Nasal Bleeding (Epistaxis) in Children: Diagnostic Evaluation Learning Tool
Clinical History Assessment
Systematic approach to history taking for a child presenting with nasal bleeding (epistaxis)
Physical Examination Guide
Systematic approach to examining a child with nasal bleeding
Diagnostic Approach
Initial Assessment
For a child presenting with epistaxis, the initial assessment should include:
- Assessment of hemodynamic stability and airway patency
- Detailed history focusing on frequency, duration, and severity of bleeding
- Complete physical examination with focus on the nasal cavity
- Evaluation of contributing factors and underlying conditions
Classification of Epistaxis
Epistaxis can be classified based on location and severity:
| Classification | Description | Clinical Significance |
|---|---|---|
| Anterior vs. Posterior | Anterior (90%): Bleeding from Kiesselbach's plexus Posterior (10%): Bleeding from sphenopalatine artery |
Anterior: More common in children, easier to control Posterior: More severe, harder to control, higher risk |
| Primary vs. Secondary | Primary: Local causes (trauma, dryness) Secondary: Systemic causes (coagulopathy, vascular) |
Primary: Often self-limited Secondary: May require treatment of underlying condition |
| Severity Grading | Mild: Self-limited, stops with pressure Moderate: Requires medical intervention Severe: Requires hospitalization |
Guides management decisions and disposition |
Differential Diagnosis
| Category | Conditions | Red Flags |
|---|---|---|
| Local Causes |
- Digital trauma (nose picking) - Mucosal dryness - Foreign body - Nasal septal deviation - Allergic rhinitis |
- Recurrent unilateral bleeding - Visible foreign body - Nasal deformity - Persistent crusting - Septal perforation |
| Inflammatory/Infectious |
- Upper respiratory infections - Sinusitis - Rhinitis - Nasal polyps - Granulomatosis with polyangiitis |
- Purulent discharge - Facial pain/swelling - Fever - Saddle nose deformity - Systemic symptoms |
| Vascular Disorders |
- Hereditary hemorrhagic telangiectasia - Arteriovenous malformations - Juvenile nasopharyngeal angiofibroma - Hypertension |
- Family history of bleeding - Telangiectasias on lips/mouth - Male adolescent with severe posterior bleeding - Elevated blood pressure |
| Hematologic |
- Von Willebrand disease - Hemophilia - Thrombocytopenia - Leukemia - DIC |
- Family history of bleeding disorders - Concurrent bruising or petechiae - Bleeding from multiple sites - Prolonged bleeding time - Hepatosplenomegaly |
| Neoplastic |
- Juvenile nasopharyngeal angiofibroma - Nasal hemangioma - Rhabdomyosarcoma - Lymphoma |
- Unilateral nasal obstruction - Facial asymmetry - Persistent/recurrent unilateral bleeding - Mass visible in nasal cavity - Weight loss |
| Medication/Drug Related |
- Anticoagulants/Antiplatelets - Nasal steroids - Nonsteroidal anti-inflammatory drugs - Nasal decongestant overuse |
- Temporal relationship to medication use - Prolonged bleeding time - Mucosal atrophy - Rebound congestion |
Laboratory Studies
Consider these studies based on history and clinical presentation:
| Investigation | Clinical Utility | When to Consider |
|---|---|---|
| Complete Blood Count | Assess for anemia, thrombocytopenia, or leukemia | Recurrent/severe epistaxis, suspected hematologic disorder |
| Coagulation Studies (PT/PTT) | Evaluate coagulation cascade function | Severe, recurrent, or family history of bleeding disorders |
| von Willebrand Panel | Diagnose von Willebrand disease | Recurrent epistaxis, family history, additional bleeding symptoms |
| Liver Function Tests | Assess liver function which affects clotting factor production | Known liver disease, jaundice, hepatomegaly |
| Renal Function Tests | Evaluate for renal disease associated with bleeding | Hypertension, suspected vasculitis, hematuria |
Advanced Studies
Reserve for concerning presentations:
| Investigation | Clinical Utility | When to Consider |
|---|---|---|
| Nasal Endoscopy | Visualize posterior nasal cavity and nasopharynx | Recurrent posterior epistaxis, suspected mass, foreign body |
| CT or MRI of Sinuses/Nasopharynx | Identify masses, vascular malformations, occult fractures | Suspected tumor, persistent unilateral epistaxis, trauma |
| Angiography | Evaluate vascular malformations or tumors | Intractable bleeding, suspected vascular anomaly |
| Allergy Testing | Identify allergic triggers | Concurrent allergic symptoms, seasonal pattern |
| ANCA Testing | Diagnose granulomatosis with polyangiitis | Recurrent epistaxis with pulmonary or renal symptoms |
Diagnostic Algorithm
A stepwise approach to diagnosing and evaluating epistaxis:
- Assess airway and hemodynamic stability - address any immediate concerns
- Determine bleeding site (anterior vs. posterior) through visualization
- Evaluate for local causes - examine for trauma, foreign bodies, mucosal irritation
- Screen for systemic symptoms suggesting underlying disorders
- Assess pattern and severity - frequency, duration, amount of bleeding
- Targeted laboratory testing based on clinical suspicion
