What is the next step in managing a 2½-year-old girl with persistent purulent unilateral nasal discharge despite two courses of oral co-trimoxazole (trimethoprim/sulfamethoxazole)?

Management of Persistent Unilateral Purulent Nasal Discharge in a 2½-Year-Old Child

The most appropriate next step in managing this 2½-year-old girl with persistent purulent unilateral nasal discharge for 6 weeks despite two courses of co-trimoxazole is nasal examination under general anesthesia (option B).

Rationale for Nasal Examination Under General Anesthesia

• Persistent unilateral purulent nasal discharge in a child, especially when it fails to respond to multiple courses of antibiotics, strongly suggests the presence of a foreign body or other structural abnormality that requires direct visualization 1
• The duration of symptoms (6 weeks) and failure of two antibiotic courses indicates this is not a simple case of acute bacterial sinusitis, which typically responds to appropriate antibiotic therapy 1
• Unilateral purulent discharge is a classic presentation of a nasal foreign body, which is common in this age group and requires direct visualization for diagnosis and removal 2, 3

Why Other Options Are Less Appropriate

A. Oral Flucloxacillin

• Not indicated as first-line therapy for persistent nasal discharge when structural causes have not been ruled out 1
• Guidelines recommend against indiscriminate use of antibiotics without evidence of bacterial infection with purulent discharge on examination 1
• The failure of two previous antibiotic courses (co-trimoxazole) suggests that another antibiotic is unlikely to resolve the issue without addressing the underlying cause 1

C. Nasal Swab for Microscopy and Culture

• While cultures may help target therapy for persistent infections, they are not useful without first identifying and addressing any underlying structural cause 1
• Nasal swabs have limited utility in diagnosing the cause of persistent unilateral discharge in children of this age group 1, 2
• Guidelines do not recommend cultures as the next step when a foreign body is suspected 1

D. Tobramycin Nasal Drops

• Topical antibiotics are not recommended as first-line therapy without identifying the underlying cause of persistent unilateral discharge 1
• In the absence of confirmed bacterial sinusitis resistant to standard therapy, topical antibiotics are not indicated 1

E. X-ray of Paranasal Sinuses

• Imaging studies are specifically not recommended for the diagnosis of sinusitis in children 1
• The American Academy of Pediatrics guidelines strongly recommend against obtaining imaging studies to distinguish bacterial sinusitis from viral URI 1
• X-rays have poor sensitivity and specificity for detecting nasal foreign bodies, which are the most common cause of unilateral purulent discharge in this age group 1, 3

Clinical Approach to Persistent Unilateral Nasal Discharge in Children

• Unilateral purulent nasal discharge that persists despite appropriate antibiotic therapy is highly suspicious for a nasal foreign body, especially in children under 5 years of age 2, 3
• Direct visualization is necessary for both diagnosis and treatment, but young children cannot cooperate with office examination of the entire nasal cavity 3
• General anesthesia provides the controlled environment needed for thorough examination, removal of any foreign body, and addressing any other pathology found 3

Important Considerations

• Rhinolithiasis (calcified masses forming around an intranasal foreign body) should be considered in cases of long-term unilateral purulent rhinorrhea 3
• After removal of any foreign body or addressing other structural issues, a short course of appropriate antibiotics may be needed to treat secondary infection 3, 4
• Failure to identify and remove a nasal foreign body can lead to complications including chronic sinusitis, local tissue erosion, and rarely, systemic infection 2, 3