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Pediatrics: Surgery > Otolaryngology
Epistaxis
Article Last Updated: Apr 28, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 10  
Author: William Gluckman, DO, MBA, Assistant Professor, Department of Surgery, Section of Emergency Medicine, University of Medicine and Dentistry of New Jersey, University Hospital
William Gluckman is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Coauthor(s):
Robert Barricella, DO, FAAP, FACEP, Director of Pediatric Emergency Department and Emergency Fellowship, Assistant Professor, Department of Pediatrics, University of Medicine and Dentistry of New Jersey;
Huma Quraishi, MD, Division Director, Assistant Professor, Department of Pediatrics, Division of Otolaryngology, University of Medicine and Dentistry of New Jersey;
Sangeeta Lamba, MD, Assistant Professor of Surgery/Medicine, Section of Emergency Medicine, University of Medicine and Dentistry New Jersey University Hospital
Editors: Orval Brown, MD, Director of Otolaryngology Clinic, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; John E McClay, MD, Assistant Professor, Department of Otolaryngology, Division of Pediatric Otolaryngology, Children's Medical Center, University of Texas Southwestern Medical School; Paul D Petry, DO, FACOP, FAAP, Consulting Staff, Freeman Pediatric Care, Freeman Health System; Maureen Strafford, MD, Arnold P Gold Foundation Associate Professor, Departments of Anesthesiology and Pediatrics, Tufts University and Tufts-New England Medical Center
Author and Editor Disclosure
Synonyms and related keywords:
epistaxis, nosebleed, nose bleed, nasal hemorrhage, anterior bleed, posterior bleed
Background
Epistaxis, or nosebleed, is a common pediatric complaint. Most incidents are rarely life threatening but cause significant parental concern. Most nosebleeds are benign, self-limiting, and spontaneous but may also be recurrent. Many uncommon causes also exist.
Epistaxis can be divided into 2 categories, anterior bleeds and posterior bleeds, based on where the bleeding originates.
Pathophysiology
Bleeding typically occurs when the mucosa is eroded and vessels become exposed and subsequently break. More than 90% of bleeds occur anteriorly and arise from the Little area, where the Kiesselbach plexus forms on the septum. The Kiesselbach plexus is where vessels from both the internal carotid artery (anterior and posterior ethmoid arteries) and the external carotid (sphenopalatine and branches of the internal maxillary arteries) converge. These capillary or venous bleeds provide a constant ooze, rather than the profuse pumping of blood observed from an arterial origin.
Posterior bleeds arise further back in the nasal cavity, are usually more profuse, and are often of arterial origin. A posterior source presents a greater risk of airway compromise, aspiration of blood, and greater difficulty controlling bleeding.
Age
Epistaxis usually occurs in children aged 2-10 years. Occurrence is unusual in infants in the absence of a coagulopathy or nasal pathology (eg, choanal atresia, neoplasm). Local trauma (eg, nose picking) does not occur until later in the toddler years. Older children and adolescents also have a less frequent incidence. Consider cocaine abuse in adolescent patients.
History
- Most nosebleeds are reported as spontaneous events and frequently are related to nose picking or other trauma; therefore, investigate the various possibilities.
- Foreign bodies inserted in the nose also may present with epistaxis, but bleeding may be less and accompanied by foul or purulent discharge if the object has been retained for some time. A unilateral nasal discharge suggests the presence of a foreign body.
- Children easily can insert small batteries from electronic devices (eg, calculators, watches, handheld video games) into their nostrils.
- Not only can local irritation and bleeding result, but these can leak and cause a chemical alkali burn that may result in local tissue necrosis. Severe complications (eg, nasal stenosis) can result from batteries.
- Removal is a priority; removing the batteries within 4 hours of insertion is best.
- Obtain a history of aspirin or warfarin use. Include investigation of suspicion of accidental ingestion (consider accidental ingestion of rat poison in toddlers).
- Obtain any family history of bleeding disorders or leukemia.
- A history of frequent recurrent nosebleeds, easy bruising, or other bleeding episodes should make the clinician suspicious of a systemic cause and prompt a hematologic workup. Children with severe epistaxis are more likely to have required nasal cauterization, an underlying coagulopathy, a positive family history of bleeding, and anemia.
- Although unusual, children with bleeding disorders (eg, Von Willebrand disease) occasionally can have normal coagulation profiles.
- More than 1 sample may be required to notice the abnormality due to biologic variability throughout the day.
- Obtain a history of whether the bleed is unilateral or bilateral and if it occurs following exercise. Also, determine if the onset was during sleep or associated with a migraine.
