Recurrent Epistaxis Peter E. Mulbury Pediatr. Rev. 1991;12;213-216 DOI: 10.1542/pir.

12-7-213

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pedsinreview.aappublications.org

Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1979. Pediatrics in Review is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 1991 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0191-9601. Online ISSN: 1526-3347.

Downloaded from http://pedsinreview.aappublications.org at Indonesia:AAP Sponsored on March 1, 2009

Recurrent
Peter E. Mulbury,

Epistaxis
MD*

The questions below should help focus the reading of this article. 1. What are the most common causes of epistaxis in children? 2. What laboratory tests should be included in the initial evaluation of a child with epistaxis possibly due to a bleeding disorder? 3. What are typical clinical findings in patients with juvenile nasopharyngeal angiofibromas? How are these necplasms best diagnosed and treated? 4. How are the different causes istaxis best treated? of ep-

dial extent of the ethmoid labyrinth. The inferior turbinate is usually a large
linear structure traversing the length

EDUCATIONAL

OBJECTIVE

of the nasal cavity.

It is composed

of

contractile sinusoidal blood vessels. The turbinates warm the inspired air, maintain its humidity, and clear particulate matter. In performing these functions, the turbinates vary dramatically in size, depending upon the environmental stimuli. Similarly, they

Further information about this topic can be found on a recent Pediatric Update tape (volume 10, issue 12). R.J.H. 123. The pediatrician should have the appropriate ability to manage
the child with recurrent epistaxis.

(Recent

Advances,

90/91)

become

engorged

during nasal infecthere and monly, a linear vessel running at the inferior aspect of the mucocutaneous junction may be identified as the probable source. This area has no subcutaneous tissue into which the injured vessel may retract, which is

tions, viral or bacterial. Finally, is a nasal cycle of engorgement

shrinkage of the turbinates curs throughout the day.

that oc-

Epistaxis is a common disorder that may be simple to control or potentially life-threatening. The primary physician should not only be capable of managing the majority of cases, but he or she should have a knowl-

The arterial supply to the nose is multiple, involving branches of both

the internal and external carotid systems. In general, the vast majority of
the supply is projected from posterior sites. The distribution of the major blood vessels supplying the mucosa

an important local mechanism of hemostasis in many other areas of the

body. Ulcer and Perforation

edge

of the

need appropriate

gressive
ANATOMY

potential causes that triage and more agtreatment.

of the septum
illustrated In the

and the turbinate

is
was Less commonly, an ulcer through the mucosa to the perichondrium may be present in chronic cases. Extension of the erosion into the under-

in Figures 1 and 2. past, much attention

focused The nose serves to warm, humi-

on the Little area, also called

the Kiesselbach plexus. This area of the anterior septum is considered to

be an anastomotic
tenor vessels.

site of several anthis an-

dify, and clean the air that we breathe. The least important functional component of the nose for hu-

Theoretically,

lying cartilage
supply leads

with its meager

to perforations.

blood
These

mans is the olfactory

nasal vault, medial the middle turbinate nform plate.

area high in the

to the insertion of beneath the crib-

atomical feature accounts for the finding that a majority of nosebleeds

occur in the anterior 2 to 3 cm of the

septal
breathing

perforations

whistle

with
small.

if the hole is relatively

septum. It is more likely that this is the area most irritated by both finger
manipulation of inspired CAUSES An overview of the causes istaxis in the pediatric patient vided in Table 1. of epis proand air. the drying effects

More troublesome is the chronic crusting of these perforations, which

in turn leads to granulation bleeding. tissue and

The sinuses are paired, air-filled extensions of the nasal cavities lined by
mucous mucoid membrane. content. coating They must be

both ventilated

and drained
The draining

of their
is pro-

Although this process is the usual cause of septal perforations, the physician must be aware of other etiologies. In the adult, previous surgery or

vided by ciliary action,

the mucous posteriorly.

