Basics
Description
- Epistaxis: bleeding from the nostril, nasal cavity, or nasopharynx
- Classified as anterior when noted through the nares or posterior when noted through the nasopharynx
Epidemiology
- More than 50% of children aged 6 " 15 years will experience epistaxis.
- Rarely seen in children younger than age 2 years
- Anterior epistaxis more common in children
- Occurs more frequently in the cold winter months when there is low humidity and when upper respiratory tract infections are more frequent
Risk Factors
- Mucosal dryness (also known as rhinitis sicca) is a frequent precursor to episodes of epistaxis as are upper respiratory tract infections.
- Children with allergic rhinitis are more prone to epistaxis.
General Prevention
- Keeping nasal passages moist with the use of humidifiers and saline nasal sprays or ointments (e.g., Vaseline) help reduce mucosal irritation and dryness.
- Ensure fingernails are short and nasal trauma (i.e., nose picking, foreign body) is discouraged
- Use appropriate protective athletic equipment to avoid trauma.
Pathophysiology
- Blood supply to the nasal cavity contains multiple anastomoses that originate from both the internal and external carotid arteries.
- Kiesselbach plexus located in the anteroinferior aspect of the nasal septum is the most common site of bleeding.
- The thin mucosal surface of the nasal septum and the lateral nasal walls is fragile and thus prone to inflammation and drying.
Etiology
- Most episodes of epistaxis are due to local inflammation and/or trauma:
- Upper respiratory infections, allergic rhinitis, rhinosinusitis, nasal vestibulitis, colonization of nasal cavity with Staphylococcus aureus
- Digital trauma, facial trauma, foreign bodies, inhalants/irritants (intranasal corticosteroids, cocaine, heroin)
- In pediatric population, epistaxis is less likely a sign of systemic illness:
- Bleeding disorders: von Willebrand disease, hemophilia, idiopathic thrombocytopenic purpura, hematologic malignancies
- Coagulopathy secondary to systemic infection, hepatic disease, renal failure, chronic aspirin or NSAID use
- Local structural/vascular abnormalities
- Septal deviation, rhinitis sicca, spurs, nasal polyps
- Telangiectasias (Osler-Weber-Rendu disease)
- Nasal neoplasms: juvenile angiofibroma, papillomas, hemangiomas
Commonly Associated Conditions
- Frequently associated with viral upper respiratory infections, allergic rhinitis, nose picking
- More than 90% of children with epistaxis do not have an underlying systemic cause.
Diagnosis
History
- Frequency and duration
- Laterality of the nosebleed
- Local trauma (nose picking, foreign body)
- Upper respiratory tract infection
- Allergies
- Obstruction
- Discharge
- Medications or drug use
- NSAIDs, aspirin, anticoagulants, cocaine
- Alternative medicines: garlic, ginkgo, ginseng
- Personal or family history of bleeding disorders, easy bruising, significant bleeding from minor wounds, frequent or heavy bleeding
- Menstrual history if applicable
Physical Exam
- Vital signs
- Use a good light source to perform direct visualization and inspection of nostril, nasal cavity, nasopharynx, and oropharynx.
- Exam of the nose may be facilitated by application of a topical vasoconstricting agent and/or anesthetic agent to enhance view and slow any current bleeding.
- General exam with particular attention to the skin (bruising, petechiae, purpura, icterus, pallor), lymph nodes, liver, and spleen
Diagnostic Tests & Interpretation
- Most episodes are minor and do not require intervention or medical evaluation.
- If history and physical exam are reassuring, diagnostic evaluation is not warranted in healthy children with easily controlled anterior epistaxis.
- If suspicious findings on history or physical exam or child has chronic recurrent epistaxis, laboratory evaluation including complete blood count with platelet count and coagulation panel are indicated.
- Studies suggest that 5 " 10% of children with chronic recurrent nosebleeds may have mild undiagnosed von Willebrand disease so consider further laboratory tests to include plasma von Willebrand factor (VWF) antigen, VWF activity, and factor VIII activity.
- Persistent unilateral bleeding warrants nasal endoscopy to rule out neoplasm.
Differential Diagnosis
Epistaxis is a common occurrence in healthy children. A detailed history and physical exam should help identify children with systemic causes for epistaxis, including bleeding disorders and malignancies.
Treatment
Acute
- Elevate the head.
- Direct pressure, applied by gently squeezing the nostrils, is usually sufficient to stop most nosebleeds.
- Vasoconstricting agents (0.25% phenylephrine, 0.05% oxymetazoline, 1:1,000 epinephrine, or 1 " 5% cocaine) will help reduce bleeding as well as improve visualization.
- Absorbable hemostatic agents, such as Floseal, a bovine-derived gelatin matrix, can also be used for refractory bleeding.