- Determine through history if hematemesis or melena occurred, since posterior bleeding in particular may present in this fashion.
Physical
- Nasal examination
- Use of a large-sized, otologic, handheld speculum can be helpful (see Image 1).
- Begin the examination with inspection, looking specifically for any obvious bleeding site on the septum that may be amenable to direct pressure or cautery.
- Anterior bleeds from the nasal septum are most common, and the site frequently can be identified if bleeding is active.
- Carefully remove by suction any large amount of clot.
- Pharynx examination
- Observe the posterior pharynx for constant dripping of blood that may signify a posterior rather than an anterior bleed.
- After placement of an anterior pack, reassess this area and, if bleeding is noted in the pharynx with an anterior pack in place, strongly consider a posterior bleed (see Images 3-4).
- Skin: Examine the skin for evidence of bruises or petechiae that may indicate an underlying hematologic abnormality.
- Vital signs
- High blood pressure (HBP) rarely, if ever, causes epistaxis on its own; however, HBP may impede clotting. Check blood pressure and complete a workup if HBP is present.
- Persistent tachycardia must be recognized as an early indicator of significant blood loss requiring intravenous fluid and, potentially, transfusion.
Causes
- The primary cause of epistaxis in children is minor trauma, such as nose picking (frequently in the setting of dry nasal membranes).
- Other common causes of nosebleeds include direct trauma with or without nasal or facial fractures, foreign body, rhinitis, and exposure to warm and dry air causing dry membranes (rhinitis sicca). Medications such as NSAID use and chronic use of nasal steroids for treatment of allergic rhinitis are also frequently involved.
- Some less common causes include leukemia, Osler-Weber-Rendu syndrome, nasal tumors, and coagulopathies, both intrinsic (eg, hemophilia, Von Willebrand disease) and acquired (eg, accidental warfarin ingestion).
- Excessive coughing causing nasal venous hypertension may be observed in pertussis or cystic fibrosis.
- Arterial hypertension rarely causes epistaxis.
- Children with migraine headaches have a higher incidence of recurrent epistaxis than children without the disease. The Kiesselbach plexus, which is part of the trigeminovascular system, has been implicated in the pathogenesis of migraine.
- Young infants with gastroesophageal reflux into the nose may have epistaxis secondary to inflammation.
- Etiologies such as liver disease, which can lead to clotting factor deficiencies (II, VII, IX, X), Osler-Weber-Rendu syndrome, which causes capillary fragility, and nasal foreign bodies that cause local trauma can be responsible for rare cases of epistaxis.
- Intranasal rhabdomyosarcoma, while rare, often begins in the nasal, orbital, or sinus area in children.
- Juvenile nasal angiofibroma in adolescent males may cause severe nasal bleeding as the initial symptom.
Lab Studies
- For the most part, lab studies are not needed for first-time or infrequent recurrences with a good history of nose picking or trauma to the nose.
- If significant blood loss, leukemia, or malignancy is suspected or if recurrent bleeding occurs, perform a CBC count with differential.
- If a coagulopathy is suspected, perform CBC, prothrombin time (PT)/activated partial thromboplastin time (aPTT), and bleeding time.
Procedures
- Direct visualization with a good directed light source, nasal speculum (see Image 1), and nasal suction should be sufficient in most patients.
- Insertion of nasal packing or cautery may be indicated and is discussed in the treatment section (see Nasal packing items and procedures).
Medical Care
- Initial treatment begins with direct pressure by squeezing the nostrils together for 5-30 minutes straight, without frequent peeking to see if the bleeding is controlled. Usually only 5-10 minutes is required.
- Patients should keep their heads elevated but not hyperextended, because hyperextension may cause bleeding into the pharynx and possible aspiration. This maneuver works more than 90% of the time.
- If bleeding is caused by excessive dryness in the home (eg, from radiator heating), patients may benefit from the following care options:
- Humidify the air with a cool mist vaporizer in the bedroom.
- Alternately, a metal basin of water may be placed on top of a radiator to humidify the ambient air.
- Nasal saline sprays are useful. Oxymetazoline (Afrin), with fewer cardiac adverse effects, also may be used. These agents should only be used for 3-5 days at a time to avoid rhinitis medicamentosa and tachyphylaxis.
- The physician may consider local application of bacitracin or petrolatum ointment directly to the Kiesselbach area with a cotton applicator to prevent further drying (studies recommend 2 wk).
- If direct pressure is not sufficient, gauze moistened with epinephrine at a ratio of 1:10,000 or phenylephrine (Neo-Synephrine) may be placed in the affected nostril to help vasoconstrict and achieve hemostasis.
