Etiology

Foreign bodies (food, beads, crayons, small toys, erasers, paper wads, buttons, batteries, beans, stones, pieces of sponge, and other small objects) are often placed in the nose by small children and developmentally delayed children and constitute ≤1% of pediatric emergency department visits. Initial symptoms are unilateral obstruction, sneezing, relatively mild discomfort, and rarely pain. Presenting clinical symptoms include history of insertion of foreign bodies (86%), mucopurulent nasal discharge (24%), foul nasal odor (9%), epistaxis (6%), nasal obstruction (3%), and mouth breathing (2%). Irritation results in mucosal swelling because some foreign bodies are hygroscopic and increase in size as water is absorbed; signs of local obstruction and discomfort can increase with time. The patient might also present with a generalized body odor known as bromhidrosis.

Diagnosis

Unilateral nasal discharge and obstruction should suggest the presence of a foreign body, which can often be seen on examination with a nasal speculum or wide otoscope placed in the nose. Purulent secretions may need to be cleared so that the foreign object can actually be seen; a headlight, suction, and topical decongestants are often needed. The object is usually situated anteriorly, but unskilled attempts at removal can force the object deeper into the nose. A long-standing foreign body can become embedded in granulation tissue or mucosa and appear as a nasal mass. A lateral skull radiograph assists in diagnosis if the foreign body is metallic or radiopaque.

Treatment

A quick examination of the nose is made to determine if a foreign body is present, and whether it needs to be removed emergently. Planning is then made for office or operating room extrication of the foreign body. Prompt removal minimizes the danger of aspiration and local tissue necrosis. This can usually be performed with topical anesthesia, using either forceps or nasal suction. If there is marked swelling, bleeding, or tissue overgrowth, general anesthesia may be needed to remove the object. Infection usually clears promptly after the removal of the object and, generally, no further therapy is necessary.

Complications

Infection often follows and gives rise to a purulent, malodorous, or bloody discharge. Local tissue damage from long-standing foreign body, or alkaline injury from a disk battery, can lead to local tissue loss and cartilage destruction. A synechia or scar band can then form, causing nasal obstruction. Loss of septal mucosa and cartilage can cause a septal perforation. Disk batteries are dangerous when placed in the nose; they leach base, which causes pain and local tissue destruction in a matter of hours.

Tetanus is a rare complication of long-standing nasal foreign bodies in nonimmunized children (Chapter 203). Toxic shock syndrome is also rare, and most commonly occurs from nasal surgical packing (Chapter 174.2); oral antibiotics should be administered when nasal surgical packing is placed.

Prevention

Tempting objects such as round, shiny beads should only be used under adult supervision. Disk batteries should be stored away from the reach of small children.

Anatomy

The most common site of bleeding is the Kiesselbach plexus, an area in the anterior septum where vessels from both the internal carotid (anterior and posterior ethmoid arteries) and external carotid (sphenopalatine and terminal branches of the internal maxillary arteries) converge. The thin mucosa in this area, as well as the anterior location, makes it prone to exposure to dry air and trauma.

Etiology

Common causes of nosebleeds from the anterior septum include digital trauma, foreign bodies, dry air, and inflammation, including upper respiratory tract infections, sinusitis, and allergic rhinitis (Table 369-1). There is often a family history of childhood epistaxis. Nasal steroid sprays are commonly used in children, and their chronic use may be associated with bleeding. Young infants with significant gastroesophageal reflux into the nose rarely present with epistaxis secondary to mucosal inflammation. Susceptibility is increased during respiratory infections and in the winter when dry air irritates the nasal mucosa, resulting in formation of fissures and crusting. Severe bleeding may be encountered with congenital vascular abnormalities, such as hereditary hemorrhagic telangiectasia (Chapter 426.3), varicosities, hemangiomas, and, in children with thrombocytopenia, deficiency of clotting factors, particularly von Willebrand disease, hypertension, renal failure, or venous congestion. Nasal polyps or other intranasal growths may be associated with epistaxis. Recurrent, and often severe, nosebleeds may be the initial presenting symptom in juvenile nasal angiofibromas, which occur in adolescent boys.

Clinical Manifestations

Epistaxis usually occurs without warning, with blood flowing slowly but freely from one nostril or occasionally from both. In children with nasal lesions, bleeding might follow physical exercise. When bleeding occurs at night, the blood may be swallowed and become apparent only when the child vomits or passes blood in the stools. Posterior epistaxis can manifest as anterior nasal bleeding or, if bleeding is copious, the patient might vomit blood as the initial symptom.

Treatment

Most nosebleeds stop spontaneously in a few minutes. The nares should be compressed and the child kept as quiet as possible, in an upright position with the head tilted forward to avoid blood trickling back into the throat. Cold compresses applied to the nose can also help. If these measures do not stop the bleeding, local application of a solution of oxymetazoline (Afrin or Neo-Synephrine) (0.25-1%) may be useful. If bleeding persists, an anterior nasal pack might need to be inserted; if bleeding originates in the posterior nasal cavity, combined anterior and posterior packing is necessary. After bleeding has been controlled, and if a bleeding site is identified, its obliteration by cautery with silver nitrate may prevent further difficulties. Because the septal cartilage derives its nutrition from the overlying mucoperichondrium, only 1 side of the septum should be cauterized at a time to reduce the chance of a septal perforation. During the winter, or in a dry environment, a room humidifier, saline drops, and petrolatum (Vaseline) applied to the septum can help to prevent epistaxis.

In patients with severe or repeated epistaxis, blood transfusions may be necessary. Otolaryngologic evaluation is indicated for these children and for those with bilateral bleeding or with hemorrhage that does not arise from the Kiesselbach plexus. Hematologic evaluation (for coagulopathy and anemia), along with nasal endoscopy and diagnostic imaging, may be needed to make a definitive diagnosis in cases of severe recurrent epistaxis. Replacement of deficient clotting factors may be required for patients who have an underlying hematologic disorder (Chapter 470). Profuse unilateral epistaxis associated with a nasal mass in an adolescent boy near puberty might signal a juvenile nasopharyngeal angiofibroma. This unusual tumor has also been reported in a 2 yr old and in 30-40 yr olds, but the incidence peaks in adolescent and preadolescent boys. CT with contrast medium enhancement and MRI are part of the initial evaluation; arteriography, embolization, and extensive surgery may be needed.

Surgical intervention may also be needed for bleeding from the internal maxillary artery or other vessels that can cause bleeding in the posterior nasal cavity.

Prevention

The discouragement of nose picking, and attention to proper humidification of the bedroom during dry winter months helps to prevent many nosebleeds. Prompt attention to nasal infections and allergies is beneficial to nasal hygiene. Prompt cessation of nasal steroid sprays prevents ongoing bleeding.