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)

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.

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.

15 Which pathogens are common in RPA?

RPA is usually a polymicrobial infection and may include Streptococcus spp., Staphylococcus aureus, and anaerobes. Haemophilus influenzae type B has become a less common pathogen since the introduction of the Hib vaccine. Less commonly, gram-negative organisms such as Klebsiella and Salmonella spp. have been cultured.

Brook I: Microbiology and management of peritonsillar, retropharyngeal, and parapharyngeal abscesses. J Oral Maxillofac Surg 62:1545–15650, 2004.

16 How wide is the normal retropharyngeal space on a lateral neck radiograph in children?

Prevertebral soft tissues at the level of C3 should measure less than two thirds of the anterior-posterior width of the body of the third cervical vertebrae. This space is markedly widened in a child with retropharyngeal abscess (Fig. 48-1).

Figure 48-1 Widened retropharyngeal space on a lateral neck radiograph of a child with retropharyngeal abscess.

Jasin ME, Osguthorpe JD: The radiographic evaluation of infants with stridor. Otolaryngol Head Neck Surg 90:736–739, 1982.

17 List the causes of a false-positive lateral neck radiograph

Jasin ME, Osguthorpe JD: The radiographic evaluation of infants with stridor. Otolaryngol Head Neck Surg 90:736–739, 1982.

18 How does CT assist in RPA management?

CT with contrast is the most reliable test in the initial evaluation. A hypodense region with rim enhancement is virtually diagnostic for an abscess, while a more heterogeneous mass without rim enhancement suggests retropharyngeal cellulitis only. However, the CT results should be clinically correlated because the false-positive and false-negative rates may be as high as 15%. CT can help demonstrate the extent of infection and the potential of airway compromise. The scan also helps the otolaryngologist decide whether intraoral drainage is feasible or whether an external approach is necessary.

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

Wetmore RF, Mahboubi, Soyupak SK. Computed tomography in the evaluation of pediatric neck infections. Otolaryngol Head Neck Surg 119:624–627, 1998.

19 Do most patients with RPA require surgery?

The management of RPA varies greatly in the literature and by surgeon. Though it was previously the standard to drain all abscesses, more clinicians are willing to attempt a trial of IV antibiotics alone on patients with retropharyngeal cellulitis or small RPA without airway compromise.

Lalakea M, Messner AH: Retropharyngeal abscess management in children: Current practices. Otolaryngol Head Neck Surg 121:398–405, 1999.

20 How far inferiorly does the retropharyngeal space extend in the neck?

The retropharyngeal space extends from the base of the skull to the level of the second thoracic vertebrae. The abscess can rupture into the prevertebral space, which communicates with the mediastinum and descends as far as the psoas muscles.

21 List some of the complications of an RPA

Earlier recognition and treatment and improved diagnostic strategies have greatly reduced the morbidity and mortality of RPAs. However, a large RPA may obstruct the airway at the pharyngeal, laryngeal, or tracheal level, and a tracheostomy may be necessary. Aspiration of purulent fluid may occur from rupture of the abscess. Sepsis, mediastinitis, jugular vein thrombosis, Lemierre’s syndrome, carotid arteritis with subsequent rupture are rare complications.

22 What findings may herald a carotid artery rupture?

A pulsatile ecchymotic mass may be found anterior to the sternocleidomastoid muscle. Bleeding from the ear, nose, or mouth may occur.

23 Define mastoiditis

Mastoiditis is an infection of the mastoid air cells. Technically, a simple case of acute otitis media leads to some inflammation of the air cells, but true coalescent mastoiditis implies bony destruction.

24 Why is it unusual to see mastoiditis in children less than 1 year old?

The mastoid air cells are not yet pneumatized.

25 How does a patient who has acute mastoiditis present?

Patients commonly present with persistent symptoms of acute otitis media, such as ear pain or drainage. Fever is common. On physical examination, the ear may protrude away from the head, and in younger children the ear is pushed down and out (Fig. 48-2). The postauricular skin is often tender, erythematous, fluctuant, or edematous. Otoscopy shows findings consistent with acute otitis media. One may see sagging of the posterosuperior external ear canal due to periosteal thickening.

