The nose warms, humidifies, and filters inspired air, and the paranasal sinuses drain into it through narrow openings. Anything that swells the mucosa or blocks drainage causes congestion, pressure, and infection risk. The anterior septum contains a rich vascular network (Kiesselbach plexus), the source of most nosebleeds.

Aspirin-exacerbated respiratory disease (Samter triad): nasal polyps + asthma + reactions to aspirin/NSAIDs.

Subjective

• Congestion (one side or both), discharge (clear, purulent, bloody), sneezing, itching
• Facial pain or pressure, headache, tooth pain, reduced smell or taste
• Duration, triggers, seasonality, allergy history
• Use of topical decongestant sprays and how long
• Medications that raise bleeding risk: anticoagulants, antiplatelets (aspirin, clopidogrel), NSAIDs, some supplements; history of hypertension or bleeding disorders

Objective

• Inspect nares and mucosa (pale and boggy in allergy; red and swollen in infection), septal position, polyps (grape-like, gray, painless)
• Discharge character; unilateral foul discharge in a child suggests a foreign body
• Epistaxis: estimate blood loss, vital signs, airway, bleeding down the posterior pharynx
• After trauma: deformity, septal hematoma (bluish swelling of the septum), clear watery drainage (possible CSF leak)

Signs of acute bacterial rhinosinusitis (ABRS) — suspect when:

• Symptoms persist 10 days or more without improvement, or
• Symptoms worsen after initial improvement ("double worsening")

Allergic rhinitis

• Intranasal corticosteroid (INCS) — the most effective first-line treatment for persistent or moderate-to-severe symptoms; works on all symptoms including congestion; full effect builds over days to weeks, so use regularly, not only when symptomatic
• Second-generation oral antihistamines (cetirizine, loratadine, fexofenadine) or intranasal antihistamine (azelastine)
• Allergen avoidance; allergen immunotherapy for selected clients
• The FDA advises reserving montelukast for allergic rhinitis when other treatments are not effective or not tolerated (neuropsychiatric boxed warning)

Nonallergic rhinitis — avoid triggers; intranasal azelastine, INCS, or intranasal ipratropium for watery rhinorrhea.

Acute rhinosinusitis

• Viral: symptom relief — saline irrigation, analgesics, INCS
• Presumed bacterial and uncomplicated: the 2025 AAO-HNSF update recommends watchful waiting without antibiotics first when follow-up is assured. If antibiotics are needed, amoxicillin with or without clavulanate for 5–7 days
• Reassess if symptoms worsen or do not improve (within 3–5 days on antibiotics); refer urgently for signs of complications

Chronic rhinosinusitis / nasal polyps

• Daily saline irrigation and INCS; short oral corticosteroid bursts for polyps
• Biologic therapy (e.g., dupilumab) for severe CRS with polyps
• Endoscopic sinus surgery or polypectomy when medical therapy fails

Epistaxis (stepwise)

1. Sit upright, lean forward, pinch the soft part of the nose firmly and continuously for 10–15 minutes (guidelines require at least 5 minutes; many protocols use 10–15)
2. Topical vasoconstrictor (e.g., oxymetazoline) on cotton pledget
3. Cautery (silver nitrate) of a visible anterior vessel
4. Anterior packing (gauze or expandable sponge/balloon)
5. Posterior bleeding: posterior pack or balloon, hospital admission, possible embolization or arterial ligation
6. Manage the cause: control severe hypertension, review anticoagulation with the provider, correct coagulopathy

Septoplasty / rhinoplasty — correct a deviated septum; internal splints or packing may be placed.

Drug safety

Listed in priority order.

1. Airway and bleeding control (epistaxis)
   • Keep the client sitting up and leaning forward so blood drains out of the nose, not down the throat (prevents aspiration and nausea from swallowed blood)
   • Do not tilt the head back and do not lie the client flat
   • Apply continuous pressure for 10–15 minutes without releasing to check; ice to the bridge of the nose may help
   • Monitor vital signs; watch for frequent swallowing (posterior bleeding), hypotension, tachycardia
   • Clients with posterior packing: monitor airway, SpO₂ (packing may cause hypoxemia and bradycardia by a vagal reflex), pain, and ensure the pack stays in position; antibiotics may be prescribed while packing is in place
2. Preoperative (nasal/sinus surgery)
   • Ask about anticoagulant, antiplatelet, NSAID, and supplement use — bleeding is the major surgical risk; the provider decides whether and when to stop them
3. Postoperative (septoplasty, sinus surgery, polypectomy)
   • Elevate head of bed 30–45 degrees; cold compresses to reduce swelling and bruising — not heat
   • Check drip pad; frequent swallowing suggests bleeding
   • Mouth breathing while packing is in place — frequent oral care and humidification
   • Periorbital bruising is expected; report vision change, severe headache, clear watery drainage
4. Comfort and secretions — humidification, fluids, saline irrigation as ordered, analgesics
5. Foreign body — prepare for removal; a button battery in the nose is an emergency (tissue necrosis)

Intranasal corticosteroid spray technique

• Shake the bottle, gently blow the nose first
• Tilt the head slightly forward, insert the tip just inside the nostril
• Use the opposite hand (right hand for left nostril) so the spray is aimed toward the outer wall of the nose / same-side ear, away from the septum
• Sniff gently while spraying; do not blow the nose right after
• Use every day as prescribed — benefit takes days to weeks; stopping when symptoms fade allows them to return

Saline irrigation

• Use only distilled, sterile, or previously boiled and cooled water (boil at least 1 minute, 3 minutes at high altitude). Never use untreated tap water — rare but fatal amoebic infections have been linked to nasal rinsing with tap water
• Use premixed packets or the provider's recipe; lean over the sink, head tilted, breathe through the mouth; clean and air-dry the device after each use

After epistaxis, nasal surgery, or foreign body removal

• Do not blow the nose forcefully; sneeze with the mouth open
• Avoid heavy lifting, straining, bending, and strenuous exercise (about 2 weeks after surgery or as instructed)
• Use a humidifier and saline gel to keep mucosa moist; avoid nose picking
• Avoid aspirin and NSAIDs unless the provider approves
• Return for bleeding that does not stop after 15 minutes of pressure, fever, severe headache, vision changes, or persistent obstruction

Rhinitis self-care

• Limit topical decongestant sprays to 3 days
• Allergen control: wash bedding in hot water, keep windows closed in pollen season, reduce indoor humidity and mold
• Avoid known nonspecific triggers (smoke, perfume) for nonallergic rhinitis

• Anterior epistaxis: sit up, lean forward, pinch the soft nose continuously 10–15 minutes — never tilt the head back
• Frequent swallowing after nasal bleeding or surgery = hidden posterior bleeding
• Intranasal corticosteroid = first-line for allergic rhinitis; use daily; aim away from the septum
• Topical decongestant sprays: maximum 3 days (rebound congestion)
• Nonallergic rhinitis: triggers are temperature, odors, irritants — allergy tests are negative
• Most acute sinusitis is viral; suspect bacterial at ≥ 10 days without improvement or double worsening
• Uncomplicated ABRS: watchful waiting first; if antibiotics are needed, amoxicillin ± clavulanate for 5–7 days
• Chronic rhinosinusitis = ≥ 12 weeks
• Nasal polyps: obstruction and loss of smell, but no pain or nasal deformity; think of asthma + aspirin sensitivity
• Before nasal surgery, check anticoagulants/antiplatelets
• Post-op: cold (not heat), head elevated, no forceful nose blowing
• Saline rinses only with distilled, sterile, or boiled and cooled water