A 3-year-old boy is brought to the office due to nasal discharge for the past 2 weeks. His mother reports clear nasal discharge that has become progressively thicker and more malodorous. The patient has had no fever, cough, or shortness of breath. He is eating normally. Medical history includes congenitally acquired HIV, and the patient has taken antiretroviral therapy since birth. Three months ago, the CD4 cell count was 520/mm3. The patient has received all age-appropriate vaccinations. He lives with his parents, 6-year-old brother, and a pet dog. The patient's father smokes cigarettes outside of the house. Growth parameters are at the 40th percentile for age. On examination, the patient is playful and interactive. There is purulent drainage from the right nostril, and the right nasal mucosa and turbinates are erythematous and swollen. There is no discharge from the left side, and the left turbinates are pink and nonedematous. The oropharynx and tonsils are normal. There is no cervical lymphadenopathy. Which of the following is the most likely cause of this patient's current symptoms?
Nasal foreign body | |
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This toddler with unilateral, purulent rhinorrhea likely has a nasal foreign body. Most nasal foreign bodies occur in children age 1-6, and a variety of objects may be involved (eg, small toys, food).
Insertion of the nasal foreign body is often unobserved by the caregiver, leading to a delay in diagnosis. In these patients, the retained object can induce inflammation (eg, nasal turbinate erythema) or cause local infection, leading to unilateral, foul-smelling, purulent discharge. Patients may also have sneezing or epistaxis.
Imaging is unhelpful because most objects are radiolucent. A visualized object can usually be safely removed in the office. However, if the object cannot be visualized because of its location or surrounding edema or if removal could cause further trauma (eg, penetrating objects), referral to otolaryngology for nasal endoscopy is appropriate. Nasal foreign bodies should not be managed expectantly because inflammation may lead to obstruction of the sinus outflow tract and cause sinusitis or periorbital cellulitis.
(Choice A) Acute bacterial sinusitis can present with purulent nasal drainage and inflamed nasal mucosa. However, nasal symptoms are typically bilateral and often accompanied by fever and cough.
(Choice B) Adenoid hypertrophy, the most common cause of nasal obstruction in children, can result in mucopurulent nasal discharge; however, bilateral symptoms would be expected.
(Choice C) Allergic rhinosinusitis can present with rhinorrhea in a well-appearing child. Parental smoking increases this risk, and pets can be a source of antigen exposure. In contrast to the symptoms of foreign body aspiration, symptoms of allergic rhinosinusitis are typically bilateral, rhinorrhea is clear, and the turbinates appear bluish or pale.
(Choice D) Mucormycosis (invasive fungal sinusitis), which is classically associated with diabetes mellitus, can present in immunocompromised patients—particularly if the CD4 count is <50/mm3—with nasal obstruction and rhinorrhea. This child with HIV is on antiretroviral therapy with a CD4 count of 520/mm3, making an opportunistic infection unlikely. Moreover, invasion of blood vessels by fungal hyphae in mucormycosis leads to ischemia (white nasal turbinates) and necrosis (black nasal turbinates), findings not seen in this patient.
Educational objective:
A nasal foreign body should be suspected in a toddler or young child with unilateral, foul-smelling, purulent nasal discharge.