Pediatrics

Epistaxis

OVERVIEW: What every practitioner needs to know

Are you sure your patient has epistaxis? What are the typical findings for this disease?

Epistaxis is a common complaint. More often than not, bleeding is evident from the front of the nose and may be unilateral or bilateral. It is possible to have posterior nasal bleeding, which may present as blood in the patient's mouth (spitting up blood or vomiting blood) rather than blood from the nose, but this is much less common.

The most common symptoms of epistaxis are obvious fresh blood from the nose and/or mouth. The next most common symptoms are nausea and vomiting (if blood has been swallowed).

Initial Management

Remember your ABCs. Epistaxis can be a life-threatening event or a harbinger of other life-threatening conditions. Bleeding in the nose can interfere with the patient's ability to adequately protect his or her airway. If the patient is neurologically altered at baseline or is incapacitated, bleeding and subsequent loss of airway protection can be life-threatening. Even neurologically intact patients can be overwhelmed and lose airway control if bleeding is brisk.

Ask yourself, is this patient protecting his or herself adequately or is the bleeding sufficient to cause aspiration and difficulty breathing. If so, call for a medical response team. This is also an appropriate time for an emergent consultation with an otolaryngologist.

Again remember your ABCs. Check the patient's vital signs. Hypertension may exacerbate epistaxis. Hypotension may indicate rapid volume loss and the need for fluid resuscitation (volume expanders and/or blood). If you find yourself in this type of situation, again ask for assistance, ensure that there is large-bore intravenous access and working suction in the room and begin efforts to stabilize the patient. Again, the otolaryngologic service should be called as well. Laboratory studies should be obtained to assess hemoglobin level, platelet level, and coagulation profile.

Far more commonly, epistaxis presents as a troublesome occurtence rather than a life-threatening emergency. In this situation, you will be afforded the time to both manage the problem and investigate its cause.

Epistaxis should first be classified as anterior, posterior, or cannot be determined. The vast majority of epistaxis is occurring from the anterior portion of the nose rather than posteriorly. Anterior bleeding tends to present with blood from the nose, whereas posterior bleeding often presents with blood from the nose as well as a significant amount of blood from the mouth as well. Posterior bleeding is more often a major significant bleeding event. Determining where the bleeding is coming from, or determining that you cannot tell where the bleeding is coming from, is an early part of epistaxis management.

Epistaxis should next be determined to be primary or secondary. Those nosebleeds that are determined to be secondary to an underlying condition will have, as a part of their management, care of the underlying condition.

Vascular Anatomy of the Nose

The majority of the blood supply comes from the external carotid artery, with a small amount from the internal carotid artery.The anterior and posterior ethmoid arteries, which supply the superior nasal cavity and superior septum, are branches of the ophthalmic artery, itself a branch of the internal carotid artery. The facial artery and internal maxillary artery are branches of the external carotid artery. The sphenopalatine artery, a branch of the internal maxillary artery, provides the majority of blood supply to the nose.

What caused this disease to develop at this time?

Environmental factors: mucosal drying

Inflammatory diseases: Wegener granulomatosis, relapsing polychondritis

Trauma: evident by physical examination, ranging from facial trauma (accidents, nonaccidental trauma), digital trauma (nose picking), foreign bodies, nasal cannulas or continuous positive airway pressure masks, iatrogenic (recent nasal or sinus surgery)

Genetic diseases: von Willebrand factor deficiency, hemophilia, hereditary hemorrhagic telangiectasia to name a few—inquire after family history or patient history of bleeding with previous procedures

Congenital lesions: vascular malformations

Aquired coagulopathy: medication use (see below), liver disease (leads to deficiency in clotting factors), renal failure, chemotherapy, hematologic malignancies

Malnutrition: evident by history and physical examination

Drugs: aspirin, clopidogrel, warfarin, cocaine use, topical nasal steroid sprays, nonprescription medications associated with bleeding.

Neoplastic causes: benign and malignant neoplasms of nasal cavity and sinuses—in the male adolescent pediatric population a bleeding intranasal mass represents juvenile nasal angiofibroma until proved otherwise

Hypertension: a common systemic condition associated with epistaxis, although a cause-and-effect relationship has not been proved

What laboratory studies should you request to help confirm the diagnosis? How should you interpret the results?