Surgical Care
- Cauterization of an identified small bleeding area. Only one side should be cauterized at a time to avoid possible septal perforation.
- Can be performed with silver nitrate sticks
- Caution advised not to burn the entire septum or cause perforation (septal perforation is a risk)
- Performed in only one nostril at a time
- Used very judiciously; must avoid nasal tissues other than the bleeding site of septum
- Presents risk of nasal stenosis of the vestibule
- Nasal packing items and procedures
- Quarter-inch strips of gauze impregnated with petroleum jelly, layered with the use of bayonet forceps (see Images 2-3)
- Oxycel cotton with bacitracin, which dissolves and does not have to be removed, preferred by some (especially helpful in patients with leukemia)
- Merocel or other tamponlike packing that expands when water is injected into it (see Image 4)
- Epistat or other balloon inflation catheter (see Image 6)
- Ligation of vessels
- Angiographic embolization
Consultations
In all children in whom lesions are not observed in the Kiesselbach area, consider an otolaryngology consult for evaluation with a flexible or rigid rhinoscopy and nasopharyngoscopy to search for the source of bleeding and to rule out any lesions causing the bleeding. This is particularly important when epistaxis is combined with nasal airway obstruction, especially when unilateral obstruction is present. Most children older than 6 years can tolerate a well-coached flexible fiberoptic examination of the nasal cavity with a 3-mm scope without significant discomfort or mental trauma if the nose is anesthetized and decongested. Other reasons for consultations are as follows:
- Otolaryngologist and/or head and neck surgeon
- Bleeding uncontrolled by direct pressure or packing
- Practitioner unfamiliar with performing anterior nasal packing
- Suspected posterior nose bleed
- Hematologist - Coagulopathy determined as cause of the epistaxis
Diet
While bleeding is occurring and the assessment is in process, the child should remain nothing by mouth (NPO). Once bleeding is controlled, a full diet can be started.
Activity
Patients with a simple controlled bleed may resume regular activity; however, instruct individuals not to forcefully blow or pick their noses. For a few days, avoiding contact sports or activities that may directly traumatize the nose is probably prudent.
Drug Category: Antibiotic agents
Antibiotics with staphylococcal and streptococcal coverage are required if nasal packing is placed. The PO route is used most commonly, because most patients are treated on an outpatient basis. If the patient requires admission, use IV medications initially. Continue all antibiotics until the packing is removed.
| Drug Name | Cephalexin (Keflex, Biocef) |
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| Description | First-generation cephalosporin arrests bacterial growth by inhibiting bacterial cell wall synthesis. |
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| Adult Dose | 250-500 mg PO qid |
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| Pediatric Dose | 25-50 mg/kg/d PO divided qid |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Coadministration with aminoglycosides increases nephrotoxic potential |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
|
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| Precautions | Adjust dose in renal impairment |
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| Drug Name | Cephazolin (Ancef) |
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| Description | First-generation semisynthetic cephalosporin that arrests bacterial cell wall synthesis, inhibiting bacterial growth. Parenteral antibiotic. |
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| Adult Dose | 1 g IV q6h until packing removed or can tolerate PO |
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| Pediatric Dose | 25-50 mg/kg/d IV divided q6-8h until packing removed or can tolerate PO |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Probenecid prolongs effect of cefazolin; coadministration with aminoglycosides may increase renal toxicity; may yield false-positive urine-dipstick test results for glucose |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
|
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| Precautions | Adjust dose in renal impairment; superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy |
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| Drug Name | Dicloxacillin (Dycill, Dynapen) |
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| Description | Binds to 1 or more penicillin-binding proteins, which in turn inhibits synthesis of bacterial cell walls. For treatment of infections caused by penicillinase-producing staphylococci. Available as a suspension of 62.5 mg/5 mL. |
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| Adult Dose | 250-500 mg PO qid |
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| Pediatric Dose | 12.5-25 mg/kg/d PO divided qid |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Decreases efficacy of oral contraceptives; increases effects of anticoagulants; probenecid and disulfiram may increase penicillin levels |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
|
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| Precautions | Monitor PT in patients taking anticoagulant medications; toxicity may increase in patients with renal impairment |
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| Drug Name | Nafcillin (Nafcil, Nallpen) |
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| Description | Parenteral penicillinase-resistant (antistaphylococcal) penicillin. |
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| Adult Dose | 1-2 g IV q4h |
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| Pediatric Dose | 50-200 mg/kg/d IV divided q4-6h |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Associated with warfarin resistance when administered concurrently; effects may decrease with bacteriostatic action of tetracycline derivatives |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
|
