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 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 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