Pediatric Primary Care (56 page)

•  External injury.

•  Nose picking.

•  Foreign bodies.

•  Chemical or caustic agents (including drugs).

3.  Rarely.

a.  Systemic illnesses.

•  Hematologic diseases.

•  Hypertension.

B.  Occurrence.

1.  Very common in children.

2.  Highest incidence 2-10 years of age.

3.  Often familial history.

C.  Clinical manifestations.

1.  Complaints of persistent, recurrent nosebleeds.

2.  May have history of:

a.  Recent or current URI.

b.  Allergies (especially nasal).

c.  Tarry stools.

d.  Medication or drug use.

e.  Persistent bleeding or bruising.

f.  Family history of epistaxis or bleeding disorders.

g.  Trauma: nose picking or foreign body insertion.

D.  Physical findings.

1.  Vital signs may reflect hypovolemia or underlying cause such as hypertension.

2.  Inspection of nose, nasopharynx, and oropharynx may reveal:

a.  Bleeding most commonly from medial anterior nares.

b.  Dry, crusted mucosa.

c.  Excoriation of mucosa, site of bleeding.

3.  General exam may find lymphadenopathy, hepatomegaly, petechial rashes, or pale skin, mucosa, nail beds.

E.  Diagnostic tests.

1.  Vital signs, including blood pressure.

2.  Hematocrit or CBC with platelets.

3.  If severe and persistent:

a.  CBC with platelets.

b.  Prothrombin and partial thromboplastic bleeding time.

F.  Differential diagnosis.

1.  Bleeding disorder: if severe and recurrent, child younger than 2 years, positive family history.

2.  Polyps, vascular abnormalities.

3.  Foreign body.

4.  Hypertension, renal disease.

G.  Treatment.

1.  Elevate head and lean forward.

2.  Pinch nares together for at least 10 minutes.

3.  Ice to nasal dorsum may be added.

4.  Packing (preferably absorbable), topical vasoconstrictive drugs may be needed.

5.  Referral to ENT if unmanageable or prolonged or abnormalities of nose.

H.  Follow up.

1.  Hct, 6-12 hours after bleed if concern for anemia.

2.  Return if unmanageable and/or persistent.

I.  Complications.

1.  Possibly mild anemia.

2.  Rare: airway obstruction, aspiration, vomiting.

J.  Education.

1.  Prevention.

a.  Humidification of air in home, especially bedroom.

b.  Nasal saline sprays, drops.

c.  Petroleum jelly applied sparingly to anterior nares.

d.  Protective athletic gear.

e.  Discouragement of nose-picking behaviors and vigorous blowing.

2.  Reassurance: amount of blood always looks greater than it is.

VI. FOREIGN BODY, NASAL

A.  Etiology.

1.  Small objects are often inserted into nose by children, causing full or partial obstruction of nares.

B.  Occurrence.

1.  Frequent, especially in young children age 3-6 years.

C.  Clinical manifestations.

1.  Child may have been observed.

2.  Initially, local symptoms of obstruction: swelling, sneezing, mild discomfort.

3.  Subsequently, persistent, purulent, unilateral discharge; may be bloody or foul smelling.

D.  Physical findings.

1.  Dependent on length of time obstruction has been present: see above symptoms. Obstruction is almost always unilateral.

2.  Examiner may be able to visualize object with nasal speculum or otoscope.

3.  Common objects include beads, buttons, toy parts, pebbles, candle wax, food, paper, cloth, button batteries.

4.  Tend to locate in floor of nasal passage or in the upper nasal fossa.

E.  Diagnostic tests.

1.  None.

F.  Differential diagnosis.

1.  Infection.

a.  Rhinosinusitis.

b.  Adenoiditis.

2.  Polyps.

3.  Nasal tumors.

G.  Treatment.

1.  Purulent discharge may need to be suctioned in order to visualize object.

2.  An older child may be told to occlude one side of nares and blow vigorously.

3.  A parent may blow gently through the child's mouth while occluding one side of the nose or an Ambu bag may be used.

4.  Removal requires:

a.  Good lighting.

b.  Topical anesthesia (generally lidocaine).

c.  Vasoconstrictor drugs (0.5% epinephrine to reduce mucosa edema).

d.  Alligator forceps, cerumen spoon (curved, wire ones best).

e.  Narrow tip suction.

f.  Passing a thin, lubricated, 5-6 Fr, balloon-tipped catheter past the foreign body, inflating balloon and pulling forward.

H.  Follow up.

1.  None, if successful removal and signs of infection clear within 1-2 days.

2.  Referral to ENT if unable or unlikely to remove easily.

3.  Consider behavioral/emotional assessment if is recurrent problem or developmentally inappropriate behavior.

I.  Complications.

1.  Chronic infection if undetected and/or not removed.

2.  Trauma to nares from removal procedure.

J.  Education.

1.  Close observation of children by caregivers.

2.  Limit access by small children to small objects.

3.  
Note:
If child swallows foreign body, especially coin, radiographic survey must be done to ensure object is in stomach. Child must be observed closely for hoarseness, dysphagia, drooling, gagging, vomiting, coughing, choking, and airway compromise including inspiratory stridor.

VII. INFECTIOUS MONONUCLEOSIS

A.  Etiology.

1.  Epstein-Barr (which is a herpesvirus) virus: 90% of cases.