Overview
Definition:
Epistaxis, commonly known as a nosebleed, is the loss of blood from the tissue lining the nose
It is a frequent occurrence in childhood, most often originating from the anterior nasal septum.
Epidemiology:
Epistaxis is common in children, with a peak incidence between the ages of 2 and 10 years
Recurrent epistaxis affects approximately 10-15% of children
Anterior nosebleeds account for over 90% of cases in this age group.
Clinical Significance:
While usually benign, epistaxis can cause significant parental anxiety and, in rare instances, lead to anemia or airway compromise
Prompt and effective management is crucial for symptom relief and preventing complications, making it a key topic for pediatric residents preparing for DNB and NEET SS exams.
Clinical Presentation
Symptoms:
Bright red blood from one or both nostrils
Blood trickling down the throat
Nasal congestion
Restlessness or irritability
May be associated with recent trauma, dry air, or upper respiratory infection.
Signs:
Visible bleeding from the anterior nares
Blood on nasal mucosa
Pale conjunctivae in severe or recurrent cases indicating anemia
Tachycardia or hypotension in cases of significant blood loss (rare in children).
Diagnostic Criteria:
Diagnosis is primarily clinical, based on the history of bleeding from the nose and physical examination findings
No specific laboratory diagnostic criteria are typically required for uncomplicated epistaxis.
Diagnostic Approach
History Taking:
Detailed history of bleeding frequency, duration, and severity
Any preceding trauma or nasal manipulation (nose picking)
Environmental factors (dry air, heating)
History of allergies or sinonasal infections
Family history of bleeding disorders or epistaxis
Medications (e.g., NSAIDs, anticoagulants).
Physical Examination:
Assess general appearance and vital signs
Gently examine the anterior nasal septum for a bleeding source, often Kiesselbach's plexus
Look for nasal masses, polyps, or foreign bodies
Examine the oropharynx for posterior bleeding
Assess for signs of anemia or coagulopathy.
Investigations:
Generally not required for simple, infrequent epistaxis
May be indicated for recurrent, severe, or refractory bleeding to rule out underlying coagulopathy (complete blood count, prothrombin time, activated partial thromboplastin time) or vascular malformations (nasal endoscopy, CT scan in select cases).
Differential Diagnosis:
Nasal trauma
Foreign body in the nose
Sinusitis
Allergic rhinitis
Nasal tumors (rare)
Hereditary hemorrhagic telangiectasia
Bleeding disorders (e.g., hemophilia, Von Willebrand disease).
Management
Initial Management:
Position the child upright and leaning forward to prevent aspiration of blood
Apply direct, continuous pressure to the soft part of the nose for 10-15 minutes
Nasal decongestant spray (oxymetazoline) may help constrict blood vessels.
Medical Management:
If bleeding persists after initial measures, nasal packing with cotton pledgets soaked in saline or an anesthetic-antibiotic ointment may be considered
Topical application of an astringent like aluminum acetate can also be tried.
Cautery Options:
For persistent or recurrent bleeding from a visible anterior source (Kiesselbach's plexus): \n1
Chemical Cautery (Silver Nitrate): A silver nitrate stick is applied to the bleeding site for a few seconds, carefully avoiding surrounding healthy mucosa
It causes superficial coagulation
\n2
Electrical Cautery: Using a radiofrequency cautery or a bipolar cautery probe to ablate the bleeding vessel under direct visualization (often requires local anesthesia or sedation).
Surgical Management:
Reserved for severe, life-threatening epistaxis or posterior bleeds unresponsive to conservative measures
May include anterior or posterior nasal packing with specialized materials, arterial ligation (sphenopalatine artery, anterior ethmoidal artery), or embolization via interventional radiology.
Supportive Care:
Educate parents on humidifying the environment, avoiding nasal trauma, and using saline nasal spray
Humidifiers and saline sprays are crucial for preventing dryness that exacerbates epistaxis.
Complications
Early Complications:
Failure of hemostasis
Pain and discomfort from packing
Nasal septal hematoma formation (if cautery is too aggressive or if initial injury was significant)
Infection.
Late Complications:
Nasal septal perforation (rare, usually from repeated aggressive cautery or trauma)
Scarring
Chronic sinusitis
Recurrence of epistaxis.
Prevention Strategies:
Gentle nasal hygiene
Humidification of room air
Avoiding nose picking
Prompt treatment of underlying sinonasal inflammation
Careful application of cautery techniques, avoiding excessive tissue destruction.
Prognosis
Factors Affecting Prognosis:
The cause of epistaxis
The severity and frequency of bleeding
The presence of underlying medical conditions (e.g., bleeding disorders)
Effectiveness of management interventions.
Outcomes:
Most cases of epistaxis in children are self-limiting or resolve with simple measures
Recurrence is common but usually manageable
Severe or refractory cases may require more aggressive interventions and a multidisciplinary approach.
Follow Up:
Children with recurrent epistaxis should have regular follow-up with their pediatrician or ENT specialist
Education on preventative measures is key
Investigations for underlying causes may be warranted if bleeding is severe or persistent.
Key Points
Exam Focus:
Kiesselbach's plexus is the most common site of epistaxis in children
Anterior epistaxis is far more common than posterior
First-line management involves direct pressure and positioning
Silver nitrate cautery is effective for visible anterior bleeding sites.
Clinical Pearls:
Always consider a foreign body in a young child with unilateral, persistent, or foul-smelling epistaxis
Ensure adequate nasal packing is applied correctly to prevent swallowing of blood and airway compromise
Sedation for nasal procedures in children requires careful risk-benefit assessment.
Common Mistakes:
Applying pressure incorrectly (e.g., tilting head back)
Insufficient duration of direct pressure
Overly aggressive cautery leading to septal perforation
Failing to consider underlying coagulopathy in cases of severe or recurrent bleeds.