- Consider advanced imaging for recurrent, severe, or unilateral epistaxis
- Consultation with specialists as indicated (ENT, hematology)
Management Strategies
General Approach to Management
Key principles in managing epistaxis in children:
- Ensure hemodynamic stability: Prioritize ABC's (Airway, Breathing, Circulation)
- Localize bleeding source: Determine if anterior or posterior epistaxis
- Control active bleeding: Use stepwise approach based on severity
- Identify and address underlying causes: Treat contributing factors
- Prevent recurrence: Education and preventive measures
- Follow-up: Ensure resolution and monitor for recurrence
First Aid and Initial Management
| Intervention | Technique | Evidence and Considerations |
|---|---|---|
| Positioning |
- Seated upright, leaning slightly forward - Avoid lying flat or head tilt backwards - Apply cold compress to nasal bridge |
- Reduces blood pressure to nasal region - Prevents blood from flowing into posterior pharynx - Minimizes risk of aspiration |
| Direct Pressure |
- Pinch the soft parts of the nostrils together - Maintain continuous pressure for 10-15 minutes - Breathe through mouth during compression |
- High success rate for anterior epistaxis - Compression should be firm but comfortable - Insufficient duration is common reason for failure |
| Vasoconstriction |
- Oxymetazoline or phenylephrine nasal spray - Apply prior to compression - Limit use to acute management only |
- Reduces blood flow to nasal mucosa - Should be followed by direct pressure - Avoid prolonged use (>3-5 days) which can worsen symptoms |
| Ice Application |
- Apply ice pack or cold compress to nasal dorsum - Apply to back of neck - Use for 10-15 minutes |
- Induces vasoconstriction - Limited evidence but minimal risk - Adjunctive to direct pressure |
Medical Interventions
| Intervention | Technique | Evidence and Considerations |
|---|---|---|
| Chemical Cautery |
- Silver nitrate application to bleeding site - Apply for 5-10 seconds - Limit to one side of septum at a time |
- Effective for discrete anterior bleeding points - Avoid bilateral cautery (risk of septal perforation) - May cause temporary discomfort - 75-80% success rate |
| Nasal Packing |
- Anterior packing: Absorbable materials (Surgicel, Gelfoam) or non-absorbable packing - Posterior packing: Rarely needed in children - Duration: 24-72 hours depending on severity |
- Reserved for failure of compression and cautery - Antibiotic prophylaxis recommended if pack remains >24-48 hours - Posterior packing requires inpatient observation - Removal may trigger rebleeding |
| Topical Hemostatic Agents |
- Topical thrombin - Gelatin-thrombin matrix - Tranexamic acid-soaked gauze |
- Accelerates clot formation - Useful for patients with coagulation disorders - May be less traumatic than traditional packing - Limited pediatric data |
| Dissolvable Packing |
- Gelatin sponge - Oxidized cellulose - Hyaluronic acid derivatives |
- No need for removal (reduces trauma) - May be preferred in children - Less discomfort than traditional packing - Higher cost than traditional methods |
Advanced Interventions
For severe, recurrent, or refractory epistaxis:
| Intervention | Description | Indications and Considerations |
|---|---|---|
| Endoscopic Cauterization |
- Precise identification of bleeding sites - Electrocautery or laser cauterization - Performed under endoscopic guidance |
- Recurrent epistaxis despite conservative measures - Posterior bleeding sites - Requires ENT specialist - Often performed under general anesthesia in children |
| Arterial Ligation |
- Endoscopic sphenopalatine artery ligation - External carotid artery branch ligation - Maxillary or ethmoid artery ligation |
- Severe, intractable posterior epistaxis - Failure of conventional management - Performed under general anesthesia - Rare in pediatric population |
| Embolization |
- Endovascular occlusion of feeding vessels - Performed by interventional radiologist - Uses coils, particles, or liquid embolic agents |
- Last resort for intractable epistaxis - Reserved for older children/adolescents - Risk of serious complications (stroke, blindness) - Rarely indicated in pediatric patients |
| Septoplasty/Turbinate Reduction |
- Surgical correction of septal deviation - Reduction of hypertrophied turbinates - Combined with endoscopic evaluation |
- Recurrent epistaxis with anatomical abnormalities - Usually deferred until facial growth complete - Consider in adolescents with anatomic predisposition - Performed under general anesthesia |
Management of Specific Conditions
| Condition | Management Approach | Follow-up Recommendations |
|---|---|---|
| Digital Trauma (Nose Picking) |
- Parental education - Keeping nails trimmed - Nasal saline moisture - Petroleum jelly to anterior septum |
- Reassess in 2-4 weeks if persistent - Monitor for behavioral triggers - Consider reinforcement strategies |
| Nasal Dryness/Environmental Factors |
- Humidification of home environment - Nasal saline sprays (2-3 times daily) - Petroleum jelly or water-soluble gel to anterior septum - Adequate hydration |