Laboratory studies that may be helpful depend on the setting in which the epistaxis has occurred. For the healthy patient who presents with epistaxis that is easily controlled and does not recur, no studies are necessary. This is the vast majority of patients, both pediatric and adult.

For patients in whom there is a positive family or personal history of a particular bleeding disorder or of easy bruising or bleeding, a coagulation profile and complete blood count as well as platelet function assay may reveal a particular coagulopathy. Tests for von Willebrand factor deficiencies are now widely available and may also be considered.

In the hospitalized, critically ill patient, it is reasonable consider ordering coagulation studies and a complete blood count, particularly in the setting of known disruptions from baseline. For example, compromised hepatic or renal function and chemotherapeutic treatment will both affect the body's ability stop epistaxis once it has started. These patients may need factor replacement, platelets, or blood to replenish stocks and prevent further bleeding.

Would imaging studies be helpful? If so, which ones?

In certain settings, radiologic studies are useful both for diagnosis and treatment of epistaxis. Depending on local experience and expertise, epistaxis refractory to medical care may be treated surgically or with interventional radiologic techniques. See the section on treatment.

If you are able to confirm that the patient has epistaxis, what treatment should be initiated?

Elements of immediate management of airway compromise and life-threatening blood loss is covered above. For epistaxis that is not life threatening, have the patient gently blow his or her nose to evacuate clots and then remain leaning forward to allow the blood to drip from the nose. Begin inspecting the nose for a source, using a nasal speculum, suction, and a headlight. If available, a rigid endoscope is an excellent alternative. Protective equipment should be worn.

In the setting of anterior nasal bleeding, topical therapy should be attempted. In escalating order of intervention: pressure (squeezing the cartilaginous portion of the nose for 20 minutes), topical vasoconstrictor spray (e.g., oxymetazoline spray) on a cotton ball placed in the nose, cauterization (topical silver nitrate), and anterior packing (unilateral or bilateral). There are commercially available packing materials specifically for epistaxis and the otolaryngologic and/or emergency medicine services will be familiar with their use. These often contain inflatable balloons that exert pressure and can be left in place for days and slowly deflated.

In the pediatric population, most bleeding is from the anterior septum, called Little area or Kiesselbach plexus, an area of vascular anastomoses. Little area/Kiesselbach plexus can be treated with pressure with or without topical vasoconstrictor spray. For prominent vessels seen on the septum or floor of the nose, antiseptic or barrier creams may be applied in an effort to reduce the chance of bleeding. These vessels may also be cauterized with silver nitrate or electrocautery in the setting of an active nosebleed or as a measure directed at preventing recurent bleeding. Evidence supporting these measures is somewhat controversial.

In the setting of posterior bleeding, topical therapy may be attempted first (topical vasoconstrictor sprayed into nasal cavity). If the site of bleeding is discrete and accessible, cautery may be performed. Commercially available packing materials exist that are long enough to reach the posterior nasal cavity and nasopharynx and can apply pressure and act as carriers for hemostatic agents to the likely area of bleeding.

If these devices do not control the hemorrhage, other devices exist that contain balloons and can be inflated to exert pressure in the posterior nose and nasopharynx. Posterior packing warrants admission to a monitored setting because pressure within the posterior nose and nasopharynx may lead to activation of the nasopulmonary reflex with resultant suppression of the respiratory drive, apnea, hypoxia, and cardiac arrhythmias.

If the nose requires packing, the next step in management varies with local expertise and preference. Packing may be left in place for hours to several days. If there is a balloon within the device, it can be deflated in steps until it is empty, and the packing device may removed some time later. While packing material is in place, antibiotics directed against Staphylococcus aureus and upper respiratory flora are prescribed. The patient is observed for a period packing removal. Alternatively, the patient requiring packing and whose medical condition permits it can proceed to surgical or interventional radiologic interevention without a waiting period.

Bleeding refractory to medical management (including packing) may require interventional radiologic procedures and/or surgical intervention, depending on available experience and expertise.

Neuroendovascular interventional radiologic services offer potential embolization of the arterial blood supply most likely responsible for the epistaxis. These therapies can be directed at the branches of the external carotid artery. The risk of stroke precludes embolization of the anterior and posterior ethmoid arteries, since these are branches of the ophthalmic artery (itself a branch of the internal carotid artery).

