Nosebleeds (Epistaxis)

Basics

Epistaxis: bleeding from the nostril, nasal cavity, or nasopharynx
Classified as either anterior or posterior
- Anterior epistaxis is from the anterior nasal septum, usually is venous from an area known as Kiesselbach plexus.
- Posterior epistaxis occurs through the nasopharynx typically arising from the sphenopalatine artery.

At least 75% of children will experience at least one episode of epistaxis, commonly occurs between the ages of 3 and 8 years.
Rarely seen in children <2 years
Up to 9% of children may have recurrent epistaxis, but the majority grows out of it.
Anterior epistaxis more common in children
Occurs more frequently in the cold winter months when there is low humidity and when upper respiratory tract infections are more frequent
Dry air from indoor heating likely increases the incidence during winter months.

Mucosal dryness (also known as rhinitis sicca) is a frequent precursor to episodes of epistaxis as are upper respiratory tract infections.
Children with allergic rhinitis are more prone to epistaxis because the nasal mucosa is more friable and inflamed.
Children with recurrent epistaxis are more likely to have nasal colonization with Staphylococcus aureus.

Keeping nasal passages moist with the use of humidifiers, saline nasal sprays and emollients (e.g., Vaseline^®) help reduce mucosal irritation, dryness and thus friability.
Ensure fingernails are short and nasal trauma (i.e., nose picking, foreign body) is discouraged.
Use appropriate protective athletic equipment to avoid trauma.

Blood supply to the nasal cavity contains multiple anastomoses that originate from both the internal and external carotid arteries.
Kiesselbach plexus is located under a thin mucosal lining in the anteroinferior aspect of the nasal septum and is the most common site of bleeding in children.
The thin mucosal surface of the nasal septum and the lateral nasal walls are fragile and thus prone to inflammation, drying, and excoriation.

Most episodes of epistaxis in the younger age group are due to digital trauma as well as local inflammation:
- Upper respiratory tract infections, allergic rhinitis, rhinosinusitis, nasal vestibulitis, colonization of nasal cavity with S. aureus.
- Digital trauma, facial trauma, foreign body insertion, inhalants/irritants (intranasal corticosteroids, cocaine, heroin)
- <2 years, must consider trauma (nonaccidental or accidental) or a serious systemic disease (leukemia)
In the pediatric population, epistaxis is less likely a sign of systemic illness:
- Acquired or congenital bleeding disorders: von Willebrand disease, hemophilia, idiopathic thrombocytopenic purpura, hematologic malignancies
- Coagulopathy secondary to systemic infection, hepatic disease, renal failure, antiplatelet agents (i.e., aspirin), NSAID use
Local structural/vascular abnormalities
- Septal deviation, rhinitis sicca, spurs, nasal polyps
- Telangiectasias (Osler-Weber-Rendu disease also known as hereditary hemorrhagic telangiectasia [HHT])
- Nasal neoplasms: juvenile angiofibroma (consider in adolescent boys), papillomas, hemangiomas

Frequently associated with viral upper respiratory tract infections, allergic rhinitis, digital trauma
>90% of children with epistaxis do not have an underlying systemic cause.

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