What is the next step in managing a 12-year-old girl with bilateral mucosal erosion and serosanguinous discharge for 3 weeks, who was previously prescribed a steroid spray for nasal congestion?

Management of Bilateral Mucosal Erosion with Serosanguinous Discharge Following Intranasal Steroid Use

Immediately discontinue the intranasal steroid spray and examine the nasal septum for mucosal erosions, as these lesions are a known complication of intranasal corticosteroid use and may precede septal perforation if the spray is not stopped. 1

Initial Management Approach

Discontinue the Offending Agent

• Stop the steroid spray immediately – the bilateral mucosal erosions with serosanguinous discharge for 3 weeks represent local irritation and potential tissue damage from the intranasal corticosteroid. 1
• The Journal of Allergy and Clinical Immunology explicitly states that the nasal septum should be periodically examined to ensure there are no mucosal erosions present, as these may precede the development of nasal septal perforations. 1, 2
• Mucosal erosions suggest an increased risk for subsequent septal perforation development if steroid use continues. 1

Perform Nasal Endoscopy

• Diagnostic nasal endoscopy should be performed to directly visualize the extent and location of mucosal erosions and rule out other pathology. 3, 4
• Nasal endoscopy is superior to CT scanning for detecting mucosal abnormalities, edema, and discharge in the nasal cavity, with 100% detection of mucopurulent discharge in middle meatus compared to CT. 3
• Endoscopy showing purulence, polyps, or watery congested mucosa correlates well with underlying pathology and guides further management. 4

Initiate Conservative Treatment

• Start nasal saline irrigation (nasal douche) to promote healing – saline removes debris, reduces tissue edema, and promotes drainage without adverse effects. 5, 6, 2
• Isotonic saline is more effective than hypertonic or hypotonic solutions for chronic nasal symptoms. 6
• Keeping the nasal mucosa moist with saline throughout the day reduces crusting and facilitates healing. 1

Assess for Secondary Infection

• If purulent discharge is present on endoscopy or there are signs of bacterial superinfection (fever, worsening pain, increased purulence), consider adding antibiotics. 1, 2
• However, antibiotics should only be used when there is clear evidence of bacterial infection, not for simple mucosal irritation. 6, 2
• Culture may be obtained if infection is suspected, though surface cultures are less reliable than direct sinus aspiration. 1

What NOT to Do

Do Not Perform Biopsy Initially

• Biopsy is not indicated as the first step in this clinical scenario – the temporal relationship between steroid spray initiation and development of bilateral mucosal erosions strongly suggests medication-related injury. 1
• Biopsy would be considered only if lesions fail to heal after discontinuation of steroids and conservative management, or if there are atypical features suggesting granulomatous disease or malignancy. 7

Do Not Order Autoimmune Screening Initially

• Autoimmune workup is premature at this stage given the clear iatrogenic etiology (recent steroid spray use). 1
• Autoimmune conditions would be considered if bilateral mucosal erosions persist despite stopping the offending agent and appropriate conservative management. 8

Do Not Continue or Restart Intranasal Steroids

• Continuing intranasal corticosteroids in the presence of mucosal erosions risks progression to septal perforation. 1
• Although intranasal corticosteroids are highly effective for rhinitis, nasal septal perforation has been rarely reported with long-term use, particularly when sprays are directed at the septum. 1, 5

Proper Technique Education for Future Use

If intranasal steroids are reintroduced after complete healing:

• Patients must be carefully instructed to direct sprays away from the nasal septum to prevent repetitive direct application. 1, 2
• The nasal septum should be periodically examined to ensure there are no mucosal erosions. 1, 5, 2
• Local side effects such as nasal irritation and bleeding can be avoided with proper administration technique. 5

Follow-Up and Monitoring

• Re-examine in 2-3 weeks to ensure healing of mucosal erosions after discontinuation of steroid spray and initiation of saline irrigation. 1
• If erosions persist beyond 3-4 weeks despite conservative management, consider referral to otolaryngology for further evaluation and possible biopsy to rule out other pathology. 5, 7
• Document the adverse reaction to guide future treatment decisions and prevent recurrence. 1

Answer to the Question

The correct answer is (c) Rinse nasal douche and antibiotics – though more precisely, the initial management should be discontinuation of the steroid spray, nasal saline irrigation (douche), and antibiotics only if there is evidence of secondary bacterial infection on examination. 1, 5, 6, 2