What are the treatment options for a lump in the right nostril after exposure to strep throat?

Nasal Lump After Strep Throat Exposure

A lump in the nostril following strep throat exposure most likely represents either a nasal vestibulitis/furuncle (bacterial skin infection) or reactive lymphoid tissue, neither of which is directly caused by Group A Streptococcus pharyngitis itself, but the patient requires evaluation to rule out complications and may need treatment based on clinical findings.

Initial Assessment and Diagnostic Approach

The key is to determine whether this represents a localized bacterial skin infection, reactive inflammation, or a complication of streptococcal infection:

• Examine for signs of bacterial skin infection including erythema, warmth, tenderness, fluctuance, or purulent drainage from the nasal lump 1
• Assess for systemic signs such as fever >100.4°F (38°C), malaise, or worsening symptoms that might indicate spreading infection 1, 2
• Look for red-flag symptoms including facial swelling beyond the nostril, severe unilateral facial pain/pressure, visual changes, severe headache, or neck stiffness that could indicate serious complications like orbital cellulitis or intracranial extension 1, 3
• Confirm whether strep throat is present or was present using rapid antigen detection test (RADT) or throat culture if the patient has concurrent throat symptoms 1, 3

Most Likely Diagnoses and Management

If the Lump Appears to be a Furuncle or Nasal Vestibulitis:

This represents a localized staphylococcal or streptococcal skin infection requiring different treatment than pharyngitis:

• For minor localized infection without systemic symptoms: Apply warm compresses and consider topical mupirocin 2% ointment applied to the affected area three times daily for 5-7 days 1
• For more significant infection with surrounding cellulitis or systemic symptoms: Oral antibiotics covering MRSA are indicated, with first-line options including trimethoprim-sulfamethoxazole DS twice daily for 7-10 days, doxycycline 100mg twice daily for 7-10 days, or clindamycin 300-450mg three times daily for 7-10 days 1
• If fluctuant abscess is present: Incision and drainage is required in addition to antibiotics 1
• Culture the drainage if purulent material is present to guide antibiotic therapy, especially if initial treatment fails 1

If Concurrent Strep Throat is Confirmed:

Treat the strep pharyngitis according to standard protocols, which will not directly address a nasal skin infection:

• First-line treatment is amoxicillin 500mg three times daily or 875mg twice daily for adults (50mg/kg/day for children, maximum 1000mg/day) for 10 days 3, 4
• For penicillin-allergic patients with non-anaphylactic reactions: Use cephalexin 500mg twice daily for 10 days 4
• For penicillin-allergic patients with anaphylactic reactions: Use clindamycin 300mg three times daily for 10 days (avoid azithromycin due to 5-8% resistance rates) 4, 5
• Complete the full 10-day course to prevent complications including acute rheumatic fever and post-streptococcal glomerulonephritis 1, 4

If the Lump Appears to be Reactive Lymphoid Tissue or Inflammatory:

This may represent reactive changes from upper respiratory infection:

• Provide symptomatic management with nasal saline irrigation, adequate hydration, and observation 3
• Reassess in 3-5 days to ensure resolution and rule out developing bacterial infection 3
• No antibiotics are indicated unless bacterial infection develops 1

Critical Pitfalls to Avoid

• Do not assume the nasal lump is directly caused by strep throat - Group A Streptococcus causes pharyngitis, not nasal vestibulitis; the nasal infection is more likely staphylococcal if bacterial 1, 2
• Do not treat a nasal skin infection with penicillin or amoxicillin alone - these do not adequately cover Staphylococcus aureus (including MRSA), which is the most common cause of nasal vestibulitis and furuncles 1
• Do not squeeze or manipulate a nasal furuncle - this can lead to cavernous sinus thrombosis through retrograde venous drainage 1
• Do not ignore signs of spreading infection including periorbital edema, vision changes, or severe headache, which require urgent imaging and possible hospitalization 1, 3

When to Refer or Escalate Care

• Immediate referral to emergency department if red-flag symptoms are present: visual changes, severe headache, altered mental status, or signs of sepsis 1
• ENT referral if the lump persists beyond 2 weeks despite appropriate treatment, is unilateral and enlarging, or if there is concern for neoplasm 1
• Reassess at 72 hours if antibiotics are prescribed to ensure clinical improvement; switch to broader coverage if no response 1, 3