Epistaxis (Nosebleed)

Most bleeding arises from the rich network of blood vessels of Kisselbach plexus in Little area of the anterior nasal septum. Most epistaxis resolves spontaneously or after a few minutes of pressure (nasal pinching). For the vast majority of cases, no medical attention is sought.

Differential Diagnosis

• Trauma
  –Dry air, especially in winter months
  –Digital trauma (nose-picking)
  –Nasogastric or nasotracheal tube
  –Blunt trauma, with or without fracture
  –Foreign body: Usually accompanied by unilateral foul-smelling rhinorrhea
  –Air pollution (indoor or outdoor)
  –Barotrauma: Diving or airplane descent in patient with upper respiratory infection
  –Chemical or caustic burn

• Inflammation
  –Upper respiratory infection (viral or bacterial)
  –Rhinitis (allergic, nonallergic with eosinophilia, atrophic, chronic): Results in increased mucosal vascularity and increased trauma from sneezing, rubbing, and nose blowing
  –Vestibulitis

• Anatomic
  –Nasal septal deviation
  –Postoperative, following sinus surgery, adenoidectomy, septoplasty, etc.
• Platelet dysfunction
  –NSAID use, especially aspirin
  –Idiopathic thrombocytopenic purpura
  –Leukemia
• Coagulopathy
  –Von Willebrand disease
  –Hemophilia
  –Liver disease
  –Anticoagulants (coumadin, heparin)
• Benign masses
  –Nasopharyngeal angiofibroma: Presents only in adolescent males
  –Pyogenic granuloma
  –Papilloma
• Malignant neoplasms
  –Rhabdomyosarcoma
  –Lymphoma

• Vascular abnormalities
  –Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease): Autosomal dominant, 90% with recurrent epistaxis
  –Hemangioma
  –Internal carotid pseudoaneurysm (suspect with massive bleed after head trauma)

Workup and Diagnosis

• History
  –Frequency, duration, precipitating factors, maneuvers required to make it stop
  –Medications, including over-the-counter and herbals
  –Family history of nosebleeds, easy bleeding, or bruising
  –Environmental history, including types of heating and cooling systems, allergies, etc.

• Physical exam
  –Assess general condition, with vital signs, to estimate acute degree of blood loss
  –Suction, or have child blow out all blood clots and fresh blood
  –Decongest (topical oxymetazoline) nose; may anesthetize with topical lidocaine or ponticaine as well
  –Anterior rhinoscopy (using otoscope is often easier and more accessible than headlight and nasal speculum)
• Labs
  –Hemoglobin and hematocrit
  –Platelet levels, coagulation studies (PT, aPTT)
  –For refractory cases, closure time (an in vitro bleeding time) and von Willebrand profile
• Hematology consultation
• Studies (for exceptional cases only)
  –CT scan with contrast
  –MRI/MRA
  –Angiography

Treatment

• Humidification
  –Nasal saline sprays
  –Aquaphor or antibiotic ointment to anterior septum
  –Vaporizer at night
• Pinch cartilaginous nose for >5–10 minutes
• Remove (physician suctioning or patient blowing out) all blood clots
• Vasoconstrictive (decongestive) sprays (oxymetazoline)
• Nasal packing
  –Petroleum gauze (many meters may be needed)
  –Premade packs: Absorbable (cellulose, gelatin), nonabsorbable, inflatable balloons
  –Posterior packing requires ICU observation
• Cauterization
  –Chemical: Silver nitrate
  –Electrical: Monopolar, bipolar
• Angiography with embolization
• Surgical ligation or clipping of feeding arteries

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

Other Book Chapters Related to Nosebleeds

Read excerpts from these other book chapters related to Nosebleeds:

Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

More About Causes of Nosebleeds

• Back to symptom: Nosebleeds: Introduction (review 260 causes)
• Next Book Extract About Nosebleeds: EPISTAXIS (Differential Diagnosis in Primary Care)
• All Book Extracts: All Online Book Extracts for Nosebleeds

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

 » Next page: EPISTAXIS (Differential Diagnosis in Primary Care)

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• Gastrointestinal Bleeding (A Pocket Manual of Differential Diagnosis)

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