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Epistaxis

Epistaxis(bleeding from nose) is common occurrence in childhood and adolescence.

>90% of nosebleedsarise from anterior aspect of nasal septum.

Principal Causes of Epistaxis

1. Trauma
2. Low environmental humidity
3. Rhinitis
4. Foreign body
5. Bleeding disorders
6. Drugs
7. Chemical irritants
8. Hypertension
9. Neoplasm

Clinical Features and Diagnosis

Trauma

Most commoncause of epistaxis in all age groups.

Area of bleeding in minor trauma isalmost always anterior portion of nasal septum. Digital manipulation(nose picking) and blunt trauma are most common causes of bleedingin this area.

Significant trauma also may cause nasalor facial fractures and epistaxis.

Nasal surgery also may cause bleeding.

History and physical exam are diagnostic.

Low Environmental Humidity

Low environmentalhumidity and hot air heating systems lead to dryness of nasal mucosa,exposure of underlying vasculature, and subsequent bleeding.

History and physical exam are diagnostic.

Rhinitis

Mild bleedingsometimes occurs with rhinitis, which can be viral, bacterial, orallergic in origin.

Nasal discharge can be purulent ornonpurulent.

See Chap.41, Nasal Discharge.

Foreign Body

Foreignbody in nose usually produces foul-smelling, unilateral nasal discharge, whichmay be blood tinged.

Beads, erasers, or vegetable matterare often seen.

Rhinoscopy is diagnostic.

Bleeding Disorders

Unusualfor epistaxis to be only manifestation of bleeding disorder. Findingsthat suggest bleeding disorder are prolonged bleeding followingcircumcision, dental manipulation, tonsillectomy, or adenoidectomy;positive family history of bleeding disorder; bleeding from othersites; easy bruising; purpura; hepatosplenomegaly; lymphadenopathy;jaundice; and massive or recurrent bleeding.

Common bleeding disorders that cancause epistaxis are idiopathic thrombocytopenic purpura, vWD, leukemia,factor VIII and IX deficiencies, and liver disease.

When bleeding disorder is suspected,screening tests should be performed: CBC and differential, analysisof blood smear, platelet count, prothrombin time, activated partialthromboplastin time, and bleeding time.

Other investigations depend on suspecteddiagnosis and results of screening tests.

See Chap.52, Purpura and Bleeding.

Drugs

Aspirin,coumadin, and heparin can cause epistaxis as well as bleeding fromother sites, especially GI tract.

History, physical exam, and a prolongedbleeding time are diagnostic.

Chemical Irritants

Although uncommon in pediatric population,some irritants that inflame nasal mucosa and cause epistaxis includenoxious fumes of sulfuric acid, ammonia, gasoline, and printer'sink.

Hypertension

Althoughoccurrence of epistaxis is rare in children with hypertension, BPshould be measured in anyone with epistaxis.

See Chap.32, Hypertension.

Neoplasm

Benign Tumors

Benign tumorsof nose, sinuses, and nasopharynx that may cause epistaxis include granulomas,hemangiomas, and juvenile nasopharyngeal angiofibromas.

Granulomas are usually due to chronicirritation.

Hemangiomas that arise from anteriornasal septum or along turbinates can usually be diagnosed by theirreddish-purple appearance.

Juvenile nasopharyngeal angiofibromasusually occur in adolescent males and appear as reddish-brown smoothmasses in nasal cavity or nasopharynx.

Flexible endoscopy is especially useful.CT and MRI show their location and extent. With juvenile angiofibromas,biopsy can lead to severe bleeding, so benefit of biopsy shouldbe carefully considered because radiologic imaging is often diagnostic.

Malignant Tumors

Primarymalignant tumors of nasopharynx and paranasal sinuses are rare inpediatric population but include nasopharyngeal carcinomas, lymphomas,rhabdomyosarcomas, and other sarcomas. All of these tumors can causeepistaxis and nasal obstruction.

Exam of nose or nasopharynx may revealfriable, ulcerating mass.

Combination of tests including nasopharyngoscopy,lateral neck and skull radiographs, CT, and MRI locate tumor anddefine its extent.

Histologic diagnosis is definitive.

Diagnostic Approach

Most commoncauses of epistaxis are trauma, excessive dryness of nasal mucosa,and viral upper respiratory infections.

In most children, bleeding stops after5 mins of continuous, firm pressure on nares, and significant bloodloss usually does not occur.

If local area of bleeding can be identifiedand no evidence of mass lesion or systemic illness is present, furtherevaluation is generally unnecessary.

Prolonged use of aspirin or anticoagulantdrugs may be responsible for epistaxis, but in such cases bleedingusually occurs elsewhere.

Presence of foreign body and hypertensioncan be determined by physical exam.

Presence of bleeding disorder withepistaxis as only manifestation is unusual but can occur with vWDand disorders of platelet function. When bleeding disorder is suspected,screening tests mentioned earlier should be performed. Because thesetests can sometimes be normal with vWD, further investigation maybe necessary. See Chap. 52, Purpuraand Bleeding.

Although benign tumors of nasal cavityand nasopharynx are unusual and malignant tumors in these areasare rare, epistaxis ± nasal obstruction sometimes is presentingfeature of such tumors.

These tumors are usually detected onnasal or nasopharyngeal exam, but general anesthesia occasionallyis required to perform adequate exam. If malignancy is suspected,CT, MRI, or both modalities may be necessary depending on the lesion.

References

1. Katsanis E, et al. Prevalence and significanceof mild bleeding disorders in children with recurrent epistaxis.J Pediatr 1988;113;73–76.
2. Kiley V, et al. Coagulation studies in children withisolated recurrent epistaxis. J Pediatr 1982;100:579–581.
3. Marple BF. Epistaxis. In: Cotton RT, Myer CM III, eds.Practical pediatric otolaryngology. Philadelphia: Lippincott-Raven,1999:427–448.
4. Mulbury PE. Recurrent epistaxis. Pediatr Rev 1991;12:213–216.
5. Nadel F, Henretig FM. Epistaxis. In: Fleisher G, LudwigS, eds. Textbook of pediatric emergency medicine, 4th ed. Baltimore:Lippincott Williams & Wilkins, 2000:227–230.
6. Schulman I. The significance of epistaxis in children.Pediatrics 1959;24:489–492.

Book Source Details

• Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
• Author(s): Paul S. Bellet
• Year of Publication: 2006
• Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.

Other Book Chapters Related to Nosebleeds

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Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2008 Williams & Wilkins.

More About Causes of Nosebleeds

• Back to symptom: Nosebleeds: Introduction (review 260 causes)
• Next Book Extract About Nosebleeds: Gastrointestinal Bleeding (The Diagnostic Approach to Symptoms and Signs in Pediatrics)
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More About This Book: Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics Authors: Paul S. Bellet Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 0-78172-899-1

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