Nasal septal perforation associated with topical corticosteroid therapy

Nasal septal perforation associated with topical corticosteroid therapy

840 Clinical and laboratory observations The Journal of Pediatrics November 1984 exacerbate schizophrenia, precipitating outbreaks of agitation, de...

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840

Clinical and laboratory observations

The Journal of Pediatrics November 1984

exacerbate schizophrenia, precipitating outbreaks of agitation, delusion, and hallucination in patients previously in

We thank Dr. Alice J. Ferris, Associate Medical Director, Sandoz Pharmaceuticals, Inc.; and Dr. Michael Katz.

remission. 7 T h e use of bromocriptine in high dose for parkinsonism has decreased in recent years, but concurrently the drug has gained widespread acceptance as a safe and effective prolactin antagonist in women postpartum. It is therefore available in the household at a time when m a n y accidental ingestions can occur. T h e often tired m o t h e r of a newborn infant is less likely to be attentive to both the newborn infant and the toddler(s). F u r t h e r m o r e , because of restricted mobility, the m o t h e r m a y net secure the pills in a safe location. Breast-feeding is one alternative to bromocriptine prescription a n d would postpone the need for the drug until a date when the m o t h e r is b e t t e r prepared to supervise her

REFERENCES

children. O t h e r n o n p h a r m a c e u t i c methods to alleviate discomfort from lactation could be used by the m o t h e r who elects not to breast-feed? Physicians who do prescribe bromocriptine should inform the patient of the potential for accidental ingestion by the toddler a n d advise how to prevent it. 9

t. Goodman LS, Gilman A, Gilman AG, editors: The pharmacological basis of therapeutics, ed 6. New York, 1980, Macmillan, pp 483-484. 2. Parkes D: Bromocriptine. N Engl J Med 301:873, 1979. 3. Rolland R: Use of bromocriptine in the inhibition of puerperal lactation. Drugs 17:326, 1979. 4. Warren DE, Nakfoor E: Acute overdose of bromocriptine. Drug Intell Clin Pharm 17:374, 1983. 5. Descotes J, Frantz P, Bourrat C: Intoxication aique par ingestion volontare de bromocriptine: Apropos de 2 observations personnelles. Bull Med Leg Toxicol 22:487, 1979. 6. Maneschi F, Cionini R, Rolla M, Navalesi R: Shock syndrome after bromocriptine. Lancet 2:462, 1977. 7. Frye PE, Pariser SF, Kim MH, O'Shaughnessy RW: Bromoeriptine associated with symptom exacerbation during neuroteptic treatment of schizoaffective schizophrenia. J Clin Psychiatry 43:252, 1982. 8. Bromocriptine to prevent lactation. Med Lett 22:48, 1980. 9. Poisoning among young children: United States. MMWR 33:129, 1984.

Nasal septal perforation associated with topical corticosteroid therapy Margaret L. Soderberg-Warner, M . D . Irvine, California

FLUNISOLIDE WAS APPROVED for intranasal use in the United S ~ t e s in 1981 and was welcomed both by patients with severe allergic rhinitis a n d by the physicians who t r e a t them. The medication reportedly had been used with safety in patients older t h a n 6 years for periods up to 2 years, t Only minimal complications have been reported associated with the i n t r a n a s a l use of flunisolide in children. This report describes a child who developed a nasal septat perforation during such t r e a t m e n t . CASE REPORT lntranasal flunisolide therapy was initiated in a 9-year-old girl for treatment of allergic rhinitis refractory to oral aadhistamiae/

From the Department of Pediatrics, University of California, lrvine. Submitted for publication Feb. 2l, 1983; accepted May 11, 1984. Reprints not available.

decongestant therapy alone. The dose was maintained at 1 spray per nostril (25 #g per spray) twice a day, except for a brief period (approximately 2 weeks) when it was increased to three times a day (150 ,,g total per day) because of increasing symptoms Of allergic rhinitis. Throughout this treatment period orally administered antihistamine/decongestant therapy was continued. One month after initiating therapy the p~itient developed what seemed at first to be a viral syndrome, with symptoms of fever, increased rhinorrhea, headache, wt~cczing, and cough productive of grecuisi~ sputum. On physical examination, however, the maxillary and frontal sinus areas were tender to percussion and the inferior turbinates of the hose ~vere swollen, with increased secretions. A clinical diagnosis of sinusitis was made and the patient was given a 10-day course of ampicillin 250 mg four times a day. No radiographs were taken. A reevaluation 10 days later revealed a normal appearing nasal 'mucosa and nontender sinus areas. In the first weeks of flunisolide therapy (he child complained of a mildly blood-tinged nasal mucus, which seemed to resolve spontaneously in the first month of topical therapy. Seven months after initiation of therapy, well-crusted nasal ulcerations were