Figure 48-2 Protruding ear in a child with acute mastoiditis.

Nussinovitch M, Yoeli R, Elishkevitz K, Varsano I: Acute mastoiditis in children: Epidemiologic, clinical, microbiologic, and therapeutic aspects over past years. Clin Pediatr 43:261–267, 2004.

26 What are the common pathogens seen in acute mastoiditis?

Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus are common pathogens. Anaerobic enteric bacteria and Pseudomonas spp. are more often seen in subacute or chronic disease. H. influenza is a rare pathogen.

Nussinovitch M, Yoeli R, Elishkevitz K, Varsano I: Acute mastoiditis in children: Epidemiologic, clinical, microbiologic, and therapeutic aspects over past years. Clin Pediatr 43:261–267, 2004.

27 What study would assist in the diagnosis and management of coalescent mastoiditis?

CT with contrast can confirm your clinical diagnosis as well as show whether there is a subperiosteal abscess, intracranial extension, or sigmoid sinus thrombosis.

Antonelli PJ, Garside JA, Mancuso AA, et al: Computed tomography and the diagnosis of coalescent mastoiditis. Otolaryngol Head Neck Surg 120:350–354, 1999.

28 List some of the central nervous system complications of mastoiditis

The temporal bone’s proximity to many important intracranial structures can lead to serious complications. Intracranial extension can include meningoencephalitis and intracerebral, epidural, or subdural abscesses. Progressive thrombophlebitis may lead to sigmoid or lateral sinus thrombosis. Any child with mastoiditis with focal neurologic symptoms should receive an immediate evaluation for intracranial spread. Other concerning findings include toxic appearance, stiff neck, persistent fever despite adequate antibiotic treatment, headache, vomiting, or unusual behavior.

Go C, Bernstein JM, de Jong AL, et al: Intracranial complications of acute mastoiditis. Int J Pediatr Otorhinolaryngol 52:143–148, 2000.

29 What is a Bezold’s abscess?

This is a type of mastoiditis that has ruptured through the mastoid tip and formed an abscess within the sternocleidomastoid muscle.

30 What is Gradenigo’s syndrome?

Gradenigo’s syndrome occurs from inflammation of the petrous apex of the temporal bone (petrositis), affecting cranial nerves V and VI. It presents as a suppurative otitis, pain around the eye and ear, abducens nerve paralysis (inability to move the eye laterally), and diplopia. Additional symptoms are facial paresis, vertigo, and fever.

31 What are the two types of postoperative tonsillectomy bleeding?

A common dictum states that bleeding occurs “in 7 minutes or 7 days”:

Liu JH, Anderson KE, Willging JP, et al: Posttonsillectomy hemorrhage: What is it and what should be recorded? Arch Otolaryngol Head Neck Surg 127:1271–1275, 2001.

32 What percentage of children has delayed hemorrhage?

About 3% of children have delayed posttonsillectomy hemorrhage. Active bleeding or the presence of a clot in the tonsillar fossa requires a return to the operating room for hemostasis.

Liu JH, Anderson KE, Willging JP, et al: Posttonsillectomy hemorrhage: What is it and what should be recorded? Arch Otolaryngol Head Neck Surg 127:1271–1275, 2001.

33 Does posttonsillectomy bleeding occur more often in redheads, during a full moon, on Friday the 13th, or in patterns of three?

No—at least not in Philadelphia.

Kumar VV, Kumar NV, Isaacson G: Superstition and post-tonsillectomy hemorrhage. Laryngoscope. 114:2031–2033, 2004.

34 How does the normal healing eschar of oropharyngeal tissue look?

The healing operative site will be covered with a grayish-white exudate. Beneath the exudate there is usually beefy-red granulation tissue. A blood clot will appear dark red, purple, or black and may be located inferiorly near the tongue.

35 What is the significance of seeing a clot on inspection of the oropharynx?

A blood clot not only shows you where the offending vessel is located, it also indicates that the vessel is in the earliest stages of hemostasis and can continue to bleed if provoked. This blood clot should never be removed in the ED as brisk bleeding and loss of the airway can ensue!

