Epistaxis, or nosebleed, is a common paediatric complaint which is usually benign, self-limiting and spontaneous. It is rarely life threatening, but can cause significant parental concern and distress.
Epistaxis is the most common otolaryngological emergency, affecting up to 60% of the population in their lifetime, with 6% requiring medical attention.1
Epistaxis usually occurs in children aged two to 10 years, with a peak frequency between three and eight years. Occurrence in infants in the absence of a coagulopathy or nasal pathology (such as choanal atresia or neoplasm) is unusual.
Local trauma (for example, nose picking) does not normally occur until later in the toddler years. Older children and adolescents also have a less frequent incidence.
The true incidence of epistaxis in children is unknown, given that only a small proportion of these patients seek medical attention. The number of children admitted to hospital for epistaxis is low compared with adults, and has remained relatively constant over the past 10 years in England.
It is reassuring that acute epistaxis in healthy children rarely requires hospital admission and in general, is not associated with an underlying bleeding disorder. It usually requires minimal intervention compared with adults.2
Blood supply to the nose
The blood supply to the nose is derived from branches of the internal (anterior and posterior ethmoidal 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% 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 ethmoidal artery, greater palatine artery and sphenopalatine artery on the anterior nasal septum.
Occasionally, anterior bleeds can also occur from the inferior turbinates, which can be hypertrophic in children. 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 and aspiration of blood, and greater difficulty in controlling bleeding.
The primary cause of epistaxis in children is minor trauma, such as nose picking, in the setting of dry nasal mucosa. There is an increased incidence of epistaxis observed during winter months3 and with airborne particulate concentration.4Nasal foreign bodies that cause local trauma can also be responsible for epistaxis, although this presentation is uncommon.
Children with migraine headaches have a higher incidence of recurrent epistaxis than those without migraine. The Kiesselbach plexus, which is part of the trigeminovascular system, has been implicated in the pathogenesis of migraine.
Young infants with gastro-oesophageal 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), an autosomal dominant disease which causes capillary fragility of the skin, mucous membrane and viscera. Most of these patients develop epistaxis by the mean age of 12 years.
Juvenile nasal angiofibroma in adolescent males may cause severe nasal bleeding as the initial symptom associated with ipsilateral nasal obstruction and discharge.5
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 resolve with no intervention, other than direct pressure at the tip of the nose. This can be performed by an older child, a parent or a carer.
However, when a child presents with epistaxis, the cornerstone of management is establishing an appropriate attitude of concern towards the child and their family. In a calm and reassuring environment, an initial assessment of the degree of blood loss should be made.
It is unusual for children presenting with epistaxis to require urgent transfer to hospital for resuscitation.
Once the child’s confidence has been gained, the nasal cavity can be examined using an illuminating nasal speculum or otoscope.6
In most cases, the source of bleeding is clearly visible, arising from the anterior nasal septum. If facilities are available, the blood clot can be gently removed by suctioning and the bleeding point cauterised with a silver nitrate stick.
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, although the child should be careful not to pick or forcefully blow their nose. For a few days, it is is prudent to avoid contact sports or activities that may directly traumatise the nose.
Although barrier ointments, such as neomycin/chlorhexidine or petroleum jelly, are frequently prescribed, the evidence base supporting their use compared with no treatment or silver nitrate cautery is weak.7
When to refer
Bleeding uncontrolled by direct pressure should be urgently referred to hospital. These children may require resuscitation, nasal pack insertion or even endoscopic artery ligation. In most other cases, referral to the outpatients department would be sufficient.
Children in whom lesions are not observed in the Kiesselbach area should be considered for referral to otolaryngology for evaluation with a flexible or rigid rhinoscopy and nasopharyngoscopy to search for the source of bleeding and rule out any lesions as the cause of 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 fibreoptic examination of the nasal cavity without significant discomfort or mental trauma if the nose is anaesthetised and decongested.
Children with recurrent idiopathic epistaxis should be referred for silver nitrate cautery, which can be performed after application of local anaesthetic 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, for further management or to investigate causes.
- Mr Samuel Leong, Consultant ENT surgeon and rhinologist, Aintree University Hospital NHS Foundation Trust, Liverpool, United Kingdom
- Small M, Murray JAM, Maran AGD. A study of patients with epistaxis requiring admission to hospital. Health Bull (Edinb) 1982; 40: 20-9
- Brown NJ, Berkowitz RG. Epistaxis in healthy children requiring hospital admission. Int J Pediatr Otorhinolaryngol 2004; 68(9): 1181-4
- Tomkinson A, Bremmer-Smith A, Craven C et al. Hospital epistaxis admission rate and ambient temperature. Clin Otolaryngol Allied Sci 1995; 20(3): 239-40
- Bray D, Monnery P, Toma AG. Airborne environmental pollutant concentration and hospital epistaxis presentation: a five-year review. Clin Otolaryngol Allied Sci 2004; 29(6): 655-8
- Leong SC. A systematic review of surgical outcomes for advanced juvenile nasopharyngeal angiofibroma with intracranial involvement. Laryngoscope 2013; 123(5): 1125-31
- Leong SC, Roe RJ, Karkanevatos A. No frills management of epistaxis. Emerg Med J 2005; 22(7): 470-2
- Qureishi A, Burton MJ. Interventions for recurrent idiopathic epistaxis (nosebleeds) in children. Cochrane Database Syst Rev 2012 Sep 12; 9: CD004461