In this lecture, we’ll discuss
epistaxis, nasal trauma and sinusitis.
Everything about noses.
So epistaxis and nasal trauma first.
Most nosebleeds in children are
from digital manipulations.
Nosebleeds can be
severe and are common
and do not mean there’s
necessarily a bleeding disorder.
But very rarely, it can be truly excessive
and then it’s a bleeding disorder.
With that said, we see this all the time.
About half of children will have a
nosebleed between the ages of 6 and 10
and in children under 2 though,
that’s when you might think about
something like child abuse as a cause.
So why are your anterior bleeds so common?
Well, the anterior bleeds are
usually from digital trauma
and they arise from the
So the Keisselbach plexus is
right in that anterior chamber
and is very prone
to easy bleeding.
Posterior bleeds are more likely to
result in swallowed blood and emesis
and those are usually
pathologic and far rarer.
So if we have a child with an
anterior bleed, what do we do?
The first thing to do is apply pressure.
And don’t constantly check.
Just put both fingers over
the edge of the nose,
usually with a gauze or a Kleenex
and squeeze and do not
let up for 15 minutes.
Almost all will stop on their own.
You can also ice the nasal bridge to
constrict some of the plexus blood
and you can also if you wish, use
an intranasal vasoconstrictor
like a puffer that you use for colds
with phenylephrine or some
equivalent alpha agonist,
it will also cause a vasoconstriction in
the nose and may prevent some bleeding.
If it’s very severe because
of a deep excoriation,
you could use silver
nitrate as well.
If that still hasn’t worked, that’s when
we might use something like packing.
Oftentimes, we’ll use either a nasal tampon,
which is a device used for the nose
or we can also use a foley or
some other inflatable device.
They market them periodically, that
inflate both in the back and front
and can encapture that area with
blood and prevent further bleeding.
You should consider a workup for a bleeding
only if problems are truly hard to stop
and then you would of course, get a
CBC to look for thrombocytopenia
and a PT/PTT to look for
So we would always pack the nose
in the event of a posterior bleed.
Posterior bleeds are very unusually and
usually will present with some anemia
because this bleed can go on for
quite a while with swallowed blood.
For that, you definitely want to
consult ear, nose and throat doctor
for direct imaging or consider an MRI of
the head to look for some posterior tumor
or some other source of bleed.
If the bleed is from nasal trauma,
the most important thing to do
is to inspect the nasal septum.
In fact, and child who’s
incurred direct nasal trauma,
say from a baseball to the nose,
you should inspect the septum.
The septum is the space between
the nostrils up inside.
If that is wider than it should be,
if you can see the septum up the
nose when you’re looking up there,
that patient is going to
have a cosmetic problem,
unless you immediately solve the problem.
The idea there is that a septal
hematoma is a surgical emergency
because if left unchecked, it can eventually
result in a saddle nose deformity,
which is very hard to reconstruct and
reconfigure with plastic surgery.
For nasal fractures, we typically
will set them immediately
or after healing, they can go see an ear,
nose and throat doctor and have them reset.