36 Why do children die from postoperative bleeding?

The usual mechanism of death is aspiration of blood, though some may die from hemorrhagic shock.

37 How should you manage a patient who is actively bleeding after tonsillectomy in the ED?

Assess the ABCs, with particular attention to obstruction of airway due to blood, as well as circulatory compromise due to blood loss. It is important to calm the patient and the family. Examination will show if any active bleeding is present. Any clot in the tonsillar fossa should be left undisturbed! For severe, active bleeding, the site should be tamponaded with gauze and digital pressure until the otolaryngologist arrives.

38 Is postadenoidectomy bleeding treated differently?

Bleeding from the adenoid bed poses less of a threat because the nasopharynx is supplied with fewer blood vessels than the tonsillar bed. Nonetheless, persistent nasopharyngeal hemorrhage still requires surgical intervention.

39 What is quinsy?

Quinsy is derived from the Latin word for “sore throat” (cynanche) and refers to a peritonsillar abscess (PTA).

40 Define the classic presentation of PTA

PTAs are most commonly seen in late adolescence, but have been rarely reported in young infants. Patients often present with a muffled voice, trismus, and odynophagia. Other symptoms may include fever, worsening sore throat, ear pain, and neck pain.

41 Which way does the uvula point when there is a PTA?

The abscess pushes the uvula away to the contralateral side of the oropharynx.

42 What other physical examination findings may you find?

The tonsils and pharynx will be erythematous and there may be an exudate on the tonsils, as in straightforward tonsillitis. One tonsil may be larger than the other, but by itself this asymmetry does not suggest PTA. A PTA should be suspected when the soft palate is red and bulging on one side while the uvula is deviated to the contralateral side. Often there is ipsilateral cervical adenopathy and trismus.

43 What should be considered in your differential diagnosis of a PTA?

It is often difficult to differentiate a peritonsillar cellulitis from an abscess. The significant asymmetry of tonsil size, the presence of uvular deviation, and palatine fullness are more consistent with a PTA. Children with mononucleosis also have very enlarged tonsils with exudate, though they are usually symmetrically enlarged. It is unusual for tonsillitis from other viruses to be confused with a PTA. If the patient has significant respiratory symptoms, one may be concerned about epiglottitis or RPA. Since the introduction of the Hib vaccine, epiglottitis is extremely rare. Though not always true, children with RPAs or epiglottitis are usually younger than 4 years of age, whereas PTAs are usually seen in teenagers.

44 What are the common pathogens in PTA?

As one would imagine, Streptococcus pyogenes is the most common pathogen. Staphylococcus aureus and oral anaerobes are common pathogens as well.

Brook I: Microbiology and management of peritonsillar, retropharyngeal, and parapharyngeal abscesses. J Oral Maxillofac Surg 62:1545–1550, 2004.

45 How is a PTA treated?

When physical examination suggests a PTA, the peritonsillar space should be aspirated by an otolaryngologist. Aspiration of pus confirms the diagnosis and often gives the patient immediate symptomatic relief. Some practitioners prefer a course of IV antibiotics, with aspiration reserved for treatment failures. Once drained, PTA is treated just like acute tonsillitis: with antibiotics, hydration, and analgesics. Repeated aspirations are occasionally necessary. Penicillin usually provides adequate coverage. For patients who are allergic or have not responded to penicillin, clindamycin provides excellent coverage. Route of administration will depend on the patient’s general appearance and ability to swallow.

Johnson RF, Stewart MG, Wright CC: An evidence-based review of the treatment of peritonsillar abscess. Otolaryngol Head Neck Surg 128:332–343, 2003.

46 List the four findings of Lemierre’s syndrome

47 What findings would make you suspect Lemierre’s syndrome?

Patients with recent or prolonged pharyngitis who have persistent fever, lateral neck pain/swelling, myalgias/arthralgias, and pulmonary decompensation should arouse suspicion.

Venglarcik J: Lemierre’s syndrome. Pediatr Infect Dis J 22:921–923, 2003.