eMedicine Specialties > Pediatrics: Surgery > Otolaryngology

Epistaxis

William Gluckman, DO, MBA, FACEP, Assistant Professor, Department of Surgery, Section of Emergency Medicine, University of Medicine and Dentistry of New Jersey, University Hospital; Attending Emergency Physician, St Joseph's Regional Medical Center; President and CEO, FastER Urgent Care
Robert Barricella, DO, FAAP, FACEP, Director of Pediatric Emergency Department and Emergency Fellowship, Assistant Professor, Department of Pediatrics, University of Medicine and Dentistry of New Jersey; Huma Quraishi, MD, Division Director, Assistant Professor, Department of Pediatrics, Division of Otolaryngology, University of Medicine and Dentistry of New Jersey; Sangeeta Lamba, MD, Resident Physician, Section of Emergency Medicine, University Hospital, University of Medicine and Dentistry of New Jersey

Updated: Oct 27, 2008

Introduction

Background

Epistaxis, or nosebleed, is a common pediatric complaint. Most incidents are rarely life threatening but cause significant parental concern.¹ Most nosebleeds are benign, self-limiting, and spontaneous but may also be recurrent. Many uncommon causes are also noted.

Epistaxis can be divided into 2 categories, anterior bleeds and posterior bleeds, based on where the bleeding originates.

Pathophysiology

Bleeding typically occurs when the mucosa is eroded and vessels become exposed and subsequently break. More than 90% of bleeds occur anteriorly and arise from the Little area, where the Kiesselbach plexus forms on the septum.² The Kiesselbach plexus is where vessels from both the internal carotid artery (anterior and posterior ethmoid arteries) and the external carotid (sphenopalatine and branches of the internal maxillary arteries) converge. These capillary or venous bleeds provide a constant ooze, rather than the profuse pumping of blood observed from an arterial origin.

Posterior bleeds arise further back in the nasal cavity, are usually more profuse, and are often of arterial origin. A posterior source presents a greater risk of airway compromise, aspiration of blood, and greater difficulty controlling bleeding.

Age

Epistaxis usually occurs in children aged 2-10 years. Occurrence is unusual in infants in the absence of a coagulopathy or nasal pathology (eg, choanal atresia, neoplasm). Local trauma (eg, nose picking) does not occur until later in the toddler years. Older children and adolescents also have a less frequent incidence. Consider cocaine abuse in adolescent patients.

Clinical

History

Most nosebleeds are reported as spontaneous events and are frequently related to nose picking or other trauma; therefore, investigate the various possibilities.
Foreign bodies inserted in the nose may also present with epistaxis, but bleeding may be less and accompanied by foul or purulent discharge if the object has been retained for some time. A unilateral nasal discharge suggests the presence of a foreign body.
- Children easily can insert small batteries from electronic devices (eg, calculators, watches, handheld video games) into their nostrils.
- Not only can local irritation and bleeding result, but these can leak and cause a chemical alkali burn that may result in local tissue necrosis. Severe complications (eg, nasal stenosis) can result from batteries.
- Removal is a priority; removing the batteries within 4 hours of insertion is best.
Obtain a history of aspirin or warfarin use. Include investigation of suspicion of accidental ingestion (consider accidental ingestion of rat poison in toddlers).
Obtain any family history of bleeding disorders or leukemia.
A history of frequent recurrent nosebleeds, easy bruising, or other bleeding episodes should make the clinician suspicious of a systemic cause and prompt a hematologic workup. Children with severe epistaxis are more likely to have required nasal cauterization, an underlying coagulopathy, a positive family history of bleeding, and anemia.
- Although unusual, children with bleeding disorders (eg, von Willebrand disease) can occasionally have normal coagulation profiles.
- More than one sample may be required to notice the abnormality due to biologic variability throughout the day.
Obtain a history of whether the bleed is unilateral or bilateral and if it occurs following exercise. Also, determine if the onset was during sleep or associated with a migraine.
Determine through history if hematemesis or melena occurred because posterior bleeding in particular may present in this fashion.

