Disclaimer: Please note that the following is a general guideline/ discussion only. SNOTTY CHILD
Definition
Chronic Nasal discharge is when the is discharge over 3 months or longer. When child presents with chronic or recurrent nasal discharge management may differ according to the age group.
Aetiology
Purulent unilateral Discharge: Foreign Body-unless proven otherwise
most FBs is wedged at the inferior turbinate-the nasal valve
Infants (up to 3 years of age)
Clear Discharge: Viral illness not an allergy
Purulent Discharge: bacterial infection of adenoids
Discharge with obstructive breathing: Mostly due to adenoid hypertrophy, turbinate congestion is possible, however, if presents very young congenital pathology such as meningocele, choanal atresia must be excluded
Over 3 yrs of age
Clear Discharge: allergy (in older kids it is less likely due to viral illness)
Purulent: Adenoids, sinusitis as a result
With obstructive breathing: adenoids, tonsils may contribute, turbinate congestion, less likely for congenital to present for the first time at this age
History
Unilateral or Bilateral?
Age and clear or purulent?
If older and clear discharge other symptoms of allergy?
If obstructive age of presentation, severity: may requite nase-endoscopy
If not treatment responsive-hx suggestive of ciliary immotility i.e. CF, Immune dysfunction-these are rare only if unresponsive to treatment
Social circumstances
Other related issues i.e. OME
Examination
General-mouth breathing, allergy crease on the nose, any notable syndromic features
Anterior Rhinoscopy- will reveal a foreign body, turbinate congestion
Oral exam- ensure normal palate, size of tonsil
Ear-high incidence of OME
R side Rhinoscopy:
Good technique will show IT-inferior Turbinate, S-Septum, MT-Middle Turbinate
Investigations
Generally, clinical diagnosis superceds investigations.
Lateral neck XR- not necessary, if turbinates not congested it will be postnasal space. If any unusual features: i.e. significant obstruction, very young presentation- a nase-endoscope may be performed in clinic. if not examination under anaesthesia
Sleep study- not needed to diagnose obstructive berthing. A good clinical history is more sensitive and sleep study could easily underreport OSA. a child only needs one apnoea episode to be diagnosed of OSA, as apposed to adults. (please read my blogs on OSA in adults and children)
Allergy testing-preserve for those who fail treatment, as immunotherapy is prolonged and less tolerated by children. Nasal sprays and simple surgery may find a cure more effectively and quickly.
Other investigations; Immune study , CF investigations reserved to those children with ongoing mucopurulent discharge despite treatment
Treatment
If unilateral and FB remove
Under 3 yrs
Clear discharge no obstructive features- Fess spray
Purulent Discharge- amoxyl or augmentin 4 weeks
Ongoing nasal discharge/ obstructive breathing-EUA-adenoids,collation of turbinates dependant on findings
Over 3 yrs
Clear discharge no obstructive features-FESS,topical steroid spray
Purulent-as above
Ongoing nasal discharge/ obstructive breathing- turbinate coblation, adenoidectomy, tonsillectomy (safer when over 3 yrs of age) dependant on findings
If ongoing clear rhinitis despite all of the above- discuss allergy testing and immune therapy
If ongoing purulent discharge despite all of the above- investigate for other underlying possibilities such as immune dysfunction, ciliary dysfunction-CF