which

moves
and then

medially

The nasal septum merely partitions the sides of the nose. The turbinates are the major anatomical Structures on the nose. There are three of these
scroll-shaped structures on each lateral wall of the nasal cavity. The su-

Digital

Manipulation

cocaine abuse are concerns; in children, however, less favorable diagnoses such as vasculitis, granulomatous disorder, or lymphoma must be
considered. Inflammation Significant epistaxis may occur

perior turbinate is a relatively small variable structure, whereas the middle turbinate is composed largely of
ethmoid
*

Most nosebleeds are due to digital manipulation and occur in the anterior third of the nasal vault. The bleeding site is almost always at or just posterior to the mucocutaneous juncture. An anterior deviation of the septum may result in a specific area
being more vulnerable to drying and, therefore, to crusting and irritation at that point. From either cause, a distinct excrescence of a vessel or, corn-

air cells and defines

Rochester,

the me-

with any acute or chronic inflammatory disorder within the nose simply as a consequence of the resultant hyperernia of the mucosa. Such causes include allergy and the
chronic purulent rhinitis that may be

1641 East Avenue,

NY 14610.

associated

with adenoidal

hypertroPIR 213

vol. 12 no. 7 january 1991 pediatrics in review Downloaded from http://pedsinreview.aappublications.org at Indonesia:AAP Sponsored on March 1, 2009

Epistaxis

TABLE

1.

Causes

of Epistaxis

Anterior ethmoidal

artery
ethmoidal artery

Bleeding abnormalities Hemophilia

Leukemia
Osler-Weber-Rendu syndrome von Willebrand syndrome

Digital manipulation Inflammatory

ftJlergic

Bacterial Adenoid infection tion Foreign body

or obstruc-

Sinusitis
Dryness

Viral Neoplastic Benign Granulomas Hemangiomas Juvenile nasopharyngeal

an-

giofibroma
Polyps Malignant Structural Perforation Septal deviation
Ucer

Fig 1. Blood supply to lateral wall of nose. Site of most posterior nosebleeds Reproduced with permission from Cummings et al. Otolaryngology: Head and Neck Louis, MO: CV. Mosby; 1986:1

is shown. Surgery. St

Traumatic

Septal branch of anterior ethmoidal Frontal Watershed sinus area

artery

vious source or cause, consideration of bleeding disorders is in order. Epistaxis and complication excessive bleeding as a of surgery are the two

Septal cartilage

Sphenoid sinus

most frequent symptoms of von Willebrand disease. This disorder is a combination of varying degrees of factor VIII deficiency and a lack of platelet adhesiveness. The latter may only be apparent in response to challenge with nstocetin. The condition varies widely in its expression, from
normal hemostasis to a definite pro-

Septal branch of superior labial artery Palate

Fig 2. BlOOd supply to nasal septum. Kiesselbach area is site of most anterior epistaxis. Reproduced with permission from Cummings et al. Otolaryngology: Head and Neck Surgery. St Louis, MO: CV. Mosby; 1986:1

longation of the bleeding time, particularly in response to challenge. Factor VIII and IX hemophilias may also cause epistaxis. Similarly, epistaxis and bruising are frequently the early signs of leukemia. A complete blood count with a differential nd a smear, platelet count, bleeding time, prothrombin time, and partial thromboplastin time should constitute the
initial workup.

phy or infections. Sinusitisdoes ocoften secondary to adenoidal obstruction, particularly in younger children. When rhinitis is unilateral and associated with a foulsmelling discharge, the presence of a foreign body must be ruled out. Finally, abuse of decongestant medicur in childhood, PIR 214

cations results in rhinitis medicamentosa; this condition however, is not commonly associated with epistaxis. Bleeding Disorders

Whenever epistaxis s persistentor recurrent in the absence of an ob-

Osler-Weber-Rendu syndrome, although not actually a factor deficiency, may be grouped with bleeding disorders. Hereditary telangiectasis, as it is also known, includes multiple mucosal telangiectasias,particularly of the nose. Telangiectasias also oc-

pediatrics in review #{