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| Precautions | To optimize therapy, determine causative organisms and susceptibility |
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| Drug Name | Sulfamethoxazole and trimethoprim (Bactrim, Septra, Cotrim) |
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| Description | Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. |
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| Adult Dose | 160 mg (trimethoprim)/800 mg (sulfamethoxazole) PO q12h (ie, 1 double-strength [DS] tab q12h) |
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| Pediatric Dose | 5-10 mg/kg/d (based on trimethoprim component) PO divided bid |
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| Contraindications | Documented hypersensitivity; megaloblastic anemia due to folate deficiency |
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| Interactions | May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly patients; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
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| Precautions | Do not use near term in pregnancy because of risk of kernicterus in the newborn; discontinue at first appearance of rash or sign of adverse reaction; obtain CBCs frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; caution in folate deficiency (eg, chronic alcoholics, elderly patients, those receiving anticonvulsant therapy, or those with malabsorption syndrome); hemolysis may occur in individuals with G-6-PD deficiency; patients with AIDS may not tolerate or respond; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation |
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| Drug Name | Clindamycin (Cleocin) |
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| Description | Semisynthetic derivative of lincomycin that inhibits protein synthesis by binding to 50s ribosomal subunit. Available as 75-mg/5 mL oral suspension. |
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| Adult Dose | 300 mg PO qid
600 mg IV q8h |
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| Pediatric Dose | 8-25 mg/kg/d PO divided tid/qid
20-40 mg/kg/d IV divided q6-8h |
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| Contraindications | Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis |
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| Interactions | Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
|
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| Precautions | Benzyl alcohol is used as a preservative and has demonstrated toxicity in neonates; adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile |
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Further Inpatient Care
- When no airway concerns are present, no admission is usually necessary for a unilateral anterior pack.
Further Outpatient Care
- If epistaxis continues following an emergency department visit, an otolaryngologist consultation for a full examination of the nasal cavity and nasopharynx with a flexible or rigid rhinoscopy and nasopharyngoscopy may be required.
In/Out Patient Meds
- No medications are required for a simple epistaxis. An antibiotic with staphylococcal coverage (eg, cephalexin PO, cephazolin IV) or antistaphylococcal penicillin (eg, dicloxacillin PO, nafcillin IV) is required for patients sent home or admitted with anterior or posterior packing in place.
Transfer
- If bleeding cannot be controlled with direct pressure, transfer to an emergency department is required.
- If bleeding cannot be controlled in an emergency department without an otolaryngologist, transfer is required to a facility with this service.
Deterrence/Prevention
- Nose picking is difficult to deter and is going to occur. Keeping the child's nails well trimmed may be helpful.
- Protection from direct trauma from some sports activities occurs with helmet and/or face piece use.
- A hot dry home environment may benefit from humidifiers, better thermostatic control, saline spray, and antibiotic ointment on the Kiesselbach area.
- Consider drug education relating to use or accidental ingestion of aspirin, warfarin (eg, rat poison in toddlers), or drug abuse in adolescents.
Complications
- One complication is excessive bleeding to the point of shock requiring transfusion. If significant blood loss is apparent, undertake transfer to an emergency department for observation, frequent monitoring of vital signs, and completion of at least 2 hematocrits.
- Airway compromise is another potential complication. Excessive bleeding into the pharynx causes coughing and gagging. If this occurs in an infant who is unable to roll over and clear the blood, aspiration and subsequent respiratory arrest occur.
Prognosis
- Patients with epistaxis that occurs from dry membranes or minor trauma do well with no long-term effects.
- Patients with bleeding from a hematologic problem or cancer have a variable prognosis.
Patient Education
Medical/Legal Pitfalls
- Failure to prescribe an antibiotic for patients treated as outpatients with nasal packing is a pitfall due to the risk of toxic shock syndrome and sinusitis.
- Mistaking a posterior bleed for an anterior bleed and allowing a patient to go home, only to have the patient return a short time later with complications from excessive bleeding or aspiration, is another potential pitfall.
- Failure to admit for observation all patients who require posterior nasal packing is a potential pitfall. Significant respiratory distress can occur from posterior packing, especially if it becomes dislodged.
- Failure to consult an otolaryngologist and/or head and neck surgeon is another potential pitfall when bleeding cannot be controlled by direct pressure or packing, if the practitioner is unfamiliar with performing anterior nasal packing, or if a posterior nose bleed is suspected.
| Media file 6:
Epistat anterior and/or posterior nasal catheter. |
 |  View Full Size Image | |
Media type: Photo
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Epistaxis excerpt Article Last Updated: Apr 28, 2006
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