A snotty nose: more than just a cold
The present case has been reported in BMJ. A healthy 3-year-old girl presented with a 5-day history of right-sided cheek and eye swelling and pain, associated with right-sided green nasal discharge. Examination revealed diffuse erythematous swelling around the right cheek, jawline and eye.

Oral antibiotics for suspected periorbital cellulitis were ineffective. Blood inflammatory markers and ultrasound of her neck and parotid glands were normal. She was discharged as having viral parotitis. Antibiotics and nasal drops were later restarted for clinical sinusitis; however, she showed no improvement, now having 3 weeks of right-sided facial swelling with thick green and intermittently bloody nasal discharge. Further history revealed possible squint, mastication pain and breathing difficulty through the right nostril.

Cranial imaging demonstrated a large central but predominantly right-sided nasopharyngeal tumour, extending into the ethmoid sinuses and orbits (with medial recti distortion), infratemporal fossa and pterygoid muscles and anterior and middle cranial fossae. There was accompanying skull base destruction.

Staging and biopsy confirmed the diagnosis of non-metastatic parameningeal rhabdomyosarcoma (PM-RMS). Chemoradiotherapy ensued.

Learning points
• Clinicians should consider nasopharyngeal malignancy in persistent unilateral rhinorrhea, among other symptoms.

• Para-meningeal rhabdomyosarcoma may invade critical facial and intracranial structures and hence diagnosis should not be delayed.

Read more here: http://casereports.bmj.com/content/2018/bcr-2018-226686.full
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