Epistaxis- Nosebleeds

Nosebleeds occur commonly during childhood. They are most common during the early school aged years and usually requires no diagnostic evaluation. 

Most bleeding is from the anterior septum (Kiesselbach's plexus) where there is a large number of blood vessels. This area has little subcutaneous tissue to allow blood vessel retraction that aids in hemostasis. 

Common Etiologies

  1. Digital manipulation 
  2. Dryness of the nasal tissues most commonly during the winter months. Nosepicking increases the risk of bleeding. Rubbing susceptible area on the pillow may lead to bleeding while child is asleep. 
  3. Ulcerations of the mucosa
  4. Inflammation of the mucosa secondary to allergies or infections
  5. Bleeding disorders
    1. VonWillebrand's Disease- decrease of VW factor which helps transport factor VIII and affects platelet adhesiveness. May also be associated with low levels of factor VIII
    2. Factor VIII and IX deficiencies
    3. Leukemia
    4. platelets 
  6. Osler Weber Rendu Syndrome- mucosal telangectasias
  7. Granulomas secondary to chronic infections
  8. Inflammatory disorders- may occur in various systemic inflammatory disorders i.e. Wegener's granulomatosis.
  9. Polyps
  10. Benign and malignant tumors including angiofibromas and rhabdomyosarcomas
  11. Trauma 
  12. Unilateral purulent bloody drainage with foul smell usually associated with foreign body in the nose.
  13. Postoperative- after adenoidectomy, sinus surgery, septal surgery, rhinoplasty, and /or turbinectomy.  May occur up to two weeks post-op and usulayy resolves spontaneously.
  14. Medications- NSAIDs and anticoagulants.
Evaluation and Treatment
  1. History- family history of bleeding , previous nosebleeds, medications including nasal sprays, trauma, , surgery
  2. Physical examination- location of the bleeding, petechiae, bruising, evidence of trauma, lymphadenopathy, organomegaly, skin changes
  3. Compression-The correct way to stop the bleeding is to pinch the nose, putting pressure on Kieselbach's plexus while sitting up and bending forward at the waist.  Tilt the head forward. This will prevent posterior trickling of blood which can cause nausea and vomiting. This usually works in 5- 10 minutes. This position may also facilitate clot formation.
  4. Vasoconstriction- Local vasoconstriction by application of topical vasoconstrictor (0.05 oxymetazoline chloride or 0.25, 0.5 or 1.0% phenylephrine.)
  5. Nasal packing- If the bleeding is severe, may need to use packing with nasal packs made of Merocel, gelatin (Gelfoam), regenerated cellulose (Surgicel), microfibrillar collagen (Avitene), or Vaseline or Xeroform gauze.
  7. If unable to stop the bleeding, or is recurrent, ENT may need to cauterize the area with silver nitrate.
  8. Fibrin glue
  9. Vaporizer in the room at night to prevent drying of the nasal mucosa.  Also cold on bridge of the nose or nape of the neck can stimulate autonomic responses leading to narrowing of blood vessels.
  10. Use of Vaseline or antibacterial ointment to prevent scab formation in the nose that causes itching and increases manipulation.
  11. Cotton swab soaked with Witch Hazel inside the nostril could lead to vasoconstriction of tiny blood vessels. 
Reference
  1. Mulbury, Peter E. Recurrent Epistaxix. Pediatrics in Review. January 1991
  2. Index of Suspicion. Case 3. Pediatrics in Review May 2004
  3. Schlosser RJ. Epistaxis.  NEJM Feb 19,2009
  4. Bernius, M. Perlin, D. Pediatric ear, nose and throat emergencies. Pediatr Clin North Am 2006; 53:195.
  5. Edelstein, DR, Khabie, N. Epistaxis. In: Primary Pediatric Care, 4th ed, Hoekelman, RA (Ed), Mosby, St. Louis 2001, p. 1058.
  6. Guarisco, JL, Graham, HD, 3rd. Epistaxis in children: causes, diagnosis, and treatment. Ear Nose Throat J 1989; 68: 522.
  7. Index of Suspicion. Case 3. Pediatrics in Review May 2004
  8. Manning, SC. Culberston, MC. Epistaxis. In: Pediatric Otolaryngology, 4th ed (Bluestone, CD, Casselbrant, ML, Stool, SE, Dohar, JE, et al (Eds), Saunders, Philadelphia 2002. p. 925.
  9. Nadel, F, Henretig, FM. Epistaxis. In: Textobook of Pediatric Emergency Medicine, 5th ed, Fleisher, GR, Ludwig, S, Henretig, FM (Eds), Lippincott, Williams & Wilkins, Philadelphia 2006. p. 263.
  10. Vaiman, M. Martinovich, U. Eviatar, E. et al. Fibrin glue in initial treatment of epistaxis. Rhinology 2002; 40:88