Evaluation of epistaxis in children

INTRODUCTION — Epistaxis is common in children. Childhood nosebleeds are rarely severe and seldom require hospital admission [1]. Nonetheless, frequent minor nosebleeds can be both bothersome and alarming for caregivers and children.

The evaluation of epistaxis in children will be reviewed here. The epidemiology, etiology, and management of epistaxis in children are discussed separately. (See "Causes of epistaxis in children" and "Management of epistaxis in children".)

OVERVIEW — Although nosebleeds in children are rarely life threatening, the initial evaluation should focus upon the respiratory and hemodynamic stability of the patient rather than the bleeding. Normal appearance, vital signs, and respiratory function are evidence that the examiner can safely attend to the presenting complaint. On the other hand, abnormalities in these indices may signal an emergency. Airway intervention and fluid resuscitation are sometimes necessary in massive epistaxis. (See 'Emergency assessment' below.)

The goal of the evaluation is to determine the site and etiology of bleeding. Nosebleeds in children have a variety of etiologies, ranging from self-limited mucosal irritation to life-threatening neoplasms (table 1). Distinguishing between local and systemic causes of bleeding is critical to the institution of timely and appropriate therapy. (See "Causes of epistaxis in children" and "Management of epistaxis in children".)

EMERGENCY ASSESSMENT — Rapid assessment of general appearance, vital signs, airway stability, and mental status are necessary to identify children with respiratory or hemodynamic instability who require airway intervention and/or fluid resuscitation [2]. Airway intervention is needed for patients who are spitting or regurgitating blood to the point that they cannot maintain oxygenation or their airway. (See "Technique of emergency endotracheal intubation in children" and "Hypovolemic shock in children in resource-abundant settings: Initial evaluation and management", section on 'Fluid resuscitation' and "Management of epistaxis in children".)

Rapid assessment and stabilization is followed immediately by attempts to identify the source of bleeding and initiation of measures to control it, usually in consultation with otolaryngology [3]. Blood factors or platelets should be administered to patients who have bleeding disorders that can be treated with such products. The remainder of the evaluation is undertaken after the patient is stabilized.

HISTORY — Important aspects of the history in a child with epistaxis include [3]:

●How old is the child?

Epistaxis is rare in children younger than two years (approximately 1 per 10,000) and should prompt consideration of trauma (intentional or unintentional) or serious illness (eg, thrombocytopenia) (table 1). Epistaxis in this age group has also been associated with asphyxiation, either intentional or unintentional [4-7] Thus, presence of epistaxis in children younger than two years of age should prompt assessment for other signs of child abuse (table 2 and table 3) [8].

●When did the bleeding begin?

Prolonged bleeding despite correctly applied direct compression may be suggestive of a bleeding disorder [9-11].

●Has there been any bleeding or unusual bruising elsewhere in the body?

Bleeding elsewhere in the body, particularly if it is prolonged, is suggestive of a bleeding disorder. Areas of ecchymosis may indicate a bleeding disorder.

●Any prior visits to the emergency department (ED) for epistaxis?

Prior ED visits are associated with an increased risk of a bleeding diathesis [6].

●Is it bilateral or unilateral?

Unilateral bleeding indicates that there may be an isolated lesion or minor trauma, whereas bilateral bleeding is more suggestive of general mucosal irritation, systemic etiology or major nasal trauma. (See "Causes of epistaxis in children".)

●How much blood has been lost?

Estimation of the quantity of blood loss is difficult; the quantity of bleeding in posterior epistaxis is often underestimated because much of the blood is swallowed [3].

●Is there blood in the mouth or vomitus?

Posterior bleeding is suggested by initial awareness of bleeding in the back of the throat and/or swallowed blood. Patients with swallowed blood may present with complaints of hematemesis or melena [3].

●What measures were taken to stop the bleeding?

Bleeding that is difficult to control with anterior pressure may indicate a bleeding disorder or a posterior source of bleeding [3].

●Is there a history of trauma (including nose picking)?

Some providers find that asking children which finger they use to pick their nose elicits a more honest answer about nose picking [3]. Nasal trauma (ie, a broken nose) usually causes epistaxis that in most cases resolves spontaneously.

●Is there a history of nasal congestion, discharge, or obstruction? Has there been an insertion of a foreign body?

Bloody discharge from one side of the nose suggests the possibility of a foreign body in the nose, particularly if the nasal discharge is foul smelling. In patients with a button battery in the nose and associated tissue necrosis, the discharge may also have a black color; in addition, facial pain and swelling may be present (see "Diagnosis and management of intranasal foreign bodies"). Nasal obstruction with mucopurulent drainage and facial pain, especially during the winter suggests chronic sinusitis. Progressively worsening nasal obstruction, particularly if it is associated with epistaxis, implies possible nasal tumor (table 1). (See "Allergic rhinitis: Clinical manifestations, epidemiology, and diagnosis" and "Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis".)

●Is there a recent history of nasal surgery?

Occasionally children will have epistaxis after an adenoidectomy or other nasal surgery; post-operative epistaxis usually is self-limiting but can require intervention by the otolaryngologist.