- Follow-up if no improvement in 2-3 weeks - Seasonal adjustments to prevention strategies - Consider allergen reduction if allergic component |
| Allergic Rhinitis |
- Antihistamines - Nasal corticosteroids (use proper technique) - Saline irrigation - Allergen avoidance |
- Follow-up in 4-6 weeks - Consider allergy testing if poor response - Seasonal adjustments to therapy - Monitor for medication side effects |
| Coagulation Disorders |
- Hematology consultation - Factor replacement therapy if indicated - Antifibrinolytics (tranexamic acid) - Avoid NSAIDs and antiplatelet agents |
- Close follow-up with hematology - Education about bleeding precautions - Emergency care plan - Genetic counseling if hereditary condition |
| Nasal Foreign Body |
- Removal with appropriate instruments - Topical decongestant before removal - Consider sedation if needed - Post-removal saline irrigation |
- Immediate resolution expected - Follow-up if persistent symptoms - Education to prevent recurrence |
Prevention Strategies
- Environmental modifications: Humidification, avoiding dry heat, adequate hydration
- Nasal moisturization: Saline sprays, gels, petroleum jelly to anterior septum
- Behavioral interventions: Discourage nose picking, teach proper nose blowing technique
- Medical management: Control allergic rhinitis, proper use of nasal sprays
- Trauma prevention: Sports safety equipment, supervision during play
- Dietary considerations: Adequate vitamin K intake, omega-3 fatty acids
When to Refer
- ENT referral:
- Recurrent epistaxis (>3-4 episodes/month) despite conservative measures
- Severe bleeding requiring nasal packing
- Suspected posterior epistaxis
- Anatomic abnormalities requiring surgical correction
- Unilateral recurrent epistaxis (concern for mass lesion)
- Hematology referral:
- Suspected bleeding disorder (family history, multiple bleeding sites)
- Abnormal coagulation studies
- Severe anemia secondary to epistaxis
- Need for specialized hemostatic management
- Emergency department referral:
- Severe, uncontrollable bleeding
- Hemodynamic instability
- Significant blood loss or symptomatic anemia
- Need for airway management
- Other specialists:
- Rheumatology: Suspected vasculitis or autoimmune disease
- Allergy/Immunology: Severe allergic rhinitis, immunodeficiency
- Interventional Radiology: Consideration for embolization in severe cases
Patient and Family Education
- First aid techniques: Proper positioning, pressure application, when to seek emergency care
- Prevention strategies: Humidification, saline sprays, avoiding digital trauma
- Red flags: Signs indicating need for medical attention
- Medication administration: Proper nasal spray technique to avoid septal injury
- Follow-up plans: When to return for evaluation, importance of adherence to prevention
Introduction to Epistaxis in Children
Epistaxis, commonly known as nosebleed, is a frequent occurrence in the pediatric population. It affects up to 60% of children at some point during their childhood, with peak incidence between ages 3 and 8 years. While often benign, epistaxis can sometimes indicate underlying pathology and may cause significant anxiety for both children and parents.
Understanding the anatomy of the nasal cavity is crucial for proper management:
- The nasal septum divides the nasal cavity into two chambers.
- Little's area (Kiesselbach's plexus) is located on the anterior-inferior portion of the nasal septum and is the most common site of bleeding in children.
- This area is highly vascularized, receiving blood supply from both internal and external carotid arteries.
Etiology of Pediatric Epistaxis
The causes of epistaxis in children can be broadly categorized into local and systemic factors:
Local Factors:
- Digital trauma (nose picking) - most common cause in children
- Nasal mucosal dryness and irritation
- Upper respiratory tract infections
- Foreign bodies
- Nasal septal deviation
- Allergic rhinitis
- Chemical irritants
- Nasal polyps
- Trauma (including iatrogenic from nasogastric tube insertion)
Systemic Factors:
- Coagulation disorders (e.g., von Willebrand disease, hemophilia)
- Platelet disorders (e.g., idiopathic thrombocytopenic purpura)
- Vascular malformations (e.g., hereditary hemorrhagic telangiectasia)
- Hypertension (rare in children but should be considered)
- Hematological malignancies
- Vitamin K deficiency
- Medications (e.g., NSAIDs, anticoagulants)
Clinical Presentation of Epistaxis in Children
The presentation of epistaxis can vary from mild to severe:
- Unilateral or bilateral nasal bleeding
- Anterior bleeding (most common) - blood flows out of the nostrils
- Posterior bleeding (less common) - blood flows down the pharynx
- Associated symptoms may include:
- Nasal congestion
- Rhinorrhea
- Facial pain or headache
- Symptoms of underlying conditions (e.g., fever in case of infection)
It's important to assess the severity of bleeding and any signs of hemodynamic instability, especially in cases of prolonged or heavy bleeding.
