A 7-year-old boy is brought to the emergency department by his parents for worsening symptoms of previously diagnosed acute sinusitis. Initially, the pediatrician prescribed decongestants and sent the patient home. Since then, the patient has developed a nasal discharge with worsening pain. The patient has a medical history of asthma which is well-controlled with albuterol. His temperature is 99.5°F (37.5°C), blood pressure is 90/48 mmHg, pulse is 124/min, respirations are 17/min, and oxygen saturation is 98% on room air. The cardiopulmonary exam is within normal limits. Inspection of the patient's nose reveals a unilateral purulent discharge mixed with blood. The rest of the patient's exam is within normal limits. Which of the following is the most likely diagnosis?
Foreign body obstruction
Nasopharyngeal carcinoma
Bleeding and infected vessel of Kiesselbach plexus
Septal perforation
Foreign body obstruction
This patient presents with unilateral bloody/purulent discharge from the nose suggesting a diagnosis of a nasal foreign body.

The most common cause of unilateral nasal symptoms in a pediatric patient is a nasal foreign body. Nasal foreign bodies tend to be unilateral (though bilateral symptoms are plausible) and present with a purulent and bloody discharge. The treatment of choice is to remove the object which may be done in the emergency department or operating room depending on how deep the object is. Visualization of the object should be attempted when possible in order to allow for safe retrieval.

Krulewitz and Fix review the evidence regarding the diagnosis and treatment of patients with epistaxis. They discuss how foreign body insertion is a major risk factor for the development of epistaxis. They recommend assessment of airway and breathing in the setting of severe epistaxis.

Incorrect Answers:
Answer A: A bleeding and infected vessel of the Kiesselbach plexus could suggest a complicated case of epistaxis. The persistent, unilateral symptoms in this patient point toward a different diagnosis. A high index of suspicion for foreign bodies should be suspected in children.

Answer C: Nasopharyngeal carcinoma tends to occur in young male patients and can be associated with infectious mononucleosis. Epistaxis can be a symptom and the mass can be visualized. This disease tends to present in older patients and is far less common than foreign bodies. Treatment is with surgical resection.

Answer D: Septal perforation can occur secondary to repeat cocaine use but would not present with unilateral nasal discharge in a pediatric patient. It would be highly unlikely in a pediatric patient with no history of drug use. Treatment is with cessation of the offending agent.

Answer E: Sinusitis with bacterial superinfection would typically present with systemic symptoms as well as bilateral symptoms. Though this diagnosis is possible, it is less likely than a foreign body. Treatment is with systemic antibiotic therapy.

Bullet Summary:
A nasal foreign body presents with unilateral bloody/purulent nasal discharge.