Pediatric emergency medicine trisk 142

CHAPTER 26 ■ EPISTAXIS
EVA M. DELGADO, FRANCES M. NADEL

INTRODUCTION
Epistaxis (nose bleeding) is a common symptom in young children and may be
alarming to parents due to overestimation of blood loss. It is usually encountered
first at about age 3 years and increases in frequency until peaking again in
adolescence. An orderly approach to the history and physical examination is
necessary to identify the small minority of patients who require emergent
hemorrhage control, laboratory investigation, or consultation with an
otorhinolaryngologist (i.e., an Ear Nose and Throat [ENT] specialist) for further
management.

PATHOPHYSIOLOGY
Minor trauma, nasal inflammation, desiccation, congestion, as well as the rich
vascular supply of the nose, contribute to the frequency of nosebleeds in
otherwise normal children. The nose is also a favored site for recurrent minor
trauma, especially habitual, often absent-minded picking. The nasal mucosa is
closely applied to the perichondrium and periosteum of the nasal septum and
lateral nasal walls giving little structural support to its supply of small blood
vessels. These vessels join to form plexiform networks like Kiesselbach plexus in
Little’s area of the anterior nasal septum, about 0.5 cm from the tip of the nose
and a frequent source of epistaxis blood (see Fig. 118.8 in ENT Emergencies).

DIFFERENTIAL DIAGNOSIS
Local Causes
Epistaxis is most often the result of local predisposing factors including
inflammation, irritation, infection, or trauma ( Table 26.1 ). The most common
causes of epistaxis are found in Table 26.2 . Acute upper respiratory infections,
whether localized as in colds or secondary to more generalized infections such as
measles, infectious mononucleosis, or influenza-like illnesses, contribute to the

onset of epistaxis. Nasal colonization with Staphylococcus aureus may predispose
to a more friable mucosa and to furuncles, both of which can cause epistaxis.
Allergic rhinitis and treatment of this condition with nasal corticosteroids can
lead to epistaxis. Rhinitis sicca refers to desiccation of the nasal mucosa due to


the use of heating systems in cold winter climates with low ambient humidity. It
is this hot, dry air that increases the risk of epistaxis. Rhinitis sicca is also
important to consider in the differential of a child with dependence on any
respiratory device that instills dry air into the nares such as nasal cannula, nasal
noninvasive ventilation, or other similar systems.
Inspection may reveal a nasal foreign body, which is sometimes suspected by
history of insertion or by reports of chronic or recurrent unilateral epistaxis
accompanied by mucopurulent drainage or foul breath. Also discoverable by
examination are telangiectasias (Osler–Weber–Rendu disease), hemangiomas, or
evidence of other uncommon tumors that cause nosebleeds. Juvenile
nasopharyngeal angiofibromas may be seen in adolescent boys with nasal
obstruction, mucopurulent discharge, and severe epistaxis. These benign tumors
may bulge into the nasal cavity, sometimes causing problems by invading
adjacent structures. A rare childhood malignant tumor, nasopharyngeal
lymphoepithelioma, may cause a syndrome of epistaxis, torticollis, trismus, and
unilateral cervical lymphadenopathy. Other rare local causes of epistaxis include
nasal diphtheria and granulomatosis with polyangiitis (formerly known as
Wegener’s).

Systemic Causes
Children rarely present with a nosebleed as their only manifestation of a more
systemic disease, though there are several conditions that can increase the risk for
epistaxis ( Table 26.1 ). In children with severe or recurrent nosebleeds, a
concerning family history, or constitutional signs and symptoms, the physician

should consider a systemic process. Von Willebrand disease and platelet
dysfunction are two of the more common systemic diseases that cause recurrent
or severe nosebleeds. Less common systemic factors include hematologic
diseases such as leukemia, hemophilia, and clotting disorders associated with
severe hepatic dysfunction or uremia. Arterial hypertension rarely is a cause of
epistaxis in children. Increased nasal venous pressure secondary to paroxysmal
coughing, which can occur in pertussis or cystic fibrosis, occasionally may cause
nosebleeds. Vicarious menstruation refers to a condition occasionally found in
adolescent girls in whom monthly epistaxis related to vascular congestion of the
nasal mucosa occurs concordant with menses and is presumably related to cyclic
changes in hormone levels. Nosebleeds in infants, especially preambulatory
children, are rare, and one should consider the possibility of child abuse,
asphyxiation, or some systemic disorder.

EVALUATION AND DECISION


Rarely are nosebleeds in children life-threatening or require more than simple
measures to gain control of hemorrhage. However, one’s evaluation should begin
with hemorrhage control and identification of children who are unstable by noting
alterations in the patient’s general appearance, vital signs, airway, color, and
mental status (see Chapter 10 Shock ). Steady pressure and efforts to calm the
child and family often provide sufficient treatment. The child can sit on a parent’s
lap with the head tilted slightly forward, and using some distraction such as a toy
or video, the adult can provide pressure to the anterior nose for 5 to 10 minutes to
achieve hemostasis. This is usually effective since most bleeding in children is
from the anterior nasal septum, but may be helped by the use of a cotton (dental)
roll under the upper lip to compress the labial artery. The addition of cotton
pledgets moistened with a few drops of oxymetazoline (Afrin) or epinephrine
(1:1,000), will occasionally be required to help achieve hemostasis. Topical

hemostatic agents are gaining in popularity for recalcitrant adult epistaxis, with
new data emerging in children. Persistent bleeding may require cautery of a
unilateral, anterior bleeding site with a silver nitrate stick, or in more severe
cases, nasal packing or the use of expandable nasal tampons (see Chapter 130
Procedures sections on Nasal Cauterization and Nasal Packing—Anterior and
Posterior). Patients who require nasal tampons face the risk of toxic shock
syndrome and so typically need antibiotics and ENT follow-up. More severe
epistaxis may require surgical or angiographic intervention (see Figure 118.9 in
ENT Emergencies, Algorithm for the management of epistaxis).


TABLE 26.1
DIFFERENTIAL DIAGNOSIS OF EPISTAXIS