The nose

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14.2 The nose

Stuart Lewena, Gervase Chaney

Rhinitis and sinusitis

1 Acute rhinitis is common and largely due to viral infections.

2 Mucopurulent discharge does not mean bacterial infection.

3 Antibiotics might be indicated in prolonged cases of nasal discharge (> 10–14 days duration), indicating possible sinusitis.

4 Constant nasal discharge may be due to perennial allergic rhinitis.

Epistaxis

1 Epistaxis is common and largely responds to simple first aid – compression of the nose.

2 Severe cases are uncommon, but are a medical emergency, requiring nasal packing and urgent ENT referral.

3 Underlying bleeding tendency should be excluded in cases with a family history of bleeding tendency or those with severe recurrent epistaxis.

Nasal trauma

1 Nasal trauma is common.

2 Most injuries will require little or no intervention. However, a careful examination to exclude septal haematoma is essential.

3 Septal haematoma requires urgent ENT referral.

4 Acute assessment can be difficult and a review, once the swelling has settled, is required to manage any deformity.

Rhinitis and sinusitis

Introduction

Viral upper respiratory tract infections causing rhinitis and inflammation of the upper respiratory tract are a frequent cause of febrile illness presentations amongst children to emergency departments. Children will commonly experience three to eight of these infections per year, even more if attending day care. After exclusion of more significant illness, education and symptomatic treatment is all that is required. Despite recommendations against such practice, many children will have been prescribed antibiotics. Bacterial sinusitis has been estimated as complicating only 0.5–5% of upper respiratory tract infections. Most of these will resolve without antibiotic treatment.

History

The common cold usually commences with a throat irritation and clear, thin nasal discharge and progresses to a thick, mucopurulent discharge after a few days. This does not indicate bacterial infection. Sneezing, nasal obstruction, systemic features such as malaise and low-grade fever, and cough are common. Generally the duration is about 7 days.

Persistence of mucopurulent nasal discharge without improvement for longer than 10–14 days, or more severe acute symptoms, such as high fever, headache, facial pain and/or swelling are more indicative of bacterial sinusitis.

Persistent clear nasal discharge is more likely due to perennial allergic rhinitis. This may be associated with sneeze, and itchy eyes and/or nose. Unilateral nasal discharge, particularly offensive, is suggestive of a nasal foreign body.

Examination

In rhinosinusitis, nasal discharge is the usual finding. This may be clear or mucopurulent and, as already discussed, is not indicative of cause. A red throat is a common association. In allergic rhinitis, the nasal mucosa will be pale and swollen. Facial swelling, such as orbital/periorbital and/or facial tenderness may occur in sinusitis.

Investigations

Investigations are not indicated for the common cold. Sinusitis is also a clinical diagnosis. Radiological investigations for acute sinusitis are difficult to interpret, as similar findings may be found in the common cold or even asymptomatic children. Also, the sinuses of young children are poorly developed, with frontal and sphenoid sinuses not appearing till 5–6 years of age. Radiological investigations should be reserved for those cases with suspected complications of orbital/intracranial extension, or possibly in recurrent cases.

If aspirated under general anaesthesia, sinusitis fluid most commonly cultures Pneumococcus, followed by Haemophilus influenzae, Moraxella catarrhalis and then viruses. Nasopharyngeal cultures are not predictive and therefore not useful.

Treatment

Antibiotics are not indicated for the common cold and have been shown neither to alter the course of the illness nor prevent the development of complications. Perennial allergic rhinitis responds best to intranasal corticosteroids, but these are often not tolerated well by children.

Even in bacterial sinusitis, the majority of cases will resolve spontaneously. Nasal decongestants may provide some short-term relief. If antibiotics are used, amoxicillin is recommended as first-line treatment for 10–14 days duration. Amoxicillin + clavulanate can be kept for those cases failing to respond in 48–72 hours.

Complications

Bacterial complications of the common cold do occur, such as otitis media, but cannot be prevented by antibiotic use. Asthma is frequently precipitated by upper respiratory tract infections.

Ethmoid sinusitis can spread to cause orbital cellulitis or intracranially, causing an abscess or cavernous sinus thrombosis.

Prevention

Breast-feeding has a protective effect on the number of upper respiratory tract infections experienced by young children. Day care attendance and environmental tobacco exposure increase the number of episodes.

Epistaxis

Introduction

Although epistaxis is common in childhood (affecting about 6–9%), it is usually mild and usually does not require any medical intervention, let alone presentation to an emergency department (ED).

History

The frequency and severity of episodes should be determined together with first aid measures undertaken. A history of abnormal bleeding/bruising, infections or trauma should be sought.

Examination

In the majority of cases, positive examination findings are limited to the nose. Bleeding can be unilateral or bilateral. Crusting and vessels in Little’s area are commonly seen. The remainder of the examination should exclude hypertension, abnormal bruising or petechiae and findings of lymphadenopathy or hepatosplenomegaly.

Investigations

Investigation for bleeding disorders is frequently performed. However, the vast majority of these will be normal unless there are other indications of bleeding tendency or family history. A more severe history of epistaxis, with frequent bleeds of greater volume and duration, is more suggestive of a bleeding disorder such as von Willebrand disease and warrants appropriate testing.