- Parental reassurance is an important, but often neglected, aspect of therapy.
Chronic
- Aggressive moisturization including saline irrigation, Vaseline applied with a Q-tip, and sleeping with a humidifier are important for prevention.
- Avoidance of trauma such as repetitive digital manipulation
- Silver nitrate cautery can be performed selectively on prominent vasculature on the anterior septum known as Kiesselbach plexus. This should only be done unilaterally to avoid the risk of septal perforation. If adequate time is given for healing (approximately 1 month), cautery can be performed on the contralateral side.
- For persistent bleeding despite silver nitrate cautery, more powerful cauterization such as Bovie electrocautery can be performed. This procedure is generally not tolerated in patients without general anesthesia.
- In rare cases that do not respond to cautery, vessel embolization by an interventional radiologist or surgical vessel ligation may be required.
Issues for Referral
Otorhinolaryngologic consultation may be needed for severe nosebleeds or when posterior nasal packing, fracture reduction, surgery, or embolization is required. Nasal endoscopy is now routinely used.
Ongoing Care
Follow-up Recommendations
- Nosebleeds are easily controlled and self-limited in most instances.
- Referral to an otorhinolaryngologist is indicated for patients with specific local abnormalities, such as polyps, tumors, or vascular malformations, or severe nosebleeds, recurrent nosebleeds, and/or posteriorly located nosebleeds.
- Identification of systemic illness may require referral to the appropriate specialist.
Patient Monitoring
- Blood clots in the nasopharynx should be removed to enhance visualization.
- Failure to detect a posterior location within the nasal cavity as the source of bleeding may interfere with measures to control bleeding.
- After nasal packing, it is essential to examine the oropharynx to confirm adequate hemostasis.
- Absorbable-type packing should be used, if required, in patients with bleeding disorders. Removable packings are prone to rebleeding on removal.
- Impregnation of nasal packings with antibiotic ointment reduces the risk of toxic shock syndrome.
Patient Education
Families should be given instructions in basic first aid for nosebleeds because minor insults, such as sneezing or excessive manipulation, may cause nosebleeds to recur.
Prognosis
- Uncomplicated epistaxis is most often self-limited or resolves with simple first-aid techniques.
- Refractory or recurrent epistaxis may require more specialized techniques by an otorhinolaryngologist.
Complications
- Usually uncomplicated
- Rare complications: significant blood loss, airway obstruction, aspiration, and vomiting
Additional Reading
- Bernius M, Perlin D. Pediatric ear, nose, and throat emergencies. Pediatr Clin North Am. 2006;53(2):195 " 214. [View Abstract]
- Calder N, Kang S, Fraser L, et al. A double-blind randomized controlled trial of management of recurrent nosebleeds in children. Otolaryngol Head Neck Surg. 2009;140(5):670 " 674. [View Abstract]
- Gifford TO, Orlandi RR. Epistaxis. Otolaryngol Clin North Am. 2008;41(3):525 " 536. [View Abstract]
- Melia L, McGarry GW. Epistaxis: update on management. Curr Opin Otolaryngol Head Neck Surg. 2011;19(1):30 " 35. [View Abstract]
- Qureishi A, Burton MJ. Interventions for recurrent idiopathic epistaxis (nosebleeds) in children. Cochrane Database Syst Rev. 2012;9:CD004461. [View Abstract]
- Viehweg TL, Roberson JB, Hudson JW. Epistaxis: diagnosis and treatment. J Oral Maxillofac Surg. 2006;64(3):511 " 518. [View Abstract]
Codes
ICD09
ICD10
SNOMED
- 12441001 Epistaxis (disorder)
- 232354002 Anterior epistaxis
- 232355001 Posterior epistaxis
- 232356000 Traumatic epistaxis
FAQ
- Q: How should I explain to a child to stop a nosebleed that occurs at home?
- A: The child or parent should apply pressure by compressing the lateral cartilaginous surface of the external nose together for at least 5 minutes. It is important to keep the head elevated but not hyperextended to avoid aspiration of the blood. This can be accomplished either by sitting or standing while bending forward slightly at the waist. Avoid lying down or tilting the head backward. Avoid checking prior to 5 minutes have elapsed to see if bleeding has ceased.
- Q: When should I work-up a patient to ensure there is not an underlying systemic cause for epistaxis?
- A: Most children do not require laboratory evaluation. If the history or physical is concerning or the child has chronic recurrent epistaxis, initial laboratory evaluation may include complete blood count with platelets and coagulation panel. In addition, you can consider checking for von Willebrand disease, as data suggests that up to 5 " 10% of children with chronic recurrent epistaxis may have a mild form of the disease.