What is the initial management for a child presenting with mucopurulent discharge and blood in one nostril?

Management of Mucopurulent Discharge with Blood in One Nostril in a Child

The initial management for a child presenting with mucopurulent discharge and blood in one nostril should include anterior rhinoscopy to evaluate for a nasal foreign body, which is a common cause of unilateral nasal symptoms in children. 1, 2

Initial Evaluation

Physical Examination

• Perform anterior rhinoscopy to visualize the nasal cavity
• Look specifically for:
  • Foreign bodies (present in approximately 7% of children with epistaxis) 1
  • Site of bleeding
  • Mucosal inflammation or irritation
  • Nasal masses or polyps
  • Septal deviation or perforation

Key Considerations

• Unilateral symptoms (discharge with blood) strongly suggest:
  1. Nasal foreign body (most common in children)
  2. Local trauma (including digital trauma/nose picking)
  3. Possible nasal mass (less common)

Management Algorithm

Step 1: Control Active Bleeding (if present)

• Apply firm sustained compression to the lower third of the nose for 10-15 minutes 2
• Have the child lean forward slightly to prevent blood from flowing down the throat 2
• Consider using a vasoconstrictor spray such as oxymetazoline to help constrict blood vessels 2

Step 2: Remove Blood Clots and Visualize

• Gently remove any blood clots by suction or having the child blow their nose 1
• This helps identify the bleeding site and any underlying pathology

Step 3: Foreign Body Evaluation and Removal

• If a foreign body is visualized:
  • Remove it promptly to prevent complications
  • Disk batteries require immediate removal (can cause tissue necrosis within 3 hours) 1
  • Delayed diagnosis of nasal foreign bodies can lead to nasal infection, sinusitis, and septal perforations 1

Step 4: Further Management Based on Findings

• If no foreign body is found but unilateral symptoms persist:
  • Consider referral for nasal endoscopy to evaluate for:
    • Posterior foreign bodies not visible on anterior rhinoscopy
    • Nasal masses (including benign lesions like pyogenic granuloma)
    • Juvenile nasopharyngeal angiofibroma (in adolescent males) 1

When to Consider Acute Bacterial Sinusitis

Consider acute bacterial sinusitis if the child presents with:

1. Persistent illness (nasal discharge of any quality or daytime cough lasting >10 days without improvement)
2. Worsening course (worsening or new onset of nasal discharge after initial improvement)
3. Severe onset (concurrent fever ≥39°C/102.2°F and purulent nasal discharge for at least 3 consecutive days) 1

If acute bacterial sinusitis is diagnosed:

• For severe onset or worsening course: Prescribe antibiotic therapy
• For persistent illness: Either prescribe antibiotics or offer additional observation for 3 days
• First-line treatment: Amoxicillin with or without clavulanate 1

When to Refer for Specialist Evaluation

Refer to otolaryngology if:

• Foreign body cannot be visualized or removed
• Recurrent unilateral nasal bleeding despite treatment
• Persistent unilateral mucopurulent discharge despite treatment
• Suspicion of nasal mass requiring endoscopic evaluation 1, 2

Important Pitfalls to Avoid

1. Delayed diagnosis of foreign bodies: Particularly disk batteries which can cause rapid tissue necrosis 1
2. Missing underlying pathology: Unilateral symptoms should always raise suspicion for anatomic abnormalities or masses 1
3. Unnecessary imaging: Routine imaging is not recommended for uncomplicated cases 1
4. Overuse of antibiotics: Not all nasal discharge requires antibiotics; consider the clinical presentation carefully 1, 3

Remember that unilateral nasal symptoms in children are concerning and warrant thorough evaluation, with nasal foreign body being the most common cause that requires prompt identification and removal to prevent complications.