Treatment

First aid treatment of epistaxis is firm compression of the alar nasae, applying pressure over Little’s area. This will result in cessation of bleeding in the majority of cases. The use of anaesthetic/vasoconstrictor spray or soaked pledgets may assist in haemostasis. If these measures fail, nasal cautery can be used for a well-identified bleeding site or an anterior nasal pack inserted. Purpose-made self-expanding nasal packs have made this procedure much easier. These packs should be lubricated with antibiotic ointment before insertion. Children with epistaxis that has required packing should be considered for investigation of underlying bleeding problems and have an ear, nose and throat (ENT) referral. Posterior nasal packing or other more invasive procedures are rarely required in children, but may be needed in severe epistaxis in the context of resuscitation and urgent ENT consultation.

Complications

Rarely, recurrent epistaxis is sufficient to cause anaemia. Care should be taken when applying nasal cautery to avoid damage to the underlying septal cartilage. Bilateral cautery should be avoided for this reason.

Nasal trauma

Introduction

Nasal trauma is common in children. It can occur at any age, but is most frequent in early primary-age groups. Like most injuries, there is a male predominance.

History and examination

The most common mechanism of injury is falls, usually at home, followed by sports injuries. Child abuse (inflicted injury) should be considered, particularly in the younger (non-mobile) child. A careful history is therefore required.

The types of injury are varied, from abrasions and lacerations of the soft tissues to fractures, dislocations and cartilage damage. More than minor epistaxis is unusual. Due to swelling it is often difficult to make a thorough assessment of the extent of injury in the acute setting – particularly for deformity. Examination must include an examination of the nasal cavities. Deviation, swelling and/or discolouration of the nasal septum may indicate a septal haematoma and urgent ENT consultation for evacuation is indicated.

Investigations

Nasal X-rays offer no benefit. A young child’s nose is predominantly cartilage, and even when a fracture of the nasal bones is identified, this information does not influence management. Facial X-ray or computerised tomography (CT) should be limited to those suspected of more serious facial bony injury.

Treatment

Most nasal injuries require no acute intervention beyond analgesia. However, follow up may be required to determine the extent of deformity. The timing of this is recommended to be about 1 week post-injury, as the swelling has usually resolved by then, and, if required, further treatment can be instituted.

Complications

Septal haematoma, ± abscess formation, is the main complication that causes long-term damage and therefore concern. It may present later down the track and may have been missed on earlier assessment. Haematomas can be very painful and frequently cause nasal obstruction. On its own, a septal haematoma can cause nasal cartilage damage, including aseptic necrosis. However, the development of an abscess is almost always associated with cartilage damage and potentially severe nasal deformity. Staphylococcus aureus, Streptococcus pneumoniae and Strep. pyogenes have all been cultured. Meningitis or cavernous sinus thrombosis may also complicate a septal abscess.

Epistaxis

The choice of which children to test and extent of investigation for bleeding disorders is still uncertain. For the severe and recurrent cases, thorough coagulation testing, including for von Willebrand disease, is appropriate.

Nasal trauma

Open rhinoplasty for nasal deformities may affect nasal growth in itself and should be used as conservatively as possible.

Further reading

Canty P.A., Berkowitz R.G. Hematoma and abscess of the nasal septum in children. Arch Otolaryngol Head Neck Surg. 1996;122(12):1373-1376.

Crockett D.M., Mungo R.P., Thompson R.E. Maxillofacial trauma. Paediatr Clin N Am. 1989;36(6):1471-1494.

East C.A., O’Donaghue G. Acute nasal trauma in children. J Paediatr Surg. 1987;22(4):308-310.

Ghosh A., Jackson R. Towards evidence based emergency medicine: Best BETs from the Manchester Royal Infirmary. Cautery or cream for epistaxis in children. Emerg Med J. 2001;18(3):210.

Ginsburg C.M. Nasal septal hematoma. Paediatr Rev. 1998;19(4):142-143.

Katsanis E., Luke K.H., Hsu E., et al. Prevalence and significance of mild bleeding disorders in children with recurrent epistaxis. J Paediatr. 1988;113(11):73-76.

Makura Z.G., Porter G.C., McCormick M.S. Paediatric epistaxis: Alder Hey experience. J Laryngol Otol. 2002;116(11):903-906.

Nyquist A.-C., Gonzales R., Steiner J.F., et al. Antibiotic prescribing for children with colds, upper respiratory tract infections, and bronchitis. JAMA. 1998;279(11):875-877.

O’Brien K.L., Dowell S.F., Schwartz B., et al. Acute sinusitis—Principles of judicious use of antimicrobial agents. Paediatrics. 1998;101(1):174-177.

Rosenstein N., Phillips W.R., Gerber M.A., et al. The common cold—Principles of judicious use of antimicrobial agents. Paediatrics. 1998;101(1):181-184.

Ruddy J., Proops D.W., Pearman K., et al. Management of epistaxis in children. Int J Paediatr Otorhinolaryngol. 1991;21(2):139-142.

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