A previously healthy 4-year-old boy with Down syndrome is brought to the physician by his mother because of a foul-smelling discharge from the right nostril for the past 2 weeks. In this period, his mother has noticed the patient has had loud breathing while inhaling which was not present before. His temperature is 37°C (98.6°F), pulse is 90 beats/min, respirations are 22/min, and blood pressure is 90/60 mm Hg. Physical examination shows malodorous, grey discharge in the right nasal cavity. Endoscopic examination of the nose confirms the diagnosis.
Which of the following is the most likely diagnosis?
- A) Allergic rhinitis
- B) Foreign body
- C) Juvenile nasopharyngeal angiofibroma
- D) Nasal hematoma
- E) Nasopharyngeal carcinoma
B) Foreign body
A foreign body inserted into the nose can become lodged high in the nasal cavities or the paranasal sinuses. This is a common cause of acute and chronic nasal symptoms in young children, especially when the symptoms are unilateral. Foreign nasal bodies often present in a patient as rhinorrhea and can progress to infection with purulent, malodorous discharge. These symptoms are isolated to the side of the foreign body unlike sinusitis and upper respiratory infections, which can present with similar symptoms bilaterally. Diagnosis is made by direct visualization, and treatment consists of foreign body removal.
Answer choice A: Allergic rhinitis, is incorrect. Allergic rhinitis typically presents with sneezing and bilateral rhinorrhea and nasal obstruction and is often accompanied by itching of the eyes and nose. Postnasal drip may result in cough.
Answer choice C: Juvenile nasopharyngeal angiofibroma, is incorrect. Juvenile nasopharyngeal angiofibroma is a highly vascular but benign tumor that occurs primarily in adolescent males that can cause epistaxis as well as problems as a result of local invasion of adjacent structures.
Answer choice D: Nasal hematoma, is incorrect. A nasal, or septal, hematoma may result from trauma to the nasal septum. Blood collects in the space between the nasal cartilage and overlying mucoperichondrium and can obstruct blood flow to the nasal cartilage, potentially resulting in avascular necrosis of the nasal cartilage.
Answer choice E: Nasopharyngeal carcinoma, is incorrect. Though nasopharyngeal carcinoma is the predominant tumor type arising in the nasopharynx, it is rare in the United States and has a peak incidence between ages 50-59 years.
Key Learning Point
Foreign body in the nasal cavity is a frequent cause of unexplained unilateral nasal symptoms in young children.