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Respiratory Tract Symptom Complexes
Mucopurulent Rhinorrhea
Mucopurulent rhinorrhea (i.e., purulent nasal discharge) denotes nasal discharge that is thick, opaque, and colored. It occurs at any age and usually is a manifestation of a self-limited and uncomplicated viral upper respiratory tract infection (URI). Mucopurulent rhinorrhea is most problematic in children <3 years, due to a protracted course and frequent recurrences, especially in those in out-of-home childcare ; parental concern and misperception about the cause; and the overprescription of antibiotics by healthcare providers. Occasionally, this symptom is a clue to the diagnosis of a treatable bacterial infection or underlying condition.
Acute, sporadic mucopurulent rhinorrhea has an infectious cause and almost always is the manifestation of a viral URI or the uncomplicated common cold due to rhinoviruses, coronaviruses including SARS-CoV-2, human metapneumovirus (MPV), influenza, enteroviruses, parainfluenza, respiratory syncytial virus (RSV), adenoviruses, or other circulating viruses. , Children <6 years of age have an average of 6–8 “colds” per year. When the problem is chronic, unusually recurrent or persistent, or unilateral, broader underlying anatomic, obstructive, immunologic, and allergic disorders are considered ( Table 21.1 ). Onset in an infant <3 months of age heightens suspicion of an anatomic anomaly, ciliary dyskinesia, or cystic fibrosis. Multiple diagnoses of bacterial complications such as sinusitis, otitis media, or pneumonia in infants prompts consideration of an immunologic deficiency, especially humoral immunodeficiency (e.g., hypogammaglobulinemia, agammaglobulinemia, human immunodeficiency virus [HIV] infection); neutrophil defect; cystic fibrosis; or ciliary dyskinesia. URIs are conspicuously severe in such instances, with recrudescence occurring almost immediately after discontinuation of antibiotic therapy. Unilateral nasal discharge and obstruction should prompt investigation for a foreign body, mass lesion, or unilateral posterior choanal atresia.
TABLE 21.1
Causes of Mucopurulent Rhinorrhea
| Acute | Chronic Or Recurrent | |
|---|---|---|
| Underlying Conditions | Obstructing Lesions | |
| Viral nasopharyngitis Bacterial sinusitis Streptococcal nasopharyngitis Anaerobic bacterial nasopharyngitis (nasal foreign body) Adenoiditis Syphilis Pertussis Cerebrospinal fluid rhinorrhea b |
Allergy a Medications a (antihypertensives, oral estrogens, α 1 -adrenergic agonists, aspirin and nonsteroidal antiinflammatory drugs) Rhinitis medicamentosa a Cocaine use a Pregnancy a Hypothyroidism a Immunoglobulin deficiency Human immunodeficiency virus (HIV) infection Cystic fibrosis Ciliary dyskinesia Other systemic diseases |
Polyps Congenital nasal anomalies (choanal atresia or stenosis, Tornwaldt cyst, deviated septum) Neuroembryonal mass (dermoid, encephalocele, glioma, teratoma) Tumor (hemangioma, angiofibroma, neurofibroma, lipoma, craniopharyngioma) Neoplasm (lymphoma, rhabdomyosarcoma, nasopharyngeal carcinoma) |
a Rhinorrhea characteristically is clear, but an opaque, white discharge is not unusual.
Table 21.2 shows differentiating features of important or common causes of acute mucopurulent rhinorrhea. Allergic rhinitis is included because of its place in the differential diagnosis for older children and adolescents.