Volume 105 Number 5

noticed on the anterior nasal septum. Because evidence of infection or inflammation was not clinically apparent around the ulceration sites, no cultures were taken. Review of the records revealed that 2 months prior to the appearance of the ulcerations the nasal septum appeared intact and the mucous membranes of the nose were normal in appearance. One month after the appearance of the ulcerations, however, the child's mother reported that the child had "put her finger through a hole in her nose"; a large anterior nasal septal perforation was observed at the bony-cartilaginous junction. Flunisolide therapy was stopped. The symptoms of allergic rhinitis then worsened for a period of several months, but improved during the summer months, lmmunotherapy has subsequently been successfully initiated in this child. The perforation has continued to be occasionally symptomatic, with periodic crusting, which has been minimized with a therapeutic regimen of lubrication and humidification (petroleum jelly and a saline nasal spray). To date the perforation has not healed nor changed in size. DISCUSSION In clinical studies conducted prior to the release of flunisolide for intranasal use, nasal septal perforation was observed in three of 6 adults (in a study of 595 adults) in whom the nasal septum had been previously compromised by disease or septal surgical procedures. Two other adults developed ulcerations, but flunisolide therapy was not stopped and perforation did not occur. N o perforations or ulcerations occurred in children. The only adverse effects noted in children were bleeding or a blood-tinged nasal mucus (thought to be caused by the propylene glycol vehicle) and, commonly, a transient stinging Sensation on application of the spray to the nasal mucosa (personal communication, Syntex Laboratories, Department of Clinical Research, Palo Alto; Calif., 1983). A review of the literature 2-7 confirmed that the cornp l a i n t o f a transient stinging sensation was the most common adverse effect noted in children during treatment periods ranging from 4 weeks to 6 months. In no instance was ulceration or septal perforation no,ted in children. In a lengthier study of adults, a nasal septal culture in one patient grew Candida tropicalis after 5 months of intranasal treatment with flunisolide; subsequently a perforation developed at the boney-cartilaginous junction of the septum, and the patient was dropped from the study. A biospy of the site surrounding the perforation was negative for Candida, 8 and the reason for the perforation was unclear. Children have been given intranasal flunisolide therapy for as long as 6 months, at daily total doses of 50 to 100 ug. 4 One continuing study of at least 12 months duration has assessed A C T H responses in 27 children who used

Clinical and laboratory observations

84 1

daily doses of 1 spray flunisolide per nostril twice a day (100 izg); no adverse effects other than a transient burning sensation were noted (unpublished observations, Sheldon S. Siegel, M.D.). Nasal septal perforations have been described in association with topical use of other steroids. Two adults had used intranasal dexamethasone for >2 years before a septal perforation was noted; no specific lesion was noted on the septum before perforation. There was no speculation as to the cause of the perforation in either case, but a common observation was that the mucosa was quite dry. 9 The most common cause of nasal septal perforation is trauma secondary to local surgical procedures or digital trauma. ~~ It is difficult to prove that the nasal septal perforation in our patient was directly caused by intranasal use of flunisolide. No routine intranasal cultures were taken and no biopsies were performed. Perhaps the combination of topical corticosteroid therapy and antihistamines compromised the nasal septal blood supply. The cause, however, remains speculative. The perforation occurred in an area that lends itself to factitial ulceration, and many children are inveterate nose pickers. Although cause and effect in this case cannot be definitively proved, nasal septal perforation may be a potential complication of intranasal flunisolide treatment in children. REFERENCES

1. Nasalide assessment and review. Palo Alto, Calif.; 1981, Syntex Laboratories. 2. Gale AE, Solomon E, Tao BSK: lntranasal topical flunisotide therapy in children with seasonal allergic rhinitis. Clin Allergy 10:527, t980. 3. Sahay JN, Chatterjee SS, Encler C: A comparative trial of flunisolide and beclomethason e dipropionate in the treatment of perennial allergic rhinitis. Clin Allergy 10:65, i980. 4. Sarsfield JK, Thomson CE: Flunisolide nasal spray for perennial rhinitis in children. Br Med J 2:95, 1979. 5. Siegel S, Katz R, Rachelefsky G, et at: Flunisolide aerosol treatment of perennial allergic rhinitis in children. J Allergy Clin Immunol 61:152, 1978. 6. Strem EL, Austrian S, Geller GR, et al: Flunisolide nasal spray for the treatment of children with seasonal allergic rhinitis. Ann Allergy 41:145, i978. 7. Pakes GE, Brogden RN, Heel RC, et al: Flunisolide: A review ol its pharmacological properties and therapeutic ellicacy in rhinitis. Drugs 19:397, 1980. ;~. Jones LM, Speetor S L English GM, et al: Treatment of perennial rhinitis with flunisolide corticosteroid spray. Ann Allergy 42:139, 1979. 9. Miller FF: Occurrence of na~al ~cptal perforation with u~c ot intranasal dexamethasone aerosol. Ann Allergy 34:107, 1975. 10. DeWeesc DD, Saunders WIt, editors: Textbook of otolar~,ngology. St. l.ouis, 1982, CV Moslby, p 201.