Adapted from Nadel FN, Henretig FM Epistaxis. In: Textbook of Pediatric Emergency Medicine, 5th ed. Fleisher GR, Ludwig S, Henretig, FM (eds). Philadelphia, Lippincott Williams & Wilkins, 2006, pp 417–425.

6 What historical factors make one suspicious for a systemic cause of a nosebleed?

Children with a history of bleeding from other sources, easy bruising, weight loss, or other constitutional symptoms, a family history of a bleeding disorder, and severe or recurrent nosebleeds may need more extensive workup or subsequent follow-up.

Sandoval C, Dong S, Visintainer P, et al: Clinical and laboratory features of 178 children with recurrent epistaxis. J Pediatr Hematol Oncol 24:47–49, 2002.

7 What steps should be taken for a patient who has a nosebleed in the emergency department (ED)?

Calming the patient and family is often the most important step. For an anterior bleed, insert a roll of cotton saturated with a topical decongestant (oxymetazoline or adrenaline) in the affected side and squeeze the nose gently for 5 minutes to compress the cotton against the septum. If the bleeding site is visible, it can then be cauterized with silver nitrate. Adding a topical anesthetic to the cotton ball greatly decreases the amount of discomfort of cautery. If the bleeding cannot be stopped with cautery, the nose should then be packed. Bleeding that cannot be stopped with these measures should be evaluated by an otolaryngologist without delay.

8 What findings would make you more suspicious for a posterior nosebleed?

Suspect a posterior nosebleed when no obvious site is visible anteriorly. Bleeding from both nostrils and blood in the posterior pharynx suggest a posterior nosebleed, but can occur from brisk anterior epistaxis. Continued bleeding despite adequate anterior pressure is also concerning. Posterior nasal bleeding is rare in children.

Alvi A, Joyner-Triplett N: Acute epistaxis. How to spot the source and stop the flow. Postgrad Med 99:83–90, 94–96, 1996.

9 A teenage male presents with recurrent, profuse unilateral epistaxis. He reports that this same side of his nose has been progressively obstructed for 2 months. What other diagnosis should you consider?

Teenage males may develop juvenile nasopharyngeal angiofibroma. These uncommon tumors arise from the sphenopalatine region and can present with severe epistaxis. The diagnosis is made with nasal endoscopy or computed tomography (CT). These patients need a referral to an otolaryngology specialist for further surgical management.

10 A teenager presents with her fifth nosebleed in as many months. Her history and physical examination are otherwise unremarkable. What additional information regarding her nosebleeds may be helpful?

One should ask her the timing of nosebleeds in relation to her menstrual cycle. Some girls may experience “vicarious menstruation” in which they have a nosebleed at the same time as their menses.

RETROPHARYNGEAL ABSCESS

11 What are the common signs and symptoms of a retropharyngeal abscess?

Commonly, there is a recent history of an upper respiratory tract infection, fever, and poor oral intake. Patients may be drooling, have a stiff neck, and have tender cervical adenopathy. Respiratory symptoms of stridor, stertor, or dyspnea are usually late findings and are rarely described in the most current series of patients. A midline mass can sometimes be seen in the posterior pharynx.

Craig FW, Schunk JE: Retropharyngeal abscess in children: Clinical presentation, utility of imaging, and current management. Pediatrics 111:1394–1398, 2003.

12 Why is it unusual to see retropharyngeal abscess in children > 4 years old?

The retropharyngeal nodes of Rouvier usually involute around 5 years of age, making retropharyngeal abscess (RPA) a rare disease in older children.

13 What is a parapharyngeal abscess?

A parapharyngeal or lateral space infection develops in the lateral aspect of the neck. This space is shaped like an inverted cone. It is divided into an anterior compartment, which contains no vital structures and is closely related to the tonsillar fossa. The posterior compartment contains some of the cranial nerves and the carotid sheath. Infection in the lateral space results from dental infection, pharyngitis, tonsillitis, parotitis, and mastoiditis.

Parapharyngeal abscesses are less common than RPA. Symptoms are very similar to those seen in RPA.

14 List the mechanisms of infection of the retropharyngeal space

Usually, bacteria in the pharynx spread via lymphatic channels to the nodes of Rouvier, where they multiply and suppurate. Other possible mechanisms include oral trauma (causing a mucosal tear), hematogenous spread during bacteremia, or, rarely, extension from vertebral osteomyelitis.

Only gold members can continue reading. Log In or Register to continue

Tags: Pediatric Emergency Medicine Secrets

Sep 1, 2016 | Posted by admin in EMERGENCY MEDICINE | Comments Off

Anesthesia Key

Fastest Anesthesia & Intensive Care & Emergency Medicine Insight Engine

Otorhinolaryngology Emergencies

EPISTAXIS

1 From what part of the nose do most nosebleeds originate?

2 What factors often contribute to nosebleeds in otherwise normal children?

3 How can one elicit a truthful answer about nose picking?

4 What is “rhinitis sicca”?

5 Though most nosebleeds occur from the benign local conditions listed above, what else should be considered in the differential diagnosis of nosebleeds?