TABLE 21.2
Differentiating Among Causes of Nasal Discharge
| Characteristic | Viral Nasopharyngitis | Acute Bacterial Sinusitis | Streptococcal Nasopharyngitis | Foreign Body–Related Bacterial Rhinitis | Allergic Rhinitis |
|---|---|---|---|---|---|
| History | |||||
| Peak age | Peak in first 2 yr after enrollment in childcare or school | 4–7 yr, Any | <3 yr | <3 yr | >2 yr |
| Onset | Acute; dryness, burning in nose or nasopharynx | Insidious with day and night cough, or with secondary fever or worsening upper respiratory tract infection symptoms; occasionally, acute, febrile, toxic | Insidious; occasionally acute, febrile, toxic | Insidious | Can be seasonal or perennial; precipitants often identified |
| Associated symptoms | Nasal congestion, nasal discharge, sneezing, cough | Malodorous breath; head or facial pain, edema | Malodorous breath ± hyponasal voice | Sneezing; nasal congestion, nasal itching; postnasal drip/cough, allergic conjunctivitis with itching and tearing; allergic facies | |
| Fever | Yes/no | No/yes | Low/high | No | No |
| Duration of discharge | 3–15 days | ≥10 days | >5 days | Chronic | Seasonal or perennial |
| Physical Examination | |||||
| Associated findings | Erythema and swelling of nasal mucosa; sometimes acute otitis media | Periorbital swelling, facial tenderness; mucopurulent rhinorrhea and postnasal discharge | Anterior cervical lymphadenitis; impetiginous lesions below nose | Mouth-breathing | Transverse nasal or lower eyelid creases; infraorbital edema and darkening, conjunctivitis, cobblestoning of conjunctivae or posterior pharynx |
| Character of discharge | Clear or colored, watery or thick | Thick, colored | Thick, colored | Unilateral, purulent, putrid bloodstained | Watery, clear |
| Rhinoscopy | Hyperemic mucosa; dry or glazed early, edematous later; crusted discharge | Normal mucosa; discharge from middle meatus | Normal, hyperemic, or excoriated mucosa | Identifiable object (button, pit, nut), boggy mass (vegetable), or rhinolith | Pale or blue, edematous turbinates |
| Diagnosis | |||||
| Diagnostic tests | None; nasal smear shows neutrophils and mononuclear cells ± inclusion bodies, pyknotic epithelial cells | No imaging unless suppurative complications suspected | Nasopharyngeal culture for Streptococcus pyogenes only | Rhinoscopy | Positive allergen skin tests or serum immunoglobulin E levels, rhinoscopy or nasal smear in rare cases |
| Etiology | |||||
| Causes | Multiple potential agents, depending on age and season | Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis | S. pyogenes | Normal nasopharyngeal facultative and anaerobic bacteria | Allergens |
| Treatment | |||||
| Therapies | Saline nasal drops, humidification; antibiotic only for secondary bacterial infection (acute otitis media or sinusitis) | Amoxicillin or amoxicillin-clavulanate (amoxicillin: 45 mg/kg/day or 80–90 mg/kg/day depending on local level of nonsusceptible S. pneumoniae ) (see text) | Penicillin V | Removal of obstruction; amoxicillin-clavulanate for tissue or sinus complication | Allergen avoidance; glucocorticoid nasal spray, oral antihistamines, antihistamine nasal sprays, leukotriene receptor antagonists, nasal saline irrigation, allergen immunotherapy |
Causes
Viral Nasopharyngitis
In uncomplicated viral nasopharyngitis or rhinitis, the nasal discharge initially is clear but can become white, yellow, or green due to mucous secretions, dryness, blood, exfoliation of damaged epithelial cells and cilia, and a leukocytic inflammatory response. High fever and persistence of discharge can occur, depending on the specific viral agent, and are more common in uncomplicated viral infection than is perceived generally.
In a study of hospitalized children, >50% with uncomplicated adenovirus, influenza, parainfluenza, or RSV infection had temperatures >39°C, and 12% had temperatures >40°C; the height of fever in these children was not different from that in children with serious bacterial infection. Fever persisted for ≥5 days in 37% of the children in the study; 20%–30% of those with adenovirus or influenza A infection had fever for ≥7 days. In another study, nasal discharge or congestion associated with uncomplicated URI persisted for 6.6 days in 1- to 2-year-old children who were in home care and for 8.9 days in children <1 year in out-of-home childcare. In a systematic review of studies on the common cold and nonspecific respiratory tract infections in children, symptoms resolved in 50% by day 10 and 7, respectively, and in 90% by days 15 and 16. ,
The bacteriology of nasopharyngeal flora in children with uncomplicated viral respiratory illnesses, mucopurulent rhinorrhea, acute otitis media, and sinusitis has been evaluated and compared with that in healthy children. , Quantitative and some qualitative differences in nasopharyngeal flora have been found in children with purulent nasopharyngitis during uncomplicated viral URIs, with studies noting isolation of Streptococcus pneumoniae , Haemophilus influenzae, and Moraxella catarrhalis , along with Peptostreptococcus spp., Fusobacterium spp., and Prevotella melaninogenica. , Differences may reflect new bacterial acquisition or exuberant proliferation in virus-induced inflammatory mucus or availability of a more robust specimen than in healthy subjects.
