Nasal Discharge
Nasal discharge in children is an everydayevent in pediatric practice.
Principal Causes of Nasal Discharge
- Anatomic
- Choanalatresia /stenosis
- Adenoid hypertrophy
- Rhinitis
- Infectious
- Viral
- Bacterial
- Allergic rhinitis
- Nonallergic rhinitis with eosinophilia
- Nonallergic rhinitis without eosinophilia
- Drug-induced
- Sinusitis
- Foreign body
- Cerebrospinal fluid rhinorrhea
Clinical Features and Diagnosis
Anatomic
Choanal Atresia/Stenosis
Unilateralchoanal atresia may produce persistent mucous discharge from thenose, as may unilateral or bilateral choanal stenosis.Flexible endoscopy is diagnostic.CT is used to delineate anatomy priorto surgery. Adenoid Hypertrophy
Common causeof upper airway obstruction and may not only cause snoring but also rhinorrhea.Lateral radiograph of upper airwaydemonstrates adenoid enlargement. Rhinitis
Infectious
Viral
Most commoncause of nasal discharge is viral upper respiratory infection. Normal preschool-or school-aged child has average of 6–8 of these infections/yr.Rhinoviruses are most frequent pathogens. Others include parainfluenzaviruses, respiratory syncytial virus, influenza viruses, and adenoviruses.Nasal discharge may be clear and wateryor mucopurulent. Associated findings include fever, headache, malaise,anorexia, myalgia, cough, sore throat, and vomiting. Infants maybe irritable and restless, with difficulty in feeding and sleeping.Nasal turbinates are inflamed and edematous. Nasal wash viral culturesare confirmatory but unnecessary in most clinical situations. Bacterial
Purulentnasal discharge may signify secondary bacterial infection. Excoriationof nares or cervical lymphadenitis suggests that pathogen is S.aureus or group A Streptococcus.Infection with C. diphtheriae, indicatedby white or yellow membrane lining nose, is rare.Positive bacterial culture of dischargeis diagnostic. Allergic Rhinitis
Occurs inresponse to specific allergens. Common seasonal allergens are airborne pollensand molds, whereas common perennial allergens are dust mites andanimal allergens (dog and cat danders). Food allergens are rarecauses of isolated rhinitis.Usual clinical manifestations are nasalcongestion, rhinorrhea, and sneezing.Allergic conjunctivitis with itchy, tearyeyes is also commonly associated with allergic rhinitis.Long-standing rhinitis may cause mouthbreathing, snoring during sleep, malaise, fatigue, and recurrentotitis media with middle ear effusion. Nasal mucosa is pale andturbinates are enlarged. Nasal discharge is usually clear. Purplediscoloration below eyes indicates venous nasal congestion. It isalso common to observe upward rubbing of nose (nasal salute). Enlargementof tonsils and adenoids also may occur.Positive history of other atopic diseases(e.g., asthma and eczema) is common. History and physical exam may be diagnosticof allergic rhinitis.If >10% of cells seen onnasal smear are eosinophils, allergic rhinitis is likely. Definitivediagnosis rests on detection of immunoglobulin E (IgE) antibodyfor specific allergens.Positive skin test results (prick orintradermal) are evidence of allergen-specific IgE. When skin testresult is questionably positive, radioallergosorbent test (RAST),which measures specific IgE antibody in serum, may be performed.Elevated total serum IgE is usuallynegative in children with allergic rhinitis and is not recommendedas screening test. Nonallergic Rhinitis with Eosinophilia
Children have perennial symptoms and nasaleosinophilia, but they lack specific IgE antibodies in serum andskin tests are negative.
Nonallergic Rhinitis without Eosinophilia
Vasomotor rhinitis describes individualswith nonallergic noninfectious rhinitis without eosinophilia. Rhinitiscan occur with exposure to cold air, high humidity, inhaled irritants,and strong odors.
