What is the appropriate assessment and management approach for a pediatric patient with a nose injury, considering their medical history and potential symptoms such as bleeding, difficulty breathing, or nasal discharge?

Assessment and Management of Pediatric Nose Injury

Immediate Examination Priorities

Every child with nasal trauma requires a complete intranasal examination to detect septal hematoma, which demands urgent drainage to prevent cartilage necrosis and permanent deformity. 1, 2

Critical First Step: Rule Out Septal Hematoma

• Perform anterior rhinoscopy on all patients after removing any blood clot to visualize the nasal septum 3, 1
• Use an otoscope with nasal adapter in young children for adequate visualization 4, 3
• Look specifically for a bluish, fluctuant swelling on the septum—this is a septal hematoma requiring urgent drainage within hours 1, 2
• Untreated septal hematomas can progress to abscess formation and cause irreversible cartilage resorption, leading to saddle nose deformity 1

Complete Intranasal Assessment

Examine for the following pathology 4, 3, 1:

• Septal deviation, dislocation, or perforation 4, 1
• Mucosal lacerations requiring repair 1
• Nasal fractures (displaced vs. undisplaced) 2, 5
• Foreign bodies (present in 7% of pediatric epistaxis cases, causing unilateral bleeding with foul-smelling discharge) 6
• Telangiectasias (suggests hereditary hemorrhagic telangiectasia if bilateral recurrent bleeding) 3, 6

Management of Active Bleeding

If epistaxis is present, follow this algorithmic approach:

First-Line Treatment (0-15 minutes)

• Seat the child with head slightly forward (not tilted back) to prevent blood from flowing into airway or stomach 3
• Apply firm, continuous pressure to the soft lower third of the nose for a full 10-15 minutes without checking if bleeding has stopped 3
• Have the child breathe through their mouth and spit out blood rather than swallowing it 3

Second-Line Treatment (if bleeding continues)

• Clean the nasal cavity of clots by gentle suction or nose blowing 3
• Apply topical vasoconstrictor spray (oxymetazoline or phenylephrine) 2 sprays into the bleeding nostril 3
• Resume firm compression for another 5-10 minutes 3
• This stops bleeding in 65-75% of emergency department cases 3

Third-Line Treatment (if bleeding persists after 15-30 minutes)

• Nasal packing is indicated for failure of compression and vasoconstrictors 3
• Use resorbable packing materials only (Nasopore, Surgicel, Floseal) in children to reduce trauma during removal 3

Imaging and Laboratory Studies

When Imaging is NOT Indicated

• X-rays are not helpful for assessment of traumatic nasal injuries 2
• Do not obtain imaging (CT or plain films) for uncomplicated epistaxis or to distinguish sinusitis from viral URI 6

When CT is Indicated

• Only if suspected orbital, maxillary, frontal, or zygomatic fractures are present 2

When Laboratory Studies are Indicated

Obtain coagulation studies with hematology referral when: 6

• Positive family history of bleeding disorders 6
• Severe or bilateral recurrent episodes of epistaxis 6
• Associated bruising, petechiae, or other bleeding manifestations suggesting immune thrombocytopenia 6
• Recurrent bilateral nosebleeds (consider hereditary hemorrhagic telangiectasia) 3, 6

Blood tests including complete blood count and coagulation screening may be indicated in severe epistaxis 2

Fracture Management

Undisplaced Fractures

• Manage conservatively without intervention if no functional symptoms are present 2

Displaced Fractures

• Refer for reduction within a 2-week window before displaced nasal bones start uniting 2, 5
• Closed reduction is the standard treatment, though this carries significant risk of posttraumatic deformities requiring secondary surgery 5

Special Considerations in Specific Age Groups

Newborns and Infants

• Nasal obstruction from trauma causes feeding difficulty and respiratory distress—these are indications for surgery 7
• Prenatal fractures generally have favorable evolution 7
• Obstetrical traumas require more aggressive management due to feeding problems 7

School-Age Children

• Nasal fractures are often associated with other facial lesions from sports or car accidents 7, 5
• Sports injuries account for 25% and auto accidents for 40% of pediatric nasal fractures 5

Post-Treatment Care and Prevention

After bleeding control or fracture management 3:

• Apply petroleum jelly or lubricating agents to nasal mucosa to prevent recurrence 3
• Use saline nasal sprays and humidifiers regularly to keep mucosa moist 3
• Avoid nasal manipulation, vigorous nose-blowing, and nasal decongestants for 7-10 days 3

Critical Pitfalls to Avoid

• Never miss a septal hematoma—this is the most time-sensitive complication requiring drainage within hours 1, 2
• Never perform bilateral simultaneous septal cautery—this increases risk of septal perforation 3
• Never assume "minor" nasal injuries are insignificant—untreated septal trauma leads to considerable functional and cosmetic abnormalities 1
• Never rely on X-rays for nasal trauma assessment—they provide no useful information 2

When to Refer to Specialist

Immediate otolaryngology referral is indicated for 3, 1:

• Confirmed or suspected septal hematoma 1, 2
• Displaced nasal fractures requiring reduction 2
• Recurrent bleeding despite appropriate treatment 3
• Unilateral epistaxis with suspected foreign body or mass 6
• Adolescent males with unilateral, unprovoked, profuse epistaxis (rule out juvenile nasopharyngeal angiofibroma) 6