Pediatric emergency medicine trisk 818

typically benign situation into a potentially emergent airway foreign body aspiration Initial Assessment A child may be witnessed placing a foreign body in the nose More commonly, the child will report what they have done to a parent or caregiver Determining what type of object was placed is important to determining approaches to removal Alternatively, when persistent nasal discharge, particularly unilaterally, is the primary complaint, gaining information about the chronicity of symptoms becomes important On physical examination, the nasal cavities may need to be suctioned to visualize if an object is present Sometimes, suctioning results in removal of the object During anterior rhinoscopy, the location of the foreign body and any other injuries should be noted Plain films are not indicated unless there is specific concern for a radio-opaque foreign body that is not identified during direct visualization Management Prior to any removal attempt, a topical nasal vasoconstricting agent such as oxymetazoline should be used to decongest the mucosa and minimize potential bleeding In the cooperative child, instruments can be used to grasp and remove the object Alternatively, a 5-French Foley catheter or commercially available device (e.g., Katz extractor) can be inserted behind the object and the balloon inflated to extract the object Young or uncooperative children may require anxiolysis or procedural sedation, although this is less common than with ear foreign bodies Otolaryngology should be consulted for long-standing foreign bodies, particularly with associated granulation tissue or concern for concurrent infection Acute and long-term management strategies will vary by case For recently placed foreign bodies, which are removed successfully, no further treatment is required For subacute or chronic foreign bodies, antibiotics are often administered after removal to prevent infections including sinusitis Children may be discharged home Caregivers should be advised that the nose may continue to have small amounts of bleeding at home When removal is not successful by emergency clinicians, otolaryngology should be consulted Subsequent removal may occur during the ED visit or in an outpatient setting Trauma to the Nose and Sinuses Goals of Treatment The goal of treatment for nasal trauma is to identify fractures or septal hematomas and to reduce the risk of cosmetic or functional deformity Nasal septal hematomas require emergent drainage, whereas bony fractures may require delayed repair (5 to days) for improved functional or cosmetic outcomes Detecting other injuries to the face associated with nasal injury including ocular, orbit, facial bone, or sinus injury is the secondary goal of treatment as these injuries may be life-threatening or have serious sequelae if not detected CLINICAL PEARLS AND PITFALLS Approximately in nasal injuries presenting to the ED will have a nasal fracture, with higher risk in younger children (i.e., less than years old) and male gender Septal hematomas should be drained promptly to avoid necrosis of the nasal cartilage resulting in perforations or external deformity A thorough assessment should be performed to avoid missing CSF rhinorrhea secondary to an associated injury Current Evidence The nose in children is composed of prominent soft cartilage, which dissipates the force of impact across the midface The bony components of the nose and septum can be fractured or displaced during injury Nasal fractures that extend to the anterior skull base and cribriform plate can result in CSF rhinorrhea Injuries to the globe, as well as fractures of the orbit and paranasal sinuses can also occur with nasal injuries Facial fractures and midface injuries are covered in Chapter 107 Facial Trauma Clinical Considerations Clinical Recognition Injuries due to minor trauma or sports are commonly associated with nasal fracture Patients typically present with nosebleed, edema, or ecchymosis Rarely, the chief complaint will be clear rhinorrhea in the setting of recent trauma Triage Children with nasal injuries are generally in mild or moderate discomfort on presentation Epistaxis should be addressed with application of direct pressure Nasal injury as part of major trauma or with associated neurologic changes warrants emergent evaluation Initial Assessment The mechanism of injury should be solicited to assess for risk of other associated concerns (e.g., closed head injury) Physical examination should focus on a careful assessment for nasal septal hematoma, obvious fracture or nasal deviation, and signs of associated ophthalmologic or severe head injury CSF leak should be considered with any clear fluid drainage from the nose Associated sinus fractures may be identified by crepitus or tenderness over the sinus Management When the history and/or examination are concerning for a simple nasal fracture, no diagnostic imaging is indicated If there is concern for CSF leak, fluid can be tested using the halo test (see above), or by assessing glucose concentration Beta2-transferrin testing is the most accurate, though results are often not available in a timeframe to be useful during acute evaluation and management Maxillofacial CT imaging may be performed if there is concern for associated bony injuries (see Chapters 107 Facial Trauma and 114 Ocular Trauma ) but is not indicated for isolated nasal fractures If persistent nasal bleeding occurs in the setting of nasal trauma, apply direct pressure, topical vasoconstrictors, and ice Routine packing and/or splinting is not indicated Once the bleeding has stopped, treatment for simple nasal fractures is supportive care with pain management and follow-up with otolaryngology or plastic surgery to assess for deformity in to days (see Fig 106.1 ) It is important that patients are followed up by an otolaryngologist to manage deformities which can occur in up 10% of injuries There is no significant difference in deformity rate for closed versus open reduction, local versus general anesthesia, and acute versus delayed repair Deformities that are not corrected lead to more functional (e.g., nasal obstruction) and cosmetic problems Compound nasal fractures or those with associated midface fractures should be treated with antibiotics for week Isolated sinus fractures should be treated with antibiotics for week and the patient should maintain “sinus precautions” which include avoidance of nose blowing, straining, swimming, and use of a straw Follow-up for sinus fractures should also occur at week, although they rarely require subsequent intervention Nasal septal hematomas should be incised and drained, and nasal packing or a pressure dressing should be left in place to avoid reaccumulation Follow-up is critical to assess for reaccumulation Admission and elevation of head of the bed is indicated for children with suspected CSF leak FIGURE 106.1 A: Postinjury edema may mask underlying nasal bone deformity B: Nasal deformity manifests as edema subsides Sinus Barotrauma Sinus barotrauma occurs when changes in pressure are not equalized by the sinus ostia between the paranasal sinuses and nasal cavities Increased differential in negative pressure causes mucosal blood vessel engorgement followed by hemorrhage into the sinuses Patients usually present with sinus pain and a history