Overview
Definition:
Anterior epistaxis refers to bleeding originating from the anterior part of the nasal cavity, most commonly from Kiesselbach's plexus (the Little's area) located on the anterior nasal septum
It is the most frequent type of nosebleed encountered in pediatrics
The management of anterior epistaxis in children often involves conservative measures including topical vasoconstrictors and, if necessary, cautery.
Epidemiology:
Epistaxis is a common emergency in pediatric practice, with an incidence that peaks between ages 2-10 years
Approximately 50% of children will experience at least one nosebleed before the age of 15
While most cases are self-limiting and benign, recurrent or severe bleeding can be a source of parental anxiety and require medical intervention
Dry air, nasal trauma, and upper respiratory infections are common triggers.
Clinical Significance:
Effective management of anterior epistaxis is crucial in pediatric care to control bleeding, prevent complications like anemia or hypovolemic shock in rare severe cases, and reduce patient and parental distress
Understanding the role of topical vasoconstrictors and the indications and techniques for nasal cautery is essential for pediatric residents preparing for DNB and NEET SS examinations, as these are core management principles.
Clinical Presentation
Symptoms:
Bright red blood emerging from one or both nares
Child may swallow blood, leading to nausea or vomiting
Restlessness and crying due to anxiety and blood loss
In severe cases, pallor, tachycardia, and hypotension may be present
History of recent trauma, dry environment, or URI is often elicited.
Signs:
Visible blood trickling from the anterior nasal vestibule
Nasal mucosa may appear dry, inflamed, or crusted
Gentle pressure on the nasal alae may control bleeding
In persistent bleeding, active arterial spurt may be observed from the septum
Examination should assess for signs of hypovolemia.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on patient history and direct visualization of bleeding from the anterior nasal cavity
There are no specific laboratory or imaging criteria for diagnosing simple anterior epistaxis
However, underlying etiologies for recurrent or severe epistaxis may warrant further investigation.
Diagnostic Approach
History Taking:
Duration and severity of bleeding
Frequency of episodes
Presence of associated symptoms like fever or malaise
History of trauma, nose picking, or foreign body
Medication use (aspirin, NSAIDs, anticoagulants)
History of bleeding disorders or familial bleeding diathesis
Recent upper respiratory infections or allergies
Environmental factors (humidity).
Physical Examination:
Vital signs assessment (heart rate, blood pressure, respiratory rate)
Examination of the anterior nasal septum for the bleeding source (Kiesselbach's plexus)
Examination of the nasal mucosa for dryness, inflammation, or ulceration
Assessment for nasal foreign bodies
Gentle palpation of the neck for lymphadenopathy
In cases of significant blood loss, a complete physical examination to assess for pallor and signs of shock is vital.
Investigations:
For uncomplicated anterior epistaxis, no routine investigations are typically required
In cases of recurrent severe epistaxis, or suspicion of underlying coagulopathy: Complete Blood Count (CBC) to assess for anemia or thrombocytopenia
Coagulation profile (PT, aPTT, INR) to rule out clotting factor deficiencies
Platelet function tests if indicated
Nasal endoscopy or rhinoscopy may be performed by a specialist to identify rarer causes.
Differential Diagnosis:
Posterior epistaxis (often more severe and bilateral)
Nasal foreign body
Nasal tumor (rare)
Sinusitis
Trauma to the face or nose
Bleeding from pharyngeal or esophageal sources (swallowed blood)
Bleeding disorders.
Management
Initial Management:
Position the child upright and leaning forward to prevent aspiration of blood
Apply direct pressure to the soft, anterior part of the nose for 10-15 minutes continuously
Encourage nasal breathing and calm the child
Pack the anterior nares with sterile gauze or cotton pledgets soaked in a vasoconstrictor if available.
Topical Vasoconstrictors:
Topical vasoconstrictors, such as oxymetazoline (e.g., 0.05% nasal spray) or dilute epinephrine (1:10,000 or 1:100,000 solution applied to gauze), can be used to reduce blood flow to the nasal mucosa
These are applied to gauze pledgets and inserted into the anterior nostril
Their effect is typically rapid, causing local vasoconstriction
They are particularly useful as an adjunct to pressure or prior to cautery.
Cautery:
Chemical cautery using silver nitrate sticks is the mainstay for controlling persistent anterior epistaxis when direct pressure and vasoconstrictors are insufficient
The bleeding site on the nasal septum should be identified and, if possible, anesthetized with a topical anesthetic spray (e.g., lidocaine with epinephrine)
The silver nitrate stick is then applied gently to the bleeding vessel for a short duration (5-10 seconds), creating a superficial burn and sealing the vessel
Electrocautery may be used in select cases by an otolaryngologist
It is essential to avoid cauterizing both sides of the nasal septum to prevent septal perforation.
Nasal Packing:
If bleeding persists despite cautery, anterior nasal packing with hemostatic agents (e.g., absorbable gelatin sponge, oxidized regenerated cellulose) or conventional gauze packing may be required
For very severe or posterior bleeding, posterior packing or balloon catheters may be necessary, usually performed by a specialist.
Complications
Early Complications:
Recurrence of bleeding
Pain and discomfort from packing or cautery
Nasal obstruction and difficulty breathing
Infection at the cautery site
Septal hematoma formation (if cautery is too deep or applied bilaterally).
Late Complications:
Septal perforation (most common with bilateral cautery or repeated trauma)
Chronic rhinitis or sinusitis
Nasal crusting and synechiae (nasal adhesions)
Anemia due to chronic blood loss (rare with anterior epistaxis).
Prevention Strategies:
Humidification of the environment, especially during dry seasons
Saline nasal sprays or gels to keep the nasal mucosa moist
Discouraging nose picking
Prompt treatment of nasal infections
Careful technique during cautery to avoid bilateral septal application.
Prognosis
Factors Affecting Prognosis:
The underlying cause of epistaxis
The severity and frequency of bleeding
Presence of coagulopathies or other systemic diseases
Adherence to post-treatment care recommendations.
Outcomes:
Most cases of anterior epistaxis in children are managed successfully with conservative measures, topical vasoconstrictors, and cautery
Recurrence rates vary, but many children outgrow epistaxis by adolescence
The prognosis for resolving bleeding is generally excellent with appropriate management.
Follow Up:
For simple, isolated episodes, no specific follow-up may be needed beyond ensuring bleeding has stopped
For recurrent or severe epistaxis, or if underlying etiologies are suspected, follow-up with a pediatrician or ENT specialist may be required to monitor for complications and investigate further
Patients should be advised to avoid blowing their nose forcefully and to use saline nasal spray for a few days post-treatment.
Key Points
Exam Focus:
Kiesselbach's plexus is the most common source of anterior epistaxis
Topical vasoconstrictors (oxymetazoline, epinephrine) and silver nitrate cautery are primary management tools
Avoid bilateral septal cautery to prevent perforation
Management emphasizes pressure, topical agents, and cautery, with packing as a secondary measure.
Clinical Pearls:
Always position the child leaning forward to prevent aspiration
Continuous, firm pressure for 10-15 minutes is crucial before considering other interventions
Topical lidocaine with epinephrine can provide both anesthesia and further vasoconstriction before cautery
Ensure adequate hemostasis before discharge, and educate parents on warning signs of recurrence.
Common Mistakes:
Failing to apply adequate continuous pressure
Bimanual compression of the nasal bridge instead of applying pressure to the soft anterior alae
Over-cauterization or bilateral cautery leading to septal perforation
Discharging patients with active bleeding or without clear instructions for home care.