Embolization is often carried out bilaterally, treating the internal maxillary arteries (and thereby its branches, including the sphenopalatine artery) and one of the facial arteries (usually the side ipsilateral to the bleeding). Abruzzo and Heran recently published a report describing the safe use of neuroendovascular therapies in the pediatric population. This therapy offers excellent long-term success, demonstrated by a growing body of supportive literature.

Surgical therapies include ethmoid artery ligation, endoscopic sphenopalatine artery ligation, transantral ligation of the maxillary artery and ligation of the external carotid artery. Anterior ethmoid artery ligation is most commonly perfomed through an external approach with an incision in the medial canthal region. The artery is ligated, clipped or cauterized.

The posterior ethmoid artery may also be approached in this fashion. This procedure is usually used to address bleeding in the superior nasal cavity. Endoscopic sphenopalatine artery ligation is used for posterior nasal cavity bleeding and has demonstrated excellent efficacy. Transantral maxillary artery ligation has given way to endoscopic sphenopalatine artery ligation.

Medical work-up can proceed simultaneously with neuroendovascular interventional or surgical management for serious bleeding. This includes laboratory studies and medical therapy directed at correcting any underlying conditions predisposing the patient to epistaxis (e.g., platelet count for thrombocytopenia).

What causes this disease and how frequent is it?

Epistaxis is a common complaint (about 10% of the population experiences epistaxis per year). It is more common in male individuals and frequent in the dry winter months. In children, epistaxis is uncommon in those younger than 2 years of age. Thirty percent of all children 0-5 years old, 56% of those 6-10 years old, and 64% of those 11-15 years old have experienced at least one episode of epistaxis.

What complications might you expect from the disease or treatment of the disease?

Topical vasconstrictors: there is one case report of oxymetazoline overuse causing stimulant psychosis in an adult patient. Oxymetazoline, like several other nasal topical decongestants, is a sympathomimetic drug. It can cross the blood-brain barrier and cause central noradrenergic effects. A study of the effects of xylometazoline did not reveal systemic side effects such as tachycardia, anxiety, restlessness, or insomnia, although patients did experience epistaxis and blood-tinged mucus.

Silver nitrate cautery can be painful and can cause recurrent epistaxis. In addition, crusting, septal perforation, and tattooing of the mucosa may occur. Chemical cautery or electrocautery when performed on the septum bilaterally can cause a septal perforation, although Felek and colleagues noted no perforations in 38 children treated with bilateral silver nitrate application.

Nasal packing requires antibiotic prophylaxis against S. aureus and can cause damage to the external nose if the material exerts pressure on the ala. Bilateral packing can cause ischemia and necrosis of the nasal septum. Posterior packing with or without balloon use can cause respiratory suppression and apnea or hypoxia as well as cardiac arrhythmias.

Embolization has been associated with serious complications including stroke, vision loss, facial paralysis, and necrosis of skin and/or mucous membranes. Pain is not an uncommon symptom of the treatment itself.

Surgical complications are associated with the particular surgical intervention performed. Each particular operation has its own attendant sequelae and risks, from external scar formation to surgical failure, infection, sensory changes to the face, vision loss, and leakage of cerebrospinal fluid. Discussion of the risks, benefits, and alternatives for each particular operation is beyond the scope of this chapter.

How can epistaxis be prevented?

Preventive measures to reduce the risk of anterior epistaxis include antiseptic and barrier ointments. Antiseptics are thought to reduce inflammation and prevent excessive drying. Barrier ointments prevent drying as well.

If digital trauma is thought to contribute, attempting to curtail this behavior will be beneficial.

If there are known hereditary diseases that are predisposing to epistaxis, disease management (or at the least awareness) will be beneficial.

What is the evidence?

The level of evidence supporting management options for epistaxis is poor, consisting mostly of reviews and "how I do it" reports. In addition, the majority of literature is written about adult patients, who experience the majority of epsitaxis requiring physician intervention.

Wormald, PJ, Bailey, BJ, Johnson, JT. "Epistaxis". Otolaryngology Head and Neck Surgery. Lippincott Williams & Wilkins. 2006.

Melia, L, McGarry, GW. "Epistaxis: update on management". Curr Opin Otolaryngol Head Neck Surg. vol. 19. 2011. pp. 30-5.

(Up-to-date review of recent management developments with extensive bibliography.)

Shakeel, M, Trinidade, A, McCluney, N. "Complementary and alternative medicine in epistaxis: a point worth considering during the patient's history". Eur J Emerg Med. vol. 17. 2010. pp. 17-9.

