ENT Part 2: who nose?

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Here is the second part in our three part ENT series looking at recognition and management of common paediatric ENT conditions.This series is based on a presentation by Rahul Santram, adapted by Tessa Davis, and checked by our resident ENT surgeon, Sinéad Davis.

Part 1 was on – the ear. Today, we look at the nose. Part 3 is on – the throat.


Rhinitis

Rhinitis is an inflammation of the nasal mucosal lining (infective or allergic).

Most kids with nasal discharge have a viral URTI.

More than 100 viruses have been implicated including: rhinovirus; coronavirus; parainfluenza; and RSV. The colour and thickness of nasal discharge alone does not predict whether bacterial infection is present.

Symptoms

Patients usually get symptoms of a viral URTI – low grade temp, rhinorrhoea, cough, and a sore throat. Symptoms resolve within ten days.

If symptoms last longer than 10 days, with little improvement, then we need to suspect bacterial superinfection.

If there is a unilateral foul purulent nasal discharge – consider a foreign body

Treatment

Keep up hydration.

Aspirate nasal secretions.

Give analgesia and antipyretics for comfort.

What about allergic rhinitis?

  • Most prevalent in school age years and rare <2 years of age
  • May be classified as intermittent/persistent and as mild/moderate-severe

Symptoms include:

  • Rhinorrhoea, nasal obstruction, nasal puritis and sneezing
  • Epistaxis is commonly associated with allergic rhinitis

Diagnosis:

  • Nasal mucosa is moist and congested
  • Inferior turbinates might have a blue/violet hue, due to significant congestion
  • Mucopurulent discharge maybe present in children, making a distinction from rhinosinusitis difficult based on clinical findings alone

Management:

  • Antihistamine
  • Topical corticosteroid spray, if age appropriate.

Sinusitis

Acute sinusitis is an inflammation of the paranasal sinuses of less than three weeks duration. Chronic sinusitis results from an unresolved acute sinusitis, which has persisted >12 weeks.

Ethmoid and maxillary sinuses are present at birth. The sphenoid sinus develops between three and five years of age. The frontal sinus develops between seven to ten years of age

Diagnosis of sinusitis is based on clinical features – sinus transillumination is not reliable for diagnosis.

Sinusitis is rare in children but complicates 0.5-5% of URTIs.

Causes

The paranasal sinuses most commonly become obstructed following viral URTIs.

Bacteria causes include – Strep pneumoniae, moxarella and haemophilus. Dental infections are an important cause.

Fungus may also cause infection but these are extremely rare in children who are not immunocompromised.

Symptoms

Patients present with fever and facial pain. In bacterial cases the facial pain and sinus congestion persist beyond the viral syndrome of cough and fever, which has often been relatively mild.

Sphenoid sinusitis causes retro-orbital pain or vertex headache.

Diagnosis

Diagnosis is usually clinical.

There is often a purulent nasal discharge.

Facial swelling, of the cheek (maxilla) or periorbital regions, may be seen in more definitive cases.

Plain radiographs have no role.

CT of sinuses are reserved for those suspected of having complicated sinusitis and sphenoid sinusitis.

Management

Nasal decongestants for three to five days only.

Amoxycillin, augmentin, or a third generation cephalosporin.

Add anti-pseudomonal cover in HIV and CF patients.

Complications

Complications are due to extension of infection:

  • Facial cellulitis
  • Orbital cellulitis
  • Cavernous sinus thrombosis
  • Meningitis
  • Cerebral abscess
  • Pott’s puffy tumor

Beware of mucomycosis – this can invade sinuses, presents with a black eschar on the nasal mucosa. It is a fungal infection seen predominantly in HIV and diabetes mellitus.


Epistaxis

Common in paediatrics and occurs at any age. Though often occurs at night (due to unconscious nose scratching/picking), bleeding may occur at any time.

6-9% of children are affected – this is usually mild and doesn’t present to ED.

Patients tend to present if the epistaxis is recurrent or frequent, which is often the case in allergic rhinitis.

Bleeding can be unilateral or bilateral.

Findings

90% of bleeds are from Kisselbach’s plexus (Little’s area). They usually settle with compression.

Treatment

No active bleeding: nasal antiseptic cream or vaseline is as effective as cautery.

If there is a family history of bleeding disorders, or large volumes of bleeding – investigate for bleeding disorder.

Active bleeding: tilt the head forward (allowing the child to spit out the blood) and apply an ice pack to the nose, while continuing to apply compression.

Ongoing bleeding in the presence of nasal deformity following recent trauma may require manipulation of nasal bones before the epistaxis can be controlled. ENT assessment is advisable.

A posterior bleed, is rare in children in the absence of trauma, but is suspected when an anterior source is not identified and the bleeding has been reported as heavy. Bleeding from both nostrils, or blood seen draining into the posterior pharynx after the anterior source has been controlled, needs assessment by ENT colleagues.

Antibiotics are not usually required unless a prolonged duration of nasal packing is anticipated.


Nasal trauma

The main injuries are abrasions, lacerations, and sof tissue injury but fractures, dislocations, and cartilage damage also occur.

The nasal bone is the most commonly fractured bone of the human body.

It is common in children (males > females) and is usually as a result of falls and fights.

Findings

Patients usually have associated epistaxis.

It is hard to assess the extent of injury in the acute setting due to swelling.

You should examine for septal deviation and septal haematoma which will need ENT attention.

Management

Most won’t need much apart from ice and analgesia.

Follow-up should be in 3-5 days when swelling has settled to assess for deformity. Referral should be made to ENT is there is deformity after the swelling resolves.

Complications

There is a risk of a septal abscess which can, rarely, lead to meningitis and/or cavernous sinus thrombosis.

 


Nasal foreign body

This is common in paediatrics, particularly in children aged two to five years – they are usually brought into ED within 24 hours.

Delayed presentation is often with purulent unilateral nasal discharge. Other symptoms include halitosis, sneezing, snoring and mouth breathing.

The foreign body is often visible. Button batteries need removal ASAP as there is risk of tissue necrosis.

Management

Most are successfully removed in ED.

First, block the contralateral nostril and try to get the child to blow their nose. Or if they are too young for this, ask the parent to hold one nostril and blow firmly into the child’s mouth.

If this fails then:

  • Spray nose with co-phenylicaine
  • Repeat the above step

Failing that, restraint is likely to be necessary, as per foreign body removal from the ear.

  • Good light source

Choose the right tool for thejob:

  • Alligator or Bayonet forceps – removal of a soft FB, but not for a bead
  • Suction
  • Right angle hook – if you can get past the foreign body e.g. a bead
  • Ballon catheter – if the hook doesn’t work but you can slip the catheter past
  • PPV ventilation

If this fails, then refer to ENT.

Complications include: epistaxis; infection; and septal perforation.

 

 

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About 

Tessa Davis is a paediatric emergency registrar from Glasgow and Sydney, but currently living in London. Tessa tries to spend time with her 3 kids in between shifts. @tessardavis | + Tessa Davis | Tessa’s DFTB posts

Author: Tessa Davis

Tessa Davis is a paediatric emergency registrar from Glasgow and Sydney, but currently living in London. Tessa tries to spend time with her 3 kids in between shifts. @tessardavis | + Tessa Davis | Tessa’s DFTB posts