●Are there associated symptoms?

Headaches and/or facial pain may be related to an intracranial mass. Fever and hepatomegaly suggest the possibility of dengue hemorrhagic fever for patients residing in or traveling from endemic regions. Hearing loss and cranial neuropathies may suggest rhabdomyosarcoma. Hearing loss, torticollis, trismus, unilateral cervical adenopathy, retrobulbar or ear pain, and neck pain may suggest nasopharyngeal carcinoma. (See "Causes of epistaxis in children".)

Past medical history, family history, and review of systems should include information regarding:

●Allergies.

●Medications (particularly nasal corticosteroids, aspirin and ibuprofen [12]), drugs of abuse (cocaine, heroin, inhalants), and complementary/alternative therapies (ie, ginkgo biloba).

●Number, frequency, and seasonality of previous episodes. Intermittent epistaxis may be caused by changes in the weather, allergies, low humidification of inspired air; colonization with pathologic bacteria (eg, Staphylococcus aureus). Intermittent epistaxis may also be related to menses [13].

●History of easy bruising or bleeding problems in the patient or family.

●Family history of hereditary hemorrhagic telangiectasia [14].

●In the child younger than two years of age, history of apparent life-threatening events or sibling death [7].

EXAMINATION

Preparation — Examination of a child with epistaxis can be difficult and may be facilitated by the application of a topical vasoconstricting and/or anesthetic agent (eg, lidocaine alone or lidocaine mixed with a vasoconstricting agent, such as 0.025 percent oxymetazoline hydrochloride) [15]. The vasoconstricting agent can be applied with a spray bottle or a cotton pledget (placed into the nose with forceps and removed after five minutes).

Along with topical anesthesia, some children may need anxiolysis or mild sedation. (See "Procedural sedation in children: Selection of medications".)

General examination — Children with epistaxis should undergo a complete general examination, with special attention to hemodynamic compromise, signs of systemic causes of bleeding, and asphyxiation [3,7,16]. The following aspects are particularly important:

●Vital signs, including blood pressure and heart rate

●Malaise suggestive of hypoxia and/or acidosis after asphyxiation [7]

●Pallor (as an indication of blood loss or anemia)

●Respiratory distress, poor skin perfusion with altered color (eg, cyanosis or grey color) due to asphyxiation [7]

●Petechiae, bruising, gingival bleeding; hemotympanum may be present due to the reflux of blood into the eustachian tube [17]

●Examination of the oropharynx (for signs of posterior bleeding)

●Mucocutaneous telangiectasias, hemangiomas

●Enlarged lymph nodes, organomegaly, petechiae, pallor (as indications of hematologic disease or malignancy)

●Icterus as a sign of liver disease (with secondary coagulopathy)

●Visual acuity and extraocular movements should be tested in children with a history of facial trauma

●Orbit (blood can reflux up the nasolacrimal duct and appear in the medial canthus and along the lower eyelid)

●Abnormal bruising, oral injury, burns, or other findings of physical child abuse, especially in children younger than two years of age (see "Physical child abuse: Recognition")

Nasopharynx — Most nosebleeds in children are anterior. Posterior bleeds are important to identify because they may require more extensive management [3]. Specific sites to be examined include the nasal septum (Kiesselbach's plexus, presence of a septal perforation), nasal cavity, inferior turbinates, and nasopharynx (figure 1).

Initial inspection may be accomplished by using one's thumb to push the tip of the nose upward. This permits examination of the vestibule, the anterior portion of the septum, and the anterior portion of the inferior turbinate [3]. A more thorough inspection for anterior septal bleeding can be completed by anterior rhinoscopy using a headlight, or head mirror and nasal speculum. Alternatively, an otoscope with a large tip may be used in the young child who has difficulty holding still. The area of Kiesselbach's plexus should be inspected first since it is the source of the majority of nosebleeds. This area should be examined for active bleeding, scabs, ulcerations, erosions, or prominent blood vessels.

Failure to identify a source of anterior bleeding may indicate posterior bleeding. Examination for more posterior bleeding is usually performed by an otolaryngologist with flexible or rigid fiberoptic endoscopy [16].

In addition to evaluation for a bleeding source, examination of the nose and nasopharynx should include inspection for other potential causes of bleeding including [3] (see "Causes of epistaxis in children"):

●Foreign bodies (picture 1) (see "Diagnosis and management of intranasal foreign bodies")

●Mucosal inflammation/lesions/crusting (suggestive of bacterial colonization)

●Masses (tumors)

●Rhinitis (infectious or allergic)

●Vascular anomalies (telangiectasia, hemangioma)

●Juvenile angiofibromas (especially in teenage boys) (image 1)

LABORATORY EVALUATION — Laboratory evaluation is not indicated in the majority of children with self-limited epistaxis. However, based upon observational and anecdotal evidence, laboratory evaluation is appropriate in the following children:

●Directly observed prolonged epistaxis (eg, >30 minutes) despite correctly applied local pressure

●Epistaxis refractory to acute measures to stop bleeding

●Epistaxis in children younger than two years of age

●Epistaxis more than two to three times per week for several weeks

●History or examination findings suggestive of a bleeding disorder or other systemic disease [2]

Consultation with a hematologist before ordering labs can ensure that all of the necessary tests are performed, since sophisticated testing may be required to detect mild bleeding disorders. (See "Approach to the child with bleeding symptoms".)

