Aldinger, Jeffrey, BS^*; Hicar, Mark D., MD, PhD^†; Gomez-Duarte, Oscar G., MD, PhD^†; Callanan, Vincent, MD^‡; Pierce, Drew, MD^§; Islam, Shamim, MD, DTM&H^†

A 3-year-old boy presented to otolaryngology clinic for persistent nasal congestion and rhinorrhea. He had first been evaluated 6 months earlier for a 1-year history of near-daily clear rhinorrhea and was given intranasal fluticasone therapy for suspected allergic rhinitis. The patient returned 3 months later having experienced little improvement. At that time, he was found to have hyponasal speech, prominent vessels in his nasal septal mucosa and substantial nasal obstruction, for which an adenoidectomy was recommended. Along with this procedure, electrocautery of the nasal mucosa given past episodes of epistaxis and placement of bilateral tympanostomy tubes for ear effusions were also performed. Now, 2 months postadenoidectomy, the family reported green discharge from both nares and a new concern of a foul odor coming from his mouth, beginning in the last 2 weeks.

The patient’s family is originally from Somalia, though he was born in New Delhi, India, where his father was a public health worker, assisting refugees to access medical care. The family moved to Buffalo, New York, when he was 1 year of age. He has no other notable travel. He had no significant illnesses in his early life while living in India, but has had a few bouts of otitis media effectively treated with amoxicillin since immigrating to the United States. He also had 1 episode of otorrhea after placement of his tympanostomy tubes, for which he received 7 days of ciprofloxacin/dexamethasone otic suspension, with resolution of symptoms. Beyond the above, a complete review of systems was positive only for frequent sneezing but no regular fevers, chills, weight loss, headaches, snoring or dysphagia. His older sister and brother both developed ongoing rhinorrhea shortly after arrival in Buffalo, but theirs resolved after adenoidectomy.

Physical examination revealed a well-appearing, afebrile child, with halitosis and yellow-green discharge from both nares. Visual inspection demonstrated what appeared to be a foreign body or scabs between the left middle and inferior turbinate of his right naris. No other significant examination findings were reported. The patient was given a 4-day course of tobramycin/dexamethasone nasal drops and subsequently taken to the operating room for suspected foreign body removal. A 3.5 × 2.2 × 0.8 cm superficial green mass was removed, which on pathologic evaluation was reported as partially desiccated nasal secretions admixed with a minute amount of blood. Six months later, the patient continued to have halitosis and crusting of both nares and underwent computed tomography without intravenous contrast. The computed tomography scan (Fig. 1) demonstrated partial resorption of the middle turbinates and adjacent ethmoid air cells bilaterally, with residual synchiae in the nares bilaterally. These findings were read as most consistent with postoperative changes from prior a nasal surgery; however, the parents firmly denied he had ever had any prior rhinosinus procedures (outside of the aforementioned foreign body removal). An additional laboratory test revealed the diagnosis.

FIGURE 1