A patient came with unilateral nasal discharge and nasal block, unilateral. What's your probable diagnosis? That's it. That's it. That's all.
Unilateral nasal discharge + nasal block in a single patient - the most likely diagnoses to consider:
Most probable: Foreign body in the nose (especially if the patient is a child - classic presentation is unilateral foul-smelling purulent discharge).
Other strong differentials:
- Unilateral choanal atresia - congenital, presents with unilateral block and discharge
- Deviated nasal septum (DNS) with secondary rhinitis - causes unilateral obstruction
- Nasal polyp (unilateral) - antrochoanal polyp is classically unilateral
- Rhinolith - calcified foreign body causing unilateral block + discharge
- Unilateral sinusitis (e.g., maxillary) - can present with unilateral purulent discharge
- Nasal tumors - e.g., inverted papilloma, juvenile nasopharyngeal angiofibroma (in adolescent males), or malignancy - must be ruled out, especially in adults with persistent unilateral symptoms
- CSF rhinorrhea (unilateral watery discharge) - post-trauma or spontaneous
Key clinical pearl: Unilateral nasal symptoms should always raise suspicion for a structural or neoplastic cause rather than simple rhinitis, which is almost always bilateral. A foreign body in children and a tumor in adults are the two "must-not-miss" diagnoses.
The workup would include anterior rhinoscopy, nasal endoscopy, and CT of the paranasal sinuses.
What if the patient is adult?
In an adult with unilateral nasal block + discharge, the priority list shifts significantly:
Top Diagnosis: Antrochoanal Polyp
- Classically unilateral
- Originates from maxillary sinus, prolapses into choana
- Causes unilateral block + mucoid discharge
Must-Not-Miss: Nasal/Sinonasal Malignancy
- Squamous cell carcinoma, adenocarcinoma, esthesioneuroblastoma
- Unilateral persistent symptoms in an adult = tumor until proven otherwise
- Associated risk: woodworkers (adenocarcinoma), nickel/chromate exposure
Other Important Differentials:
| Diagnosis | Key Feature |
|---|---|
| Inverted Papilloma | Unilateral, has malignant potential (~10%) |
| Unilateral chronic sinusitis | Purulent discharge, facial pain/pressure |
| Rhinolith | Long-standing history, foul smell |
| DNS with unilateral sinusitis | Obstruction + secondary infection |
| CSF rhinorrhea | Clear watery discharge, h/o trauma/surgery |
| Fungal sinusitis | Immunocompromised or diabetic patient |
| Wegener's granulomatosis | Bloody discharge, septal perforation, systemic features |
Bottom line for adults: Unilateral nasal symptoms = endoscopy + CT PNS mandatory to rule out neoplasm. Never assume it's simple rhinitis. The age shifts suspicion firmly toward structural pathology or malignancy.
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