Otorhinolaryngology Emergencies

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Chapter 48 Otorhinolaryngology Emergencies

Frances M. Nadel, MD, MSCE, Douglas M. Nadel, MD

EPISTAXIS

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

The vast majority of nosebleeds in children arise anteriorly (90%). On the anterior part of the septum, many capillaries converge, giving rise to Kiesselbach’s plexus. Anterior nosebleeds tend to be slow and persistent. Posterior nosebleeds usually originate from branches of the sphenopalatine artery and ethmoidal arteries. As a result, the bleeding is more profuse.

McGarry G: Nosebleeds in children. Clin Evid 10:437–440, 2003.

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

Desiccation of the fragile nasal mucosa makes the tissue more friable. Inflammation from a viral upper respiratory tract infection or allergies can also make the mucosa more likely to bleed. Finally, local trauma from nose picking is usually a major contributor.

McGarry G: Nosebleeds in children. Clin Evid 10:437–440, 2003.

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

Ask the child which finger she uses to pick her nose.

4 What is “rhinitis sicca”?

This refers to the drying of the nasal mucosa, which may make it more susceptible to bleeding. This often occurs during winter months, when dry hot air systems are being used to heat one’s house.

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

See Table 48-1.

Table 48-1 Differential Diagnosis of Epistaxis

Local predisposing factors
Trauma
  Facial trauma
  Direct nasal trauma
  Nose picking
Local inflammation
  Acute viral upper respiratory tract infection (common cold)
image
  Congenital syphilis
  Hemolytic streptococci
  Foreign body
  Acute systemic illnesses accompanied by nasal congestion:
  measles, infectious mononucleosis, acute rheumatic fever
  Allergic rhinitis
  Nasal polyps (cystic fibrosis, allergic, generalized)
  Staphylococcal furuncle
  Sinusitis
Cocaine or heroin sniffing
Telangiectasias (Osler-Weber-Rendu disease)
Juvenile angiofibroma*
Other tumors, granulomatosis (rare)*
Rhinitis sicca
Systemic predisposing factors
Hematologic diseases*
  Platelet disorders
  Quantitative: idiopathic thrombocytopenic purpura, leukemia, aplastic anemia
  Qualitative: von Willebrand’s disease, Glanzmann’s disease, uremia
  Other primary hemorrhagic diatheses: hemophilias, sickle cell anemia
  Clotting disorders associated with severe hepatic disease, disseminated intravascular coagulopathy, vitamin K deficiency
Drugs: aspirin, nonsteroidal anti-inflammatory drugs, warfarin, rodenticide, valproate
Vicarious menstruation
Hypertension*
  Arterial (unusual cause of epistaxis in children)
  Venous: superior vena cava syndrome or with paroxysmal coughing seen in pertussis and cystic fibrosis

* Life-threatening condition.

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.

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