Physical

Nasal examination
- Use of a large-sized, otologic, handheld speculum can be helpful (see Media file 1).
- Begin the examination with inspection, looking specifically for any obvious bleeding site on the septum that may be amenable to direct pressure or cautery.
- Anterior bleeds from the nasal septum are most common, and the site can frequently be identified if bleeding is active.
- Carefully remove by suction any large amount of clot.
Pharynx examination
- Observe the posterior pharynx for constant dripping of blood that may signify a posterior rather than an anterior bleed.
- After placement of an anterior pack, reassess this area and, if bleeding is noted in the pharynx with an anterior pack in place, strongly consider a posterior bleed (see Media files 3-4).
Skin: Examine the skin for evidence of bruises or petechiae that may indicate an underlying hematologic abnormality.
Vital signs
- High blood pressure (HBP) rarely, if ever, causes epistaxis on its own; however, HBP may impede clotting. Check blood pressure and complete a workup if HBP is present.
- Persistent tachycardia must be recognized as an early indicator of significant blood loss requiring intravenous fluid and, potentially, transfusion.

Causes

The primary cause of epistaxis in children is minor trauma, such as nose picking (frequently in the setting of dry nasal membranes).
Other common causes of nosebleeds include direct trauma with or without nasal or facial fractures, foreign body, rhinitis, and exposure to warm and dry air causing dry membranes (rhinitis sicca). Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) and chronic use of nasal steroids for treatment of allergic rhinitis are also frequently involved.
Some less common causes include leukemia, Osler-Weber-Rendu syndrome, nasal tumors, and coagulopathies, both intrinsic (eg, hemophilia, Von Willebrand disease) and acquired (eg, accidental warfarin ingestion).
Excessive coughing causing nasal venous hypertension may be observed in pertussis or cystic fibrosis.
Arterial hypertension rarely causes epistaxis.
Children with migraine headaches have a higher incidence of recurrent epistaxis than children without the disease.³ The Kiesselbach plexus, which is part of the trigeminovascular system, has been implicated in the pathogenesis of migraine.⁴
Young infants with gastroesophageal reflux into the nose may have epistaxis secondary to inflammation.
Etiologies such as liver disease, which can lead to clotting factor deficiencies (II, VII, IX, X); Osler-Weber-Rendu syndrome, which causes capillary fragility; and nasal foreign bodies that cause local trauma can be responsible for rare cases of epistaxis.
Intranasal rhabdomyosarcoma, although rare, often begins in the nasal, orbital, or sinus area in children.
Juvenile nasal angiofibroma in adolescent males may cause severe nasal bleeding as the initial symptom.

Workup

Laboratory Studies

For the most part, laboratory studies are not needed for first-time or infrequent recurrences with a good history of nose picking or trauma to the nose.
If significant blood loss, leukemia, or malignancy is suspected or if recurrent bleeding occurs, perform a CBC count with differential.
If a coagulopathy is suspected, perform CBC count and obtain prothrombin time (PT)/activated partial thromboplastin time (aPTT) and bleeding time.

Procedures

Direct visualization with a good directed light source, nasal speculum (see Media file 1), and nasal suction should be sufficient in most patients.
Insertion of nasal packing or cautery may be indicated and is discussed in the Treatment section.

Treatment

Medical Care

Initial treatment begins with direct pressure by squeezing the nostrils together for 5-30 minutes straight, without frequent peeking to see if the bleeding is controlled. Usually only 5-10 minutes is required.
Patients should keep their heads elevated but not hyperextended because hyperextension may cause bleeding into the pharynx and possible aspiration. This maneuver works more than 90% of the time.
If bleeding is caused by excessive dryness in the home (eg, from radiator heating), patients may benefit from the following care options:
- Humidify the air with a cool mist vaporizer in the bedroom.
- Alternately, a metal basin of water may be placed on top of a radiator to humidify the ambient air.
- Nasal saline sprays are useful. Oxymetazoline (Afrin) may also be used, with fewer cardiac adverse effects. These agents should only be used for 3-5 days at a time to avoid rhinitis medicamentosa and tachyphylaxis.
- The physician may consider local application of bacitracin or petrolatum ointment directly to the Kiesselbach area with a cotton applicator to prevent further drying (studies recommend 2 wk).
- If direct pressure is not sufficient, gauze moistened with epinephrine at a ratio of 1:10,000 or phenylephrine (Neo-Synephrine) may be placed in the affected nostril to help vasoconstrict and achieve hemostasis.