In a prospective study, there was no difference in the duration of illness or complications in children with clear or purulent nasal discharge. Cochrane meta-analyses concluded no benefit of antibiotic therapy in children with nonspecific cold, cough, or acute purulent rhinitis. , , Both a systematic and Cochrane review indicate lack of effectiveness of over-the-counter cough and cold medication in young children , ; moreover, a multiyear surveillance study found medication errors due to incorrect dosing were more common in children <6 years of age, and 74% of medication errors resulted in the need for healthcare evaluation. A Cochrane analysis found no strong evidence for or against the use of honey to relieve cough symptoms. Another Cochrane analysis concluded possible benefit of saline nasal irrigation to relieve symptoms of URI but noted inadequacies of studies performed. Several studies have evaluated strategies to prevent URIs, including probiotics, immunity-targeted approaches, such as immunomodulators, and herbal remedies; however, additional investigations are needed to establish their role in URI prevention.
Acute bacterial adenoiditis has been postulated as a cause of purulent nasal discharge when tympanic membranes are normal, Streptococcus pyogenes is not found in culture specimens, and radiographs show an enlarged adenoid shadow but no sinus abnormality. No study has been performed to validate this entity.
Mucopurulent rhinorrhea plus additional clinical features (e.g., prolonged or new fever, cough, or ill appearance, stridor, or auscultatory abnormalities) can indicate another diagnosis.
Bacterial Sinusitis
Bacterial sinusitis reportedly complicates 5%–10% of viral URIs in children. In a prospective study of 237 children 4–8 years of age, 7.1% of symptomatic URIs were complicated by sinusitis using the definitions that follow; RSV was detected more frequently in URIs leading to sinusitis. Mucopurulent rhinorrhea or daytime cough (which frequently is worse at night), or both, of 10 or more days′ duration without improvement, worsening symptoms (i.e., recrudescence after improvement or new onset fever), or severe onset of symptoms with fever ≥39°C plus purulent nasal discharge for at least 3 consecutive days suggests paranasal bacterial sinusitis and response to antibiotic therapy. A prospective study identified acquisition of a virus at the time of the sinusitis diagnosis in 29% of cases, suggesting that sequential viral infections may be responsible for new symptoms in close to one-third of children.
Guidelines on the diagnosis and management of acute bacterial rhinosinusitis have been published. , , Sinus radiographs show significant abnormalities in almost 90% of children 2–6 years old and in many older children with uncomplicated upper respiratory tract illness, supporting a clinical approach to diagnosis without imaging. Using acute otitis media isolates as surrogates for sinusitis pathogens, studies report a decreased proportion of S. pneumoniae and of penicillin-resistant isolates, thought due to universal childhood pneumococcal conjugate vaccination, whereas an increase in H. influenzae has been noted in several studies, with some reporting increased β-lactamase–producing H. influenzae. , M. catarrhalis continues to be isolated.
Streptococcal Nasopharyngitis
In children <3 years of age, S. pyogenes can be associated with high fever, toxicity, and rhinorrhea or indolent infection with irregular fever and purulent nasal discharge sometimes with associated excoriation of nares, or tender anterior cervical lymphadenitis. , , In a streptococcal outbreak studied in a childcare facility for school-aged and young children, 26% of children <3 years of age were affected, but pharyngitis was predominant, with no case of nasal streptococcosis.
Other Infectious Causes
Bacterial nasopharyngitis associated with a nasal foreign body is typified by the young age of the patient and putrid, commonly bloodstained, unilateral nasal discharge. Fever is unusual unless infection has spread to contiguous sinuses or distant sites. Prevotella, Fusobacterium, and Peptostreptococcus spp., as well as facultative flora, are responsible. Nasal discharge can be the first manifestation of congenital syphilis and a later finding in nasal diphtheria, in which discharge is putrid and sanguineous with pieces of pseudomembrane.
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