Overview
Definition:
Recurrent epistaxis refers to repeated episodes of bleeding from the nasal cavity, a common complaint in pediatric practice
It can range from mild, self-limiting nosebleeds to severe, life-threatening hemorrhages.
Epidemiology:
Epistaxis is most common in children aged 2-10 years, with a bimodal peak in early childhood and adolescence
Approximately 50-60% of children experience at least one episode of epistaxis
Recurrent epistaxis, defined as more than 4 episodes per year, is less common but warrants thorough evaluation.
Clinical Significance:
While often benign, recurrent epistaxis can cause significant anxiety for parents and children, lead to iron deficiency anemia due to chronic blood loss, and in rare cases, signal underlying systemic conditions requiring prompt diagnosis and management, making it a crucial topic for pediatric residents preparing for exams.
Clinical Presentation
Symptoms:
Frequent nosebleeds, often unilateral but can be bilateral
Bleeding may be spontaneous or triggered by minor trauma, nose picking, or dry air
Associated symptoms may include blood dripping down the pharynx, leading to gagging or swallowing of blood
pallor
and occasionally, symptoms of iron deficiency anemia such as fatigue or irritability.
Signs:
Examination may reveal active bleeding from Kiesselbach's plexus (Little's area) in the anterior nasal septum, which is the most common site
The nasal mucosa may appear dry, excoriated, or friable
In severe or chronic cases, signs of anemia like pallor of conjunctivae and nail beds may be present
Examination of the posterior nasopharynx is essential for identifying posterior bleeds.
Diagnostic Criteria:
There are no strict diagnostic criteria for recurrent epistaxis itself, but the diagnosis is made based on a history of recurrent bleeding episodes and physical examination findings
Further evaluation is indicated if bleeding is severe, prolonged, associated with other bleeding disorders, or if there are red flags suggestive of systemic disease.
Diagnostic Approach
History Taking:
Detailed history is paramount
Key points include frequency, duration, severity, and character of bleeding
Precipitating factors (trauma, dryness, infections, exertion, medications)
Associated symptoms (bruising, gum bleeding, hematuria, melena)
Family history of bleeding disorders or epistaxis
Diet and hydration status
Medications, especially nasal sprays, NSAIDs, or anticoagulants
Red flags: severe epistaxis, bleeding with head trauma, associated petechiae or purpura, prolonged bleeding after minor injuries, bleeding from other sites.
Physical Examination:
A thorough examination of the nasal cavity using a nasal speculum or otoscope is essential
Look for the source of bleeding, particularly Kiesselbach's plexus on the anterior septum
Assess the nasal mucosa for dryness, inflammation, ulceration, or telangiectasias
Palpate the neck for lymphadenopathy
Examine for signs of systemic illness, including skin petechiae/purpura, enlarged spleen or liver, and pallor.
Investigations:
Routine investigations are often not required for uncomplicated epistaxis
However, if a bleeding disorder or systemic cause is suspected, consider: Complete Blood Count (CBC) to assess for anemia and thrombocytopenia
Coagulation profile (PT, aPTT, INR) to evaluate extrinsic and intrinsic pathways
Platelet function tests if indicated
Liver function tests if coagulopathy is suspected
Imaging: Nasal endoscopy can be helpful to visualize the nasal cavity and identify specific bleeding sites, especially for recurrent or difficult-to-manage cases
Imaging of paranasal sinuses might be considered if sinusitis is suspected as a contributing factor.
Differential Diagnosis:
Anterior epistaxis (Kiesselbach's plexus)
Posterior epistaxis ( Woodruff's plexus, sphenopalatine artery)
Nasal tumors (juvenile nasopharyngeal angiofibroma, papilloma, carcinoma)
Foreign body in the nasal cavity
Sinusitis
Allergic rhinitis
Vasomotor rhinitis
Nasal trauma
Hereditary hemorrhagic telangiectasia (HHT)
Bleeding disorders (hemophilia, von Willebrand disease, platelet dysfunction)
Systemic diseases (hypertension, liver disease, renal disease).
Management
Initial Management:
Direct pressure to the anterior nasal vault for 10-15 minutes, with the child sitting upright and leaning forward to prevent aspiration
Application of topical vasoconstrictors (e.g., oxymetazoline) can help with bleeding control and visualization
Cautery (chemical or electrical) of identified bleeding points in the anterior septum if bleeding persists after direct pressure
Nasal packing (anterior balloon catheter or gauze packing) for more severe bleeding or when cautery is not effective
Intravenous fluid resuscitation and blood transfusion may be necessary for significant blood loss leading to hypovolemic shock.