Surgical Care

Cauterization of an identified small bleeding area (only one side should be cauterized at a time to avoid possible septal perforation)
- Can be performed with silver nitrate sticks
- Caution advised not to burn the entire septum or cause perforation (septal perforation is a risk)
- Performed in only one nostril at a time
- Used very judiciously; must avoid nasal tissues other than the bleeding site of septum
- Presents risk of nasal stenosis of the vestibule
Nasal packing items and procedures
- Quarter-inch strips of gauze impregnated with petroleum jelly, layered with the use of bayonet forceps (see Media file 2-3)
- Oxycel cotton with bacitracin, which dissolves and does not have to be removed, preferred by some (especially helpful in patients with leukemia)
- Merocel or other tamponlike packing that expands when water is injected into it (see Media file 4)
- Epistat, Rapid Rhino, or other balloon inflation catheter (see Media file 6)
- Ligation of vessels
- Angiographic embolization

Consultations

In all children in whom lesions are not observed in the Kiesselbach area, consider an otolaryngology consult for evaluation with a flexible or rigid rhinoscopy and nasopharyngoscopy to search for the source of bleeding and to rule out any lesions causing the bleeding. This is particularly important when epistaxis is combined with nasal airway obstruction, especially when unilateral obstruction is present. Most children older than 6 years can tolerate a well-coached flexible fiberoptic examination of the nasal cavity with a 3-mm scope without significant discomfort or mental trauma if the nose is anesthetized and decongested.

Other reasons for consultations are as follows:

Otolaryngologist and/or head and neck surgeon
- Bleeding uncontrolled by direct pressure or packing
- Practitioner unfamiliar with performing anterior nasal packing
- Suspected posterior nose bleed
Hematologist - Coagulopathy determined as cause of the epistaxis

Diet

While bleeding is occurring and the assessment is in process, the child should remain nothing by mouth (NPO). Once bleeding is controlled, a full diet can be started.

Activity

Patients with a simple controlled bleed may resume regular activity; however, instruct individuals not to forcefully blow or pick their noses. For a few days, avoiding contact sports or activities that may directly traumatize the nose is probably prudent.

Medication

Antibiotic agents

Antibiotics with staphylococcal and streptococcal coverage are required if nasal packing is placed. The oral route is used most commonly because most patients are treated on an outpatient basis. If the patient requires admission, initially use intravenous medications. Continue all antibiotics until the packing is removed.

Cephalexin (Keflex, Biocef)

First-generation cephalosporin arrests bacterial growth by inhibiting bacterial cell wall synthesis.

Dosing

Adult

250-500 mg PO qid

Pediatric

25-50 mg/kg/d PO divided qid

Interactions

Coadministration with aminoglycosides increases nephrotoxic potential

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment

Cephazolin (Ancef)

First-generation semisynthetic cephalosporin that arrests bacterial cell wall synthesis, inhibiting bacterial growth. Parenteral antibiotic.

Dosing

Adult

1 g IV q6h until packing removed or can tolerate PO

Pediatric

25-50 mg/kg/d IV divided q6-8h until packing removed or can tolerate PO

Interactions

Probenecid prolongs effect of cefazolin; coadministration with aminoglycosides may increase renal toxicity; may yield false-positive urine-dipstick test results for glucose

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment; superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy

Dicloxacillin (Dycill, Dynapen, Pathocil)

Binds to one or more penicillin-binding proteins, which, in turn, inhibits synthesis of bacterial cell walls. For treatment of infections caused by penicillinase-producing staphylococci. Available as a susp of 62.5 mg/5 mL.

Dosing

Adult

250-500 mg PO qid

Pediatric

12.5-25 mg/kg/d PO divided qid

Interactions

Decreases efficacy of PO contraceptives; increases effects of anticoagulants; probenecid and disulfiram may increase penicillin levels

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Monitor PT in patients taking anticoagulant medications; toxicity may increase in patients with renal impairment

Nafcillin (Nafcil, Nallpen)

Parenteral penicillinase-resistant (antistaphylococcal) penicillin.

Dosing

Adult

1-2 g IV q4h

Pediatric

50-200 mg/kg/d IV divided q4-6h

Interactions

Associated with warfarin resistance when administered concurrently; effects may decrease with bacteriostatic action of tetracycline derivatives

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

To optimize therapy, determine causative organisms and susceptibility

Sulfamethoxazole and trimethoprim (Bactrim, Septra, Cotrim)

Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.

