Nosebleeds (Epistaxis)



  • 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.

Risk Factors

  • 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.

General Prevention

  • 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

Commonly Associated Conditions

  • 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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