1. Imaging with CT, MRI, MRA, or angiography will help define extent of nasopharyngeal neoplasms. Because of the highly vascular nature of JNA, biopsy should never be performed. NPC does, however, require tissue diagnosis.Workup to define extent of disease is necessary prior to chemotherapy and radiation therapy.

2. Treat patients with JNA using embolization 24-48 hours prior to surgical resection. Extent of tumor determines approach. Significant blood loss can occur with resection.

3. Rule out hematologic malignancies by appropriate blood work and bone marrow biopsy.

D. Coagulopathies. Hematologic malignancies or systemic illnesses associated with epistaxis should be sought by history and physical exam and confirmed by appropriate laboratory tests. Management of bleeding is directed toward correction of clotting abnormalities. Packing should be avoided; it can traumatize mucosa, creating a larger surface that rebleeds when packing is removed. In the event of active bleeding, a temporary packing of oxymetazoline is useful. Head elevation and measures to moisten mucosa, as discussed earlier (see V, A, 4), can be used to help prevent rebleeding.

E. Foreign Body. Anterior rhinoscopy is performed using appropriate lighting and instrumentation with skilled assistance to hold child. Consider using a papoose board. Frazier suction is used to rid nose of purulent exudate and confirm presence of a foreign body. Various instruments (eg, appropriately sized nasal forceps or an angled ear hook) can then be used to extract foreign material. If bleeding is not active, refer to otolaryngologist for outpatient extraction. After removal, child and parents should be given instructions to use saline nose spray to rid nose of purulent discharge. Prescribe an oral antibiotic to combat concomitant sinusitis.

Trauma. Avoidance of further trauma to mucosa and moisturizing therapy will allow healing and prevent rebleeding. With facial fractures, refer child to specialist for reduction. Systemic Illness. Correction of hematologic abnormalities associated with systemic disease is the mainstay of treatment.

VI. Problem Case Diagnosis. The 3-year-old boy was treated with a 2-week trial of aggressive measures to keep nasal mucosa moist. Nosebleeds persisted, and he was referred to an otolaryngologist. Nasal exam and cautery were performed in the operating room. Minimal manipulation of the septum caused brisk oozing from a small branch of the nasopalatine vessels. Silver nitrate failed to control bleeding, and electrocautery was applied. Patient was discharged the same day and did well on therapy of daily saline and petroleum jelly.

VII. Teaching Pearl: Question. What is the anatomic basis of direct pressure to the anterior septum to control epistaxis?

VIII. Teaching Pearl: Answer. The nasal mucosa has a rich blood supply from the anterior ethmoidal, sphenopalatine, and nasopalatine vessels. These vessels converge on the anterior septum. This area is easily traumatized from rubbing and picking. Turbulent airflow from septal deformities causes eddy currents and drying and cracking of mucosa, making this site the most common source of bleeding. Direct pressure on the area by pinching the nostrils for 5 minutes will control most uncomplicated nosebleeds.

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