Dosing

Adult

160 mg (trimethoprim)/800 mg (sulfamethoxazole) PO q12h (ie, 1 double-strength [DS] tab q12h)

Pediatric

5-10 mg/kg/d (based on trimethoprim component) PO divided bid

Interactions

May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly patients; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine

Contraindications

Documented hypersensitivity; megaloblastic anemia due to folate deficiency

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Do not use near term in pregnancy because of risk of kernicterus in the newborn; discontinue at first appearance of rash or sign of adverse reaction; obtain CBCs frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; caution in folate deficiency (eg, chronic alcoholics, elderly patients, those receiving anticonvulsant therapy, or those with malabsorption syndrome); hemolysis may occur in individuals with G-6-PD deficiency; patients with AIDS may not tolerate or respond; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation

Clindamycin (Cleocin)

Semisynthetic derivative of lincomycin that inhibits protein synthesis by binding to 50s ribosomal subunit. Available as 75-mg/5 mL oral suspension.

Dosing

Adult

300 mg PO qid
600 mg IV q8h

Pediatric

8-25 mg/kg/d PO divided tid/qid
20-40 mg/kg/d IV divided q6-8h

Interactions

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin

Contraindications

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Benzyl alcohol is used as a preservative and has demonstrated toxicity in neonates; adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile

Follow-up

Further Inpatient Care

When no airway concerns are present, no admission is usually necessary for a unilateral anterior pack.

Further Outpatient Care

If epistaxis continues following an emergency department visit, an otolaryngologist consultation for a full examination of the nasal cavity and nasopharynx with a flexible or rigid rhinoscopy and nasopharyngoscopy may be required.

Inpatient & Outpatient Medications

No medications are required for simple epistaxis. An antibiotic with staphylococcal coverage (eg, oral cephalexin, intravenous cephazolin) or antistaphylococcal penicillin (eg, orla dicloxacillin, intravenous nafcillin) is required for patients sent home or admitted with anterior or posterior packing in place.

Transfer

If bleeding cannot be controlled with direct pressure, transfer to an emergency department is required.
If bleeding cannot be controlled in an emergency department without an otolaryngologist, transfer is required to a facility with this service.

Deterrence/Prevention

Nose picking is difficult to deter and is going to occur. Keeping the child's nails well trimmed may be helpful.
Protection from direct trauma from some sports activities occurs with helmet and/or face piece use.
A hot dry home environment may benefit from humidifiers, better thermostatic control, saline spray, and antibiotic ointment on the Kiesselbach area.
Consider drug education relating to use or accidental ingestion of aspirin, warfarin (eg, rat poison in toddlers), or drug abuse in adolescents.

Complications

One complication is excessive bleeding to the point of shock requiring transfusion. If significant blood loss is apparent, undertake transfer to an emergency department for observation, frequent monitoring of vital signs, and completion of at least 2 hematocrits.
Airway compromise is another potential complication. Excessive bleeding into the pharynx causes coughing and gagging. If this occurs in an infant who is unable to roll over and clear the blood, aspiration and subsequent respiratory arrest occur.

Prognosis

Patients with epistaxis that occurs from dry membranes or minor trauma do well with no long-term effects.
Patients with bleeding from a hematologic problem or cancer have a variable prognosis.

Patient Education

For excellent patient education resources, visit eMedicine's Ear, Nose, and Throat Center. Also, see eMedicine's patient education article Nosebleeds.

Miscellaneous

Medicolegal Pitfalls

Failure to prescribe an antibiotic for patients treated as outpatients with nasal packing is a pitfall due to the risk of toxic shock syndrome and sinusitis.
Mistaking a posterior bleed for an anterior bleed and allowing a patient to go home, only to have the patient return a short time later with complications from excessive bleeding or aspiration, is another potential pitfall.
Failure to admit for observation all patients who require posterior nasal packing is a potential pitfall. Significant respiratory distress can occur from posterior packing, especially if it becomes dislodged.
Failure to consult an otolaryngologist and/or head and neck surgeon is another potential pitfall when bleeding cannot be controlled by direct pressure or packing, if the practitioner is unfamiliar with performing anterior nasal packing, or if a posterior nose bleed is suspected.

Multimedia

Media file 1: Nasal speculum.

Media file 2: Bayonet forceps.

Media file 3: Vaseline gauze packing.

Media file 4: Expandable (Merocel) packing (dry).

Media file 5: Expandable packing (after hydration).

Media file 6: Epistat anterior and/or posterior nasal catheter.

