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 7 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 1 in 5 nasal injuries presenting to the ED will have a
nasal fracture, with higher risk in younger children (i.e., less than 5
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 4 to 7 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 1 week. Isolated sinus fractures should be treated with
antibiotics for 1 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 1 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