Epistaxis

• The nose is a highly vascular structure that frequently is exposed to infections, inflammation, and local trauma.
• Tumors or other masses are rarely present in the nose, but they may cause epistaxis.
• Profuse epistaxis in teenage males is a common presentation for juvenile nasopharyngeal angiofibroma, a very vascular fibrous benign mass that originates in the posterior nose. Profuse epistaxis associated with a posterior nasal mass or cranial neuropathy is common. The diagnosis typically is confirmed by computed tomography (CT), magnetic resonance imaging, or angiography. Biopsy is not recommended because of the risk of bleeding. Treatment is surgical excision after embolization in most cases.

The most common cause of recurrent childhood epistaxis is local trauma:

• trauma to the vessels of the anterior aspect of the nasal septum in the Kiesselbach plexus.
• this location is prone to drying, crusting, and low-grade infection.
• digital manipulation of the nose in the presence of macerated tissue results in epistaxis.
• examination of the nose reveals prominence of the blood vessels in the Kiesselbach plexus.
• treatment involves application of antibiotic ointment to lubricate the region and reduce low-grade infection and frequently, application of silver nitrate to the prominent blood vessels to cauterize them.
• Repeated cauterization may be necessary in a few patients.

Inflammation of the nose due to viral illnesses or sinusitis is another cause of epistaxis.

• typically have symptoms of nasal congestion, purulent rhinorrhea, and often fever.
• during the course of the respiratory illness, hyperemia due to the infection and maceration of nasal mucosa may result in a small amount of nasal bleeding.
• profuse bleeding is uncommon
• physical examination findings are remarkable for mucosal hyperemia without isolated prominent vessels.
• purulent exudate may be noted.

Treatment is typically supportive for the epistaxis and appropriate for the cause of the inflammation. The child described in the vignette has no symptoms or signs of inflammation. Thus, there is no need to culture the nasal secretions.

Coagulopathy is an uncommon cause of epistaxis without other evidence of bleeding problems (eg, easy bruising, free bleeding from other areas of trauma) or a positive family history. However, coagulopathy may increase the severity of epistaxis from other causes. If suspected, a von Willebrand panel, bleeding time, or other testing can be ordered to identify the cause and aid in the treatment of epistaxis. The mass in the posterior nasal passage of the child described in the vignette makes coagulopathy an unlikely cause of the epistaxis.

For recalcitrant cases of epistaxis, evaluation for a subtle coagulopathy, CT scan of the sinuses to rule out tumor or sinusitis, or nasal endoscopy to evaluate the posterior aspect of the nose are appropriate. Although sometimes required in adults, children rarely require vessel ligation to control epistaxis. Unlike in adults, hypertension is an uncommon cause of epistaxis in children. However, hypertension does need to be excluded.


References:
Herman A. Visual diagnosis: a child who has a nosebleed and high blood pressure. Pediatr Rev. 2001;22:104-107
Full text is available online for subscription or fee.

Magit AE. Tumors of the nose, paranasal sinuses, and nasopharynx. In: Bluestone CD, Casselbrant ML, Stool SE, et al, eds. Pediatric Otolaryngology. 4th ed. Philadelphia, Pa: WB Saunders; 2003:1053-1064

Manning SC, Culbertson MC Jr. Epistaxis. In: Bluestone CD, Casselbrant ML, Stool SE, et al, eds. Pediatric Otolaryngology. 4th ed. Philadelphia, Pa: WB Saunders; 2003:925-932

Wald ER. Rhinitis and acute and chronic sinusitis. In: Bluestone CD, Casselbrant ML, Stool SE, et al, eds. Pediatric Otolaryngology. 4th ed. Philadelphia, Pa: WB Saunders; 2003:995-1012