References

Moreau S, De Rugy MG, Babin E, et al. Supraselective embolization in intractable epistaxis: review of 45 cases. Laryngoscope. Jun 1998;108(6):887-8. [Medline].
Guarisco JL, Graham HD 3rd. Epistaxis in children: causes, diagnosis, and treatment. Ear Nose Throat J. Jul 1989;68(7):522, 528-30, 532 passim. [Medline].
Jarjour IT, Jarjour LK. Migraine and recurrent epistaxis in children. Pediatr Neurol. Aug 2005;33(2):94-7. [Medline].
Knight YE, Goadsby PJ. The periaqueductal grey matter modulates trigeminovascular input: a role in migraine?. Neuroscience. 2001;106(4):793-800. [Medline].
Burton MJ, Doree CJ. Interventions for recurrent idiopathic epistaxis (nosebleeds) in children. Cochrane Database Syst Rev. 2004;CD004461. [Medline].
Gupta N, Kamat D. A child with severe nosebleeds. Clin Pediatr (Phila). Mar 2007;46(2):184-6. [Medline].
McGarry G. Recurrent idiopathic epistaxis (nosebleeds). Clin Evid. Jun 2002;349-51. [Medline].
Sandoval C, Dong S, Visintainer P, et al. Clinical and laboratory features of 178 children with recurrent epistaxis. J Pediatr Hematol Oncol. Jan 2002;24(1):47-9. [Medline].
Shinkwin CA, Beasley N, Simo R, et al. Evaluation of Surgicel Nu-knit, Merocel and Vasoline gauze nasal packs: a randomized trial. Rhinology. Mar 1996;34(1):41-3. [Medline].
Teymoortash A, Sesterhenn A, Kress R, et al. Efficacy of ice packs in the management of epistaxis. Clin Otolaryngol Allied Sci. Dec 2003;28(6):545-7. [Medline].
Thaha MA, Nilssen EL, Holland S, et al. Routine coagulation screening in the management of emergency admission for epistaxis--is it necessary?. J Laryngol Otol. Jan 2000;114(1):38-40. [Medline].
Tseng EY, Narducci CA, Willing SJ, Sillers MJ. Angiographic embolization for epistaxis: a review of 114 cases. Laryngoscope. Apr 1998;108(4 Pt 1):615-9. [Medline].

Keywords

epistaxis, nosebleed, nose bleed, nasal hemorrhage, anterior bleed, posterior bleed, airway compromise, cocaine abuse, nasal stenosis, leukemia, von Willebrand disease, hematemesis, melena, rhinitis, allergic rhinitis, Osler-Weber Rendu syndrome, nasal tumors, hemophilia, pertussis, cystic fibrosis, intranasal rhabdomyosarcoma, nasal angiofibroma

Contributor Information and Disclosures

Author

Coauthor(s)

Robert Barricella, DO, FAAP, FACEP, Director of Pediatric Emergency Department and Emergency Fellowship, Assistant Professor, Department of Pediatrics, University of Medicine and Dentistry of New Jersey
Robert Barricella, DO, FAAP, FACEP is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians, and American Medical Association
Disclosure: Nothing to disclose.

Huma Quraishi, MD, Division Director, Assistant Professor, Department of Pediatrics, Division of Otolaryngology, University of Medicine and Dentistry of New Jersey
Huma Quraishi, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy and American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.

Sangeeta Lamba, MD, Resident Physician, Section of Emergency Medicine, University Hospital, University of Medicine and Dentistry of New Jersey
Sangeeta Lamba, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Orval Brown, MD, Director of Otolaryngology Clinic, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
Orval Brown, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Bronchoesophagological Association, American College of Surgeons, American Medical Association, American Society of Pediatric Otolaryngology, Society for Ear, Nose and Throat Advances in Children, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

John E McClay, MD, Assistant Professor, Department of Otolaryngology, Division of Pediatric Otolaryngology, Children's Medical Center, University of Texas Southwestern Medical School
John E McClay, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and American Medical Association
Disclosure: Nothing to disclose.

CME Editor

Paul D Petry, DO, FACOP, FAAP, Consulting Staff, Freeman Pediatric Care, Freeman Health System
Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Chief Editor

Glenn C Isaacson, MD, FACS, FAAP, Professor of Otolaryngology-Head and Neck Surgery and Pediatrics, Temple University School of Medicine
Glenn C Isaacson, MD, FACS, FAAP is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Bronchoesophagological Association, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Society of Pediatric Otolaryngology, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Covidien Honoraria Consulting

Further Reading