Laboratory evaluation for bleeding disorder may include (table 4 and algorithm 1) [3,9]:

●Blood type and screen/cross-match for patients with severe bleeding who may require transfusion

●Complete blood count with platelet count and examination of the smear (algorithm 2)

●Prothrombin time (PT)

●Activated partial thromboplastin time (PTT)

●Prothrombin time international normalized ratio (INR) if the child is receiving anticoagulation therapy

●Evaluation for von Willebrand disease, if clinically indicated. Epistaxis may be the sole indication of von Willebrand disease. (see "Clinical presentation and diagnosis of von Willebrand disease")

Additional diagnostic studies for physical child abuse are discussed separately. (See "Physical child abuse: Diagnostic evaluation and management", section on 'Laboratory studies'.)

RADIOLOGIC EVALUATION — If a nasal foreign body is suspected, a lateral face radiograph can be performed to evaluate for a button battery or other radio-opaque objects. (See "Diagnosis and management of intranasal foreign bodies", section on 'Diagnosis'.)

Contrast-enhanced computed tomography or magnetic resonance imaging should be performed in children with epistaxis if a mass is visualized or suspected. (See "Causes of epistaxis in children".)

Consultation with a pediatric oncologist and/or otolaryngologist is warranted if neoplasm is suspected. Such consultation can ensure that the appropriate laboratory evaluation, radiographs, and histopathologic studies are obtained.

Imaging in child with suspected physical child abuse is discussed separately. (See "Physical child abuse: Diagnostic evaluation and management", section on 'Imaging'.)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Nosebleeds (The Basics)")

●Beyond the Basics topic (see "Patient education: Nosebleeds (epistaxis) (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Emergency assessment – Although nosebleeds are rarely life threatening, the initial evaluation should focus on the respiratory and hemodynamic stability of the patient. Rapid assessment of general appearance, vital signs, airway stability, and mental status are necessary to identify children with epistaxis who require airway intervention and/or fluid resuscitation. Identification of the source of bleeding and initiation of bleeding control measures follow immediately. (See 'Emergency assessment' above and "Management of epistaxis in children".)

●Evaluation – Evaluation of children with epistaxis should determine the site and etiology of bleeding. Nosebleeds in children have a variety of etiologies, ranging from self-limited mucosal irritation to life-threatening neoplasms (table 1). (See 'Overview' above and "Causes of epistaxis in children".)

●History – Features that increase the likelihood of a cause other than local mucosal trauma include (see 'History' above):

•Young age (<2 years old without clear history of trauma)

•Prolonged bleeding (eg, >30 minutes) despite appropriate nasal compression (figure 2)

•Bleeding elsewhere in the body or unusual bruising

•Blood initially noted in the back of throat (suggests posterior bleeding site)

•Hematemesis (suggests copious anterior or posterior bleeding)

•Recurrent epistaxis

•Bilateral epistaxis

•Family history of a bleeding disorder

Epistaxis is associated with asphyxiation in children younger than two years of age with epistaxis and no traumatic injury or bleeding disorder. Careful history, physical examination, and when physical child abuse is suspected, additional evaluation in consultation with a multidisciplinary child abuse team is warranted in such patients. The evaluation of physical child abuse is discussed separately. (See "Physical child abuse: Diagnostic evaluation and management".)

●Physical examination – Application of a topical vasoconstricting and/or anesthetic agent (eg, lidocaine alone or lidocaine mixed with a vasoconstricting agent, such as 0.025 percent oxymetazoline hydrochloride) may facilitate examination. For some children, anxiolysis, sedation and/or analgesia may be beneficial. (See 'Preparation' above.)

Important findings of serious illness include (see 'General examination' above):

•Respiratory distress

•Pallor, petechiae/purpura, bruising, or bleeding from the gums

•Posterior bleeding

The nasal and nasopharyngeal examination is directed toward determining the site and cause of bleeding such as mucosal abnormalities, foreign bodies, masses, anatomic abnormalities, or vascular abnormalities. (See 'Nasopharynx' above.)

●Laboratory studies – Laboratory studies are not indicated for most children with self-limited epistaxis. However, evaluation for bleeding disorder (complete blood count, with platelet count and examination of the peripheral smear, prothrombin time, and activated partial thromboplastin time) is indicated in patients with frequent recurrent nosebleeds, severe nosebleeds that are difficult to control, and those with personal or family history suggestive of a bleeding disorder. Consultation with a hematologist prior to ordering blood studies can ensure that all of the necessary tests are performed, since sophisticated testing may be required to detect mild bleeding disorders. (See 'Laboratory evaluation' above.)

●Imaging – If an intranasal mass is seen or suspected, contrast-enhanced computed tomography or magnetic resonance imaging is indicated. (See 'Radiologic evaluation' above.)