Kubba, H, MacAndie, C, Botma, M. "A prospective, single-blind, randomized controlled trial of antiseptic cream for recurrent epistaxis in childhood". Clin Otolaryngol. vol. 26. 2001. pp. 465-8.

(Children in the group randomized to cream therapy experienced less epistaxis than did those who received no treatment.)

Glynn, F, Amin, M, Sheahan, P. "Prospective double blind randomized clinical trial comparing 75% versus 95% silver nitrate cauterization in the management of idiopathic childhood epistaxis". Int J Pediatr Otorhinolaryngol. vol. 75. 2011. pp. 81-4.

(Authors compared different concentrations of silver nitrate. Overall success for chemical cautery was greater than 90% at 8 weeks.)

Burton, MJ, Doree, CJ. "Interventions for recurrent idiopathic epistaxis (nosebleeds) in children". Cochrane Database Syst Rev. 2007.

(A 2004 Cochrane review of treatment options for idiopathic recurrent epistaxis in the pediatric population failed to reveal a difference in frequency of recurrence comparing antiseptic cream to no therapy, petroleum jelly to no therapy, and antiseptic cream to silver nitrate cautery. This review concluded that the best treatment for this particular condition is unkown.)

Murthy, P, Nilssen, ELK, Rao, S. "A randomized clinical trial of antiseptic nasal carrier cream and silver nitrate cautery in the treatment of recurrent anterior epistaxis". Clin Otolaryngol. vol. 24. 1999. pp. 228-31.

(Fifty patients, both children and adults, randomized to chlorhexidine and bacitracin cream with or without silver nitrate cautery. No difference in control rates of epistaxis between these groups.)

Calder, N, Kang, S, Fraser, L. "A double-blind randomized controlled trial of management of recurrent nosebleeds in children". Otolaryngol Head Neck Surg. vol. 140. 2009. pp. 670-4.

(Adding silver nitrate cautery to 4 weeks of antibiotic ointment offered a small advantage in decreasing recurrent epistaxis versus antibiotic ointment alone.)

Abruzzo, TA, Heran, MKS. "Neuroendovascular therapies in pediatric interventional radiology". Tech Vasc Interv Radiol.. vol. 14. 2011. pp. 50-6.

Strach, K, Schröck, A, Wilhelm, K. "Endovascular treatment of epistaxis: indications, management and outcome". Cardiovasc Intervent Radiol. vol. 34. 2011. pp. 1190-8.

(This is a review of 48 patients, age range 14-87 years. The primary success rate for their intervention was 93.8% and their patients experienced two major complications—necrosis of the nasal tip requiring surgery and transient unilateral hemiparesis.)

Wormald, PJ, Wee, DTH, van Hasselt, CA. "Endoscopic ligation of the sphenopalatine artery for refractory posterior epistaxis". Am J Rhinol. vol. 14. 2000. pp. 261-4.

(Review of 13 patients demonstrating 92% epistaxis control over a mean follow-up of 13 months. No complications were encountered.)

Snyderman, CH, Goldman, SA, Carrau, RL. "Endoscopic sphenopalatine artery ligation is an effective method of treatment of posterior epistaxis". Am J Rhinol. vol. 13. 1999. pp. 137-40.

(Review of 38 patients, age not specified, with 92% success. No major complications.)

Petruson, B. "Epistaxis in childhood". Rhinology. vol. 17. 1979. pp. 83-90.

Ticoll, B, Shugar, G. "Paranoid psychosis induced by oxymetazoline nasal spray". CMAJ. vol. 150. 1994. pp. 375-6.

Eccles, R, Martensson, K, Chen, SC. "Effects of intranasal xylometazoline, alone or in combination with ipratropium, in patients with common cold". Curr Med Res Opin. vol. 26. 2010. pp. 889-99.

Felek, SA, Celik, H, Islam, A. "Bilateral simultaneous nasal septal cauterization in children with recurrent epistaxis". Int J Pediatr Otorhinolaryngol. vol. 73. 2009. pp. 1390-3.

(Thirty-eight pediatric patients underwent bilateral simultaneous cauterization using silver nitrate, nine of whom underwent a second cauterization procedure. No patients experienced septal perforation. It is not clear whether or not second cauterization procedures were performed bilaterally.)
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