EPISTAXIS

EVA M. DELGADO, MD AND FRANCES M. NADEL, MD, MSCE

Epistaxis (nose bleeding) is a common symptom in young children and may be alarming to parents who often overestimate the amount of blood loss. It is usually noted first at about age 3 years and increases in frequency until peaking before or in adolescence. An orderly approach to the history and physical examination is necessary to identify the small minority of patients who require emergent hemorrhage control, laboratory investigation, or consultation with an otorhinolaryngologist (ORL) for further management.

PATHOPHYSIOLOGY

Minor trauma, nasal inflammation, desiccation, and congestion, as well as the rich vascular supply of the nose, contribute to the frequency of nosebleeds in otherwise normal children. The nose is a favored site for recurrent minor trauma, especially habitual, often absent-minded picking. The nasal mucosa is closely applied to the perichondrium and periosteum of the nasal septum and lateral nasal walls giving little structural support to its supply of small blood vessels. These vessels join to form plexiform networks like Kiesselbach plexus in Little’s Area of the anterior nasal septum, about 0.5 cm from the tip of the nose and a frequent source of epistaxis blood (see Fig. 126.9).

DIFFERENTIAL DIAGNOSIS

Local Causes

Epistaxis is most often the result of local inflammation, irritation, infection, or trauma (Table 21.1). The most common causes of epistaxis are found in Table 21.2. Acute upper respiratory infections, whether localized as in colds or secondary to more generalized infections such as measles, infectious mononucleosis, or influenza-like illnesses, contribute to the onset of epistaxis. Nasal colonization with Staphylococcus aureus may predispose to a more friable mucosa and to furuncles, both of which can cause epistaxis. Allergic rhinitis may also be a factor. Rhinitis sicca refers to desiccation of the nasal mucosa, often occurs in cold winter climates with low ambient humidity prompting the use of dry hot-air heating systems, and increases the risk of epistaxis. Rhinitis sicca is also important to consider in the differential of a child with dependence on any respiratory device that instills dry air into the nares such as nasal cannula, nasal BiPAP, or other similar systems.

Inspection may reveal a nasal foreign body, which is sometimes suspected by history of insertion or by reports of chronic or recurrent unilateral epistaxis accompanied by a mucopurulent drainage or foul breath. Also discoverable by examination are telangiectasias (Osler–Weber–Rendu disease), hemangiomas, or evidence of other uncommon tumors that cause nosebleeds. Juvenile nasopharyngeal angiofibromas may be seen in adolescent boys with nasal obstruction, mucopurulent discharge, and severe epistaxis. These benign tumors may bulge into the nasal cavity, sometimes causing problems by invading adjacent structures. A rare childhood malignant tumor, nasopharyngeal lymphoepithelioma, may cause a syndrome of epistaxis, torticollis, trismus, and unilateral cervical lymphadenopathy. Other rare local causes of epistaxis include nasal diphtheria and Wegener granulomatosis.

Systemic Causes

Children rarely present with a nosebleed as their only manifestation of a more systemic disease, though there are several conditions that can increase the risk for epistaxis (Table 21.1). In children with severe or recurrent nosebleeds, a concerning family history, or constitutional signs and symptoms, the physician should consider a systemic process. Von Willebrand disease and platelet dysfunction are two of the more common systemic diseases that cause recurrent or severe nosebleeds. Less common systemic factors include hematologic diseases such as leukemia, hemophilia, and clotting disorders associated with severe hepatic dysfunction or uremia. Arterial hypertension rarely is a cause of epistaxis in children. Increased nasal venous pressure secondary to paroxysmal coughing, which can occur in pertussis or cystic fibrosis, occasionally may cause nosebleeds. Vicarious menstruation

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