Local predisposing factors Trauma, direct and picking Nonaccidental in the preambulatory child Local inflammation: Acute viral upper respiratory tract infection (common cold) Acute infectious illnesses accompanied by nasal congestion: measles, infectious mononucleosis, acute rheumatic fever Bacterial rhinitis/sinusitis (Staphylococcal aureus ) Allergic rhinitis Rhinitis sicca Foreign body Nasal polyps (cystic fibrosis, allergic, generalized) Staphylococcal furuncle Drugs: Nasal corticosteroids Vascular malformations (telangiectasias as in Osler–Weber–Rendu disease, hemangiomas) Juvenile angiofibroma a Other tumors, granulomatosis, ectopic nasal tooth (rare) a Systemic predisposing factors Systemic lupus erythematosus (SLE) Congenital syphilis Hematologic disorders a Platelet disorders Quantitative: idiopathic thrombocytopenic purpura, leukemia, aplastic anemia Qualitative: von Willebrand disease, Glanzmann disease, uremia Hemophilias Clotting disorders associated with severe hepatic disease, disseminated intravascular coagulation (DIC), vitamin K deficiency Drugs: aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), warfarin, valproic acid, rodenticide Vicarious menstruation Hypertension a Arterial (unusual cause of epistaxis in children) Venous: superior vena cava syndrome or with paroxysmal coughing seen in pertussis and cystic fibrosis a Life-threatening condition TABLE 26.2 COMMON CAUSES OF EPISTAXIS Trauma (acute blunt and recurrent, minor) Foreign body Allergic rhinitis Rhinitis sicca Viral rhinitis While working to control bleeding, one should also seek its origin A posterior bleed is rare in children, but is important to identify since these bleeds are often harder to control and warrant more intensive therapy Blood seen in the oropharynx, blood in both nares, difficulty controlling bleeding despite adequate anterior pressure, and a normal anterior examination are more characteristic of a posterior nasal bleed but can be found with an anterior causative site Bleeding seen at any site in a child who has undergone tonsillectomy and/or adenoidectomy in the preceding to weeks is concerning and should prompt immediate evaluation by ENT (see Chapter 118 ENT Emergencies ) Patients with hemorrhagic diathesis will require correction of their underlying disorder in addition to procedural approaches described above to achieve hemostasis After treating any emergent problems, the evaluation should then proceed with a thorough history One should elicit frequency of nosebleeds, degree of difficulty in achieving hemostasis, frequency of upper respiratory infections and/or allergic discharge, symptoms of obstruction, and contributing factors such as recurrent trauma from nose picking or other causes Often asking children which finger they pick their nose with will elicit a more honest answer Other symptoms sometimes reported are sequelae of swallowed blood such as hematemesis or melena Since the differential diagnosis for these conditions includes systemic hemorrhagic disorders, one should elicit further history including family history of bleeding Menstrual history and any relation to epistaxis in adolescent girls is worth noting Physical examination must include a complete general examination with special attention paid to vital signs, including heart rate and blood pressure, evidence of hematologic disease (enlarged lymph nodes, organomegaly, petechiae, or pallor), and inspection of the nasal cavity after reasonable efforts to stop any active bleeding To facilitate the nasal examination, ask the child to blow his nose or use suction to clear the nares Using one’s thumb, the tip of the nose is pushed upward to allow examination of the vestibule, the anterior portion of the septum, and anterior portion of the inferior turbinate in search of the site of bleeding, mucosal color, excoriations, discharge, foreign body or other mass, or septal hematoma A good light source, body fluid precautions, and in some cases, a topical vasoconstrictor or decongestant can help A more thorough examination requires the use of a nasal speculum, which when passed vertically into the nares and opened, allows examination of the septum, turbinates, and middle meatus Involvement of a child life specialist, anxiolytic medications, or restraints may be necessary for such an examination in young children No laboratory workup is indicated in children without clinical evidence of severe blood loss, in whom systemic factors are not suspected, and for whom an anterior site of bleeding is identified and stopped readily with local pressure Reassurance and education about appropriate at-home management needs to be provided Home therapies may include use of a cool mist vaporizer to lessen rhinitis sicca An emollient, such as petroleum jelly or a topical antibiotic ointment, placed in the nostrils twice daily is useful for maintaining normal moistness of the nasal mucosa, and saline nasal spray may also be of some benefit Instructing parents to keep the child’s fingernails short is also helpful Occasionally, recurrent epistaxis during an acute upper respiratory infection or flare-up of allergic rhinitis may be lessened with use of an antihistamine– decongestant preparation, although care must be taken not to dry the nose excessively Potential side effects of these combination products argue against their use in children younger than years Evaluation for hemorrhagic diathesis should be performed in any child with pertinent positive findings on history, family history, or physical examination This usually would include prothrombin time, partial thromboplastin time, complete blood cell count, and a screening study for von Willebrand disease Importantly, mild bleeding abnormalities may, or may not, be detected by these screening studies, so referral to a pediatric hematologist should be considered on a case-by-case basis Certain medications, such as valproate, have been associated with epistaxis These considerations are outlined in the epistaxis algorithm ( Fig 26.1 ) Epistaxis i Rapid screen for severe blood loss, altered vital signs Unstable Stable i When stable Complete history, physical examination Yes Nasal findings? lNo Elevated blood pressure? i i i Yes i Stabilize patient ENT Consult Initiate hematologic workup Tumor Telangiectasia Polyps Furuncle Foreign body Bacterial rhinitis/sinusitis Rhinitis sicca Local trauma/irritation No t Flypertension Suspicion of occult nasal lesion or hemorrhagic diathesis, and/or severe epistaxis, frequent recurrence by history ? i i Yes No i ENT Consult CBC, PT, PTT von Willebrand screen Laboratory evidence of hematologic disorder ? jNo Yes i Minor trauma and/or local inflammation Hemophilias, leukemia, aplastic anemia, ITP, or other bleeding disorder Nasal lesion Mild hemorrhagic disease (von Willebrand disease, primary platelet disorders), or other systemic disease FIGURE 26.1 Approach to diagnosis of epistaxis ENT, ear, nose, and throat specialists; ORL, otorhinolaryngology; CBC, complete blood count; PT, prothrombin time; PTT, partial thromboplastin time; ITP, idiopathic thrombocytopenic purpura All patients discharged from the emergency department (ED) after evaluation for significant epistaxis should be given specific instructions on nares ... bleeding abnormalities may, or may not, be detected by these screening studies, so referral to a pediatric hematologist should be considered on a case-by-case basis Certain medications, such as... thromboplastin time; ITP, idiopathic thrombocytopenic purpura All patients discharged from the emergency department (ED) after evaluation for significant epistaxis should be given specific instructions