Drug-Induced
Severaldrugs may produce rhinitis, including angiotensin-converting enzymeinhibitors, beta-blockers, NSAIDs, oral contraceptives, reserpine,phentolamine, methyldopa, and guanethidine.Rhinitis medicamentosa is overuse ofnasally inhaled decongestant agents (e.g., phenylephrine or oxymetazoline),which should not be given for >5 days at a time.Repeated use of cocaine also may causerhinitis. Sinusitis
Inflammationof 1 or more paranasal sinuses, which include ethmoid, maxillary,frontal, and sphenoid sinuses.Anterior ethmoid, maxillary, and frontal sinusescommunicate with nasal cavity through middle meatus, whereas posteriorethmoid and sphenoid sinuses open into nasal cavity below superiorturbinates.Ethmoid and maxillary sinuses are presentat birth. Frontal sinus also exists but is small and does not enlargeuntil about 7 yrs of age.Sphenoid sinus is pea sized by age4 yrs. Sinus inflammation is often associatedwith viral URI. In many instances, it is self-limited and resolveswithout any specific treatment. Most episodes of acute sinusitisare thought to be bacterial complications of viral URIs.Risk factors for sinusitis includeallergic rhinitis, cystic fibrosis, immotile cilia syndrome, facialtrauma, and mechanical obstruction (choanal atresia, deviated septum,nasal polyps, foreign body, tumor).Usual pathogens causing acute sinusitisare same ones that cause acute otitis media: S. pneumoniae, nontypeableH. influenzae, and M. catarrhalis. S. aureus and anaerobic bacteriaare most common pathogens causing chronic sinusitis.Usual clinical presentation of acutesinusitis is persistent nasal discharge and cough for >10 daysor high fever and purulent nasal discharge for >3 days.Discharge can be clear, mucoid, or purulent, and cough must be presentin daytime but can be worse at night. Sinus tenderness and headachealso may occur.Although diagnosis is usually clinical,CT can be confirmatory by demonstrating sinus opacification or air-fluidlevel. This study is usually performed for suspected orbital abscessor intracranial complications. Sinus cultures may reveal specificpathogens. Foreign Body
Foreign body in nasal passage can cause unilateral,purulent, foul-smelling discharge. History and physical exam includingrhinoscopy confirm diagnosis.
Cerebrospinal Fluid (CSF) Rhinorrhea
After nasaltrauma, CSF rhinorrhea usually indicates skull fracture, usuallythrough cribriform plate.Less common cause is temporal bonefracture, where fluid enters nasopharynx via eustachian tube.Other causes may be congenital or acquired(inflammatory bone erosion, neoplasm).Measurement of >50 mg/dLglucose in nasal discharge indicates presence of CSF. Intrathecalinjection of radioisotope or dye with subsequent nuclear scintigraphyor CT, respectively, often demonstrates site of leak. Diagnostic Approach
Cause ofnasal discharge often can be determined by history and physicalexam. Most common causes are viral upper respiratory infection andallergic rhinitis.Nasal smear that shows many eosinophilssuggests allergic rhinitis, either seasonal or perennial, althoughthis same finding may occur with subgroup of nonallergic rhinitis.Skin testing remains principal methodof diagnosis with allergic disease. When skin test is definitelypositive, there is little need for other tests. When skin test isquestionably positive, RAST, which measures specific IgE antibodyin serum, may be performed.Nasal foreign body and sinusitis areother common causes of nasal discharge. Foul-smelling unilateraldischarge usually occurs with foreign body. Diagnosis of sinusitisis usually clinical.CT of sinuses should usually be reservedfor children with orbital or CNS complications or when sinus surgeryis contemplated.CSF rhinorrhea is rare occurrence butcan be associated with recurrent meningitis. Special imaging studiescan be used to locate site of leak. References
- Ball WS Jr, ed. Pediatric neuroradiology.Philadelphia: Lippincott-Raven, 1997.
- Behrman RE, et al., eds. Nelson textbook of pediatrics,16th ed. Philadelphia: WB Saunders, 2000.
- Cotton RT, Myer CM III, eds. Practical pediatric otolaryngology.Philadelphia: Lippincott-Raven, 1999.
- Dykewicz MS, Fineman S, eds. Diagnosis and managementof rhinitis: complete guidelines of the Joint Task Force on PracticeParameters in Allergy, Asthma, and Immunology. Ann Allergy Asthma Immunol1998;81(part II):478–518.
- Feigin RD, Cherry JD, eds. Textbook of pediatric infectiousdiseases, 4th ed. Philadelphia: WB Saunders, 1998.
- Long SS, et al., eds. Principles and practice of pediatricinfectious diseases. New York: Churchill Livingstone, 1997.
- Middleton E Jr, et al., eds. Allergy: principles andpractice, 5th ed. St. Louis: Mosby-Year Book, 1998.
Book Source Details
- Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
- Author(s): Paul S. Bellet
- Year of Publication: 2006
- Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2008 Williams & Wilkins.
More About Causes of Discharge
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