Managing epistaxis in children - paediatric medicine

Though a common paediatric complaint, epistaxis requires careful monitoring. By Mr Samuel Leong

Juvenile nasal angiofibroma may cause severe nasal bleeding associated with nasal obstruction (Photograph: SPL)
Juvenile nasal angiofibroma may cause severe nasal bleeding associated with nasal obstruction (Photograph: SPL)

Epistaxis is a common paediatric complaint which is usually benign, self-limiting and spontaneous. Most incidents are not life threatening but can cause significant parental concern.

Epistaxis is the commonest otolaryngological emergency affecting up to 60 per cent of the population in their lifetime, with 6 per cent requiring medical attention.

Epistaxis usually occurs in children aged two to 10 years, with a peak between three and eight years. The true incidence of epistaxis in children is unknown given that only a small number seek medical attention and the number of children admitted to hospital for epistaxis is low compared with adults. It is important to ensure that acute epistaxis requiring hospital admission in healthy children is not a marker for an underlying bleeding disorder. It is associated with a short inpatient stay, and usually requires minimal intervention compared with adults.1

Blood supply to the nose
The blood supply to the nose is derived from branches of the internal (anterior and posterior ethmoid arteries) and external carotid arteries (sphenopalatine and branches of the internal maxillary arteries). Bleeding typically occurs when the mucosa is eroded and vessels become exposed and subsequently break.

More than 90 per cent of bleeds occur anteriorly and arise from Little's area, where the Kiesselbach plexus forms on the nasal septum. The Kiesselbach plexus is a confluence of arterial blood supply from several vessels including the anterior ethmoid artery, greater palatine artery and sphenopalatine artery on the anterior nasal septum.

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.

Aetiology
The primary cause of epistaxis in children is minor trauma, such as nose picking of dry nasal mucosa.

Occurrence is unusual in infants in the absence of a coagulopathy or nasal pathology (such as choanal atresia, neoplasm).

There is an increased incidence of epistaxis observed during winter months2 and with airborne particulate concentration.3

Nasal foreign bodies that cause local trauma can also be responsible for epistaxis, although this presentation is uncommon.

Children with migraines have a higher incidence of recurrent epistaxis than children without migraines. 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.

Other less common causes of epistaxis include liver disease, which can lead to clotting factor deficiencies (II, VII, IX, X) and hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu syndrome) which is an autosomal dominant disease which causes capillary fragility of the skin, mucous membranes and visera.

The majority of these patients develop epistaxis by 12 years. Juvenile nasal angiofibroma in adolescent males may cause severe nasal bleeding.

Assessment and management
Although there are established management protocols for acute epistaxis, these are normally formulated for adults.

Most epistaxis in children is minor and tends to self-resolve without any intervention other than direct pressure at the tip of the nose. This can be performed by a parent or carer.

When a child presents with epistaxis the cornerstone of management is reassurance and an initial assessment of the degree of blood loss. It is unusual for children presenting with epistaxis to require urgent transfer to hospital. Once the confidence of the child is gained, the nasal cavity can be examined with an illuminating nasal speculum or otoscope. In most cases, the source of bleeding is clearly visible arising from the anterior nasal septum.

Care should be taken to avoid excessive cautery or cauterising both sides of the septum which may result in a septal perforation.

Patients with a simple controlled bleed may resume regular activity; however, the child should not forcefully blow or pick their nose.

It is also prudent to avoid contact sports for a few days. Although barrier ointments such as petroleum jelly or chlorhexidine and neomycin cream are frequently prescribed, the evidence base supporting their use compared with no treatment or silver nitrate cautery is weak.

When to refer
Bleeding uncontrolled by direct pressure should warrant urgent referral to hospital. These children may require resuscitation, nasal pack insertion or even endoscopic artery ligation. In most other cases, referral to outpatients would be sufficient.

Children with lesions not in the Kiesselbach area should be considered for referral to otolaryngology for evaluation with 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 six years can tolerate a well-coached flexible fibre-optic examination of the nasal cavity without discomfort or mental trauma if the nose is anaesthetised and decongested.

Children suffering with recurrent idiopathic epistaxis should be referred for silver nitrate cautery which can be performed after application of local anesthetic spray.

Alternatively, younger or less compliant children may require a general anaesthetic for cautery although this is uncommon.

Although epistaxis is common in children, few require urgent intervention. Referral to otolaryngology may be appropriate in recurrent epistaxis to investigate causes of epistaxis.

  • Mr Leong is a specialist registrar in otorhinolaryngology, Royal Liverpool and Broadgreen Hospitals NHS Trust

References
1. Brown NJ, Berkowitz RG. Int J Pediatr Otorhinolaryngol. 2004; 68(9): 1181-4.

2. Tomkinson A, Bremmer-Smith A, Craven C, et al. Clin Otolaryngol Allied Sci. 1995; 20(3): 239-40.

3. Bray D, Monnery P, Toma AG. Clin Otolaryngol Allied Sci. 2004; 29(6): 655-8.

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