Grey Nasal Discharge in Pediatric Patients
Grey nasal discharge in a child is a red flag that requires immediate evaluation for foreign body, fungal infection, or severe bacterial sinusitis—this is NOT a typical presentation of viral URI or uncomplicated bacterial sinusitis and warrants urgent assessment.
Critical Initial Assessment
Grey nasal discharge is specifically mentioned as an atypical finding that distinguishes pathological conditions from routine infections. While purulent secretions in bacterial sinusitis are typically described as "yellow-green, green, or gray," 1 the grey coloration alone—particularly if prominent—should raise immediate concern for:
- Nasal foreign body (most common cause of grey/foul-smelling unilateral discharge in children)
- Fungal sinusitis (especially in immunocompromised patients)
- Severe necrotizing bacterial infection
- Diphtheria (rare but must be considered with grey membrane) 2
Diagnostic Approach
Immediate Physical Examination Priorities
- Perform direct nasal visualization to rule out foreign body—this is the single most important first step for grey discharge 1
- Assess for unilateral vs bilateral discharge—unilateral grey discharge strongly suggests foreign body 1
- Evaluate for systemic toxicity—fever ≥39°C, ill appearance, facial swelling, or orbital involvement indicate severe infection requiring immediate intervention 1
- Check immunization status for diphtheria if grey membrane is visualized 2
Key Distinguishing Features from Typical Sinusitis
Normal bacterial sinusitis presents with yellow-green purulent discharge that evolves over 10+ days. 1, 3 Grey discharge deviates from this expected pattern and demands investigation beyond routine sinusitis management. 1
Management Algorithm
If Foreign Body Suspected (Unilateral Grey Discharge)
- Immediate ENT referral for removal under appropriate conditions
- Do NOT start antibiotics before foreign body removal unless systemic infection present
- After removal, brief antibiotic course may be warranted if secondary infection established
If No Foreign Body and Bilateral Grey Discharge
Meets severe acute bacterial sinusitis criteria (fever ≥39°C for ≥3 days with purulent/grey discharge): 1, 3
Initiate immediate antibiotic therapy—observation is NOT appropriate for severe presentation 1, 3
First-line: Amoxicillin-clavulanate 90 mg/kg/day (of amoxicillin component) divided every 12 hours for 10 days 3, 4, 5
For penicillin allergy: Cefdinir, cefpodoxime, or cefuroxime (non-type I hypersensitivity) 7, 5
For true penicillin allergy: Clarithromycin or clindamycin 5
Red Flags Requiring Hospitalization
- Difficulty breathing or respiratory distress 8
- Orbital involvement: periorbital edema, proptosis, diplopia, or vision changes 1
- Severe systemic toxicity: appears ill, poor feeding, lethargy 1
- Immunocompromised status with grey discharge (fungal sinusitis concern) 6
- Age <12 weeks with concerning findings 4
What NOT to Do
- Do NOT prescribe intranasal steroids, systemic steroids, antihistamines, or decongestants—these have no benefit in acute bacterial sinusitis 3
- Do NOT observe without antibiotics if severe criteria are met 1, 3
- Do NOT use standard-dose amoxicillin alone for grey discharge—the atypical presentation warrants broader coverage 5
Follow-Up and Reassessment
- Reassess at 48-72 hours for clinical improvement 8, 5
- If no improvement or worsening: Consider imaging (CT), ENT consultation, or alternative diagnosis including fungal infection 1
- If improving: Complete full 10-day antibiotic course 3
Critical Pitfall
The most dangerous error is assuming grey nasal discharge represents typical viral URI or routine bacterial sinusitis. The grey coloration is specifically highlighted in guidelines as atypical 1 and should trigger a more thorough evaluation than yellow-green discharge alone. Missing a foreign body or fungal infection can lead to serious complications including orbital cellulitis, intracranial extension, or chronic infection. 1, 2