16 THE NOSE AND PARANASAL SINUSES and 15 blown out of the nose, while in the later stages it becomes more viscid and may be felt passing down the throat. Nasal catarrh may be complained of either because the patient has to blow his nose frequently or because he has a postnasal drip, or because he has both. One must determine the duration of the symptoms, and, if of long-standing, one tries to discover the initial cause. The catarrh may be present all day, and every day, or it may be worse at certain times, or during certain seasons, or it may waken the patient at night if it collects in the throat. The nature of the catarrh may help the diagnosis. A thin, watery, mucoid discharge is present briefly at the onset of a coryza, while if it is of long duration it suggests a nasal allergy or a vasomotor rhinitis. A mucopurulent or purulent discharge, which is often produced on a paper handkerchief for inspection, denotes infection which may have its origin in the paranasal sinuses. Crusted material is blown out of the nose in atrophic rhinitis or rhinitis sicca, or may appear for some time following a virus infection, or following nasal surgery if the mucosal surface has been destroyed. Blood may be mixed with the catarrh in inflam- matory conditions, or due to excessive nose blowing, but it may denote malignancy. Examination of the nose should attempt to determine the origin of the catarrh, especially if it is mucopurulent or purulent, and posterior rhinoscopy is often important in locating infected catarrh in the choanae. A swab may be taken of the catarrh for bacteriological or cytological studies. Radiography of the paranasal sinuses should be performed in order to condemn or exclude the sinuses, and in children a lateral view is important to determine the presence and size of any adenoid pad which might be the cause of the catarrh. HEADACHE There is a popular belief that headache is commonly associated with chronic sinus infection, whereas sinus disease accounts for a very small proportion of headaches. In children headache is not a common complaint although many authorities claim that sinus infection is common in children. Investigation of the cause of headache may be long and painstaking, and often inconclusive. It may involve general medical, neurological, ophthalmic and psychiatric examinations, apart from a clinical study of the nose, sinuses, pharynx, teeth and ears, A careful history is important in ascertaining the position of the pain, and whether this is constant, whether it radiates from one point or whether the site of the headache varies. Descriptions of the type of pain may be difficult to classify as dull, boring, sharp, severe, agonizing etc. because patients vary in their threshold to pain, A history should be taken of the periodicity of the headache to discover whether it always appears about the same time or whether this varies. Radiography of the paranasal sinuses should always be done, even if only to exclude them as a cause. Sinus headache will be discussed later, but in general an acute sinusitis gives rise to a pain in the re^n,.olthe^sinus..involved while the headache of chronic sinusitis is usually frontal, although chronic sphenoiditis may give retro- orbital, pain. Fibrosftis of the neck muscles may cause pain in the occipital region spreading forwards over the skull to the forehead or to the mastoid area. Cervical arthritis may produce a similar pain.