persistent engorgement of the nasal turbinates, which leads to nasal obstruction and profuse watery rhinorrhea. They often complain of persistent nasal obstruction that may alternate from side to side. Sneezing is not as common as it is in allergic rhinitis.
When symptoms of a cold and cough persist longer than the patient’s fever, the URI may have subsided, and the persistent symptoms may be caused by bacterial rhinosinusitis. Bacterial rhinosinusitis should be suspected if the symptoms last more than 7 days and are associated with maxillary pain or tenderness, unilateral facial or dental pain, and bloody/purulent nasal secretions.