History Taking:
A thorough history should include:
- Frequency and duration of episodes
- Amount of blood loss
- Precipitating factors
- Associated symptoms
- Past medical history, including bleeding disorders
- Family history of bleeding disorders
- Medication history
Diagnosis of Epistaxis in Children
Diagnosis is primarily clinical, based on history and physical examination. However, further investigations may be necessary in recurrent or severe cases:
Physical Examination:
- Vital signs assessment
- Anterior rhinoscopy to identify the bleeding site
- Oropharyngeal examination for posterior bleeding
- General examination for signs of systemic diseases
Investigations:
- Complete blood count (CBC)
- Coagulation profile (PT, aPTT, INR)
- Blood typing and cross-matching (in severe cases)
- Von Willebrand factor assay (if von Willebrand disease is suspected)
- Nasal endoscopy (in recurrent or posterior epistaxis)
- Imaging studies (CT or MRI) if structural abnormalities or tumors are suspected
In most cases of simple anterior epistaxis in children, extensive investigations are not necessary. However, they should be considered in recurrent, severe, or bilateral epistaxis, or when systemic causes are suspected.
Management of Pediatric Epistaxis
The management of epistaxis in children involves both immediate control of bleeding and addressing underlying causes:
First Aid Measures:
- Reassure the child and caregiver
- Have the child sit upright and lean slightly forward
- Apply firm, constant pressure to the soft part of the nose for 10-15 minutes
- Use ice packs on the bridge of the nose and cheeks
- Advise against nose blowing, picking, or sniffing
Medical Management:
- Topical vasoconstrictors (e.g., oxymetazoline) can be applied to the bleeding site
- Chemical cautery with silver nitrate for visible bleeding vessels
- Nasal packing:
- Anterior packing with absorbable materials (e.g., Surgicel, Gelfoam)
- Non-absorbable packing (e.g., Merocel) for more persistent bleeding
- Topical hemostatic agents (e.g., tranexamic acid)
- Systemic medications:
- Oral tranexamic acid for recurrent epistaxis
- Vitamin K supplementation if deficient
Surgical Management:
Rarely needed in children, but may be considered for:
- Refractory cases
- Posterior epistaxis
- Underlying structural abnormalities
- Endoscopic cauterization
- Septoplasty
- Sphenopalatine artery ligation
Long-term Management:
- Nasal saline sprays or gels to keep mucosa moist
- Humidification of the home environment
- Treatment of underlying conditions (e.g., allergic rhinitis)
- Patient and family education on prevention and first aid measures
Complications of Epistaxis in Children
While most cases of epistaxis in children are benign, potential complications can occur, especially in severe or recurrent cases:
- Anemia: Due to significant or recurrent blood loss
- Aspiration: Particularly with posterior epistaxis
- Hypovolemic shock: Rare, but possible in severe bleeding
- Nasal septal perforation: From repeated trauma or excessive cauterization
- Sinusitis: Secondary to nasal packing
- Toxic shock syndrome: A rare complication of prolonged nasal packing
- Psychological impact: Anxiety and fear in both children and parents
Complications related to treatment:
- Mucosal injury from excessive cauterization
- Synechiae formation
- Epistaxis rebound after discontinuation of topical vasoconstrictors
Prevention of Epistaxis in Children
Preventive measures are crucial in managing recurrent epistaxis and should be part of patient education:
- Nasal hygiene:
- Gentle nose blowing
- Avoiding digital trauma (discourage nose picking)
- Regular use of saline nasal sprays or gels to keep mucosa moist
- Environmental modifications:
- Use of humidifiers, especially in dry climates
- Avoiding irritants like smoke or strong odors
- Management of underlying conditions:
- Proper treatment of allergic rhinitis
- Control of hypertension, if present
- Dietary considerations:
- Adequate hydration
- Ensuring sufficient vitamin K intake
- Medication review:
- Avoiding unnecessary use of NSAIDs or anticoagulants
- Proper use of prescribed nasal sprays
- Education:
- Teaching children and parents about first aid measures
- Recognizing signs of more serious bleeding
Regular follow-up with healthcare providers for children with recurrent epistaxis is important to monitor the effectiveness of preventive measures and to adjust management strategies as needed.