Medical Management:
Nasal humidification is key for preventing recurrence: Using a humidifier at home, especially in the bedroom
Applying petroleum jelly or antibiotic ointment to the anterior nares multiple times a day to keep the mucosa moist
Saline nasal sprays or drops to moisturize the nasal passages
Avoiding nose picking and irritants like smoke
Treating underlying allergic rhinitis or sinusitis with appropriate nasal steroids or antihistamines
Humidified oxygen therapy in hospitalized patients with severe epistaxis.
Surgical Management:
Surgical options are reserved for cases of severe, intractable epistaxis or when conservative measures fail
Indications include failure of nasal packing, recurrent severe bleeds, and specific anatomical issues
Procedures include: Nasal cautery (chemical with silver nitrate or electrical bipolar cautery)
Nasal packing (anterior and posterior)
Surgical ligation of feeding vessels (e.g., anterior ethmoidal artery, sphenopalatine artery)
Embolization of feeding arteries by interventional radiology.
Supportive Care:
Monitor vital signs, hemoglobin levels, and fluid balance in patients with significant blood loss
Provide emotional support to the child and parents
Educate the family on home care strategies for nasal humidification and avoidance of precipitating factors
Advise on signs and symptoms that require immediate medical attention.
Complications
Early Complications:
Aspiration of blood, leading to airway compromise or aspiration pneumonia
Septal hematoma, which can lead to septal perforation and saddle nose deformity if not drained
Airway obstruction due to nasal packing
Pain and discomfort from nasal packing
Acute blood loss leading to hypovolemic shock.
Late Complications:
Chronic iron deficiency anemia due to repeated blood loss
Septal perforation and saddle nose deformity
Synechiae (nasal adhesions) formation
Recurrence of epistaxis despite treatment.
Prevention Strategies:
Maintain adequate nasal humidity through humidifiers and regular application of emollients (petroleum jelly, antibiotic ointment)
Educate children to avoid nose picking and blowing their nose forcefully
Prompt treatment of underlying nasal or systemic conditions
Use saline nasal sprays regularly
Consider prophylactic nasal cautery or topical agents in individuals with very friable nasal mucosa.
Prognosis
Factors Affecting Prognosis:
The prognosis for recurrent epistaxis in children is generally good, with most cases resolving with conservative management
Factors influencing prognosis include the underlying cause, severity of bleeding, and adherence to preventive measures
Underlying coagulopathies or systemic diseases can lead to a poorer prognosis if not adequately managed.
Outcomes:
Most children with recurrent epistaxis experience a significant reduction in bleeding episodes with appropriate nasal care and humidification
Severe or intractable cases may require surgical intervention, which often leads to a good outcome
Long-term complications are rare with proper management.
Follow Up:
Regular follow-up with a pediatrician or ENT specialist is recommended, especially for children with frequent or severe epistaxis, or if underlying medical conditions are suspected
Follow-up should focus on monitoring for recurrence, assessing for anemia, and reinforcing preventive strategies
For children who have undergone surgical intervention, follow-up is crucial to monitor for healing and prevent complications.
Key Points
Exam Focus:
Recurrent epistaxis is common in children aged 2-10 years
Kiesselbach's plexus is the most frequent bleeding site
History taking is crucial to identify red flags and underlying causes
Nasal humidification and avoiding nose picking are cornerstones of conservative management
Posterior epistaxis is more serious and may require surgical intervention or embolization
Consider HHT and bleeding disorders in recurrent severe cases.
Clinical Pearls:
Always ask about iron intake and symptoms of anemia in children with frequent nosebleeds
Teach parents how to apply direct pressure effectively
Topical emollients are more effective than sprays for long-term mucosal health
A nasal speculum is essential for examining the anterior nasal septum
If bleeding is profuse and bilateral from the anterior nares, suspect a posterior source or a systemic coagulopathy.
Common Mistakes:
Underestimating the severity of recurrent epistaxis
Failing to perform a thorough nasal examination
Not considering underlying systemic diseases or bleeding disorders
Inadequate advice on nasal humidification
Relying solely on nasal sprays without emollients for mucosal dryness
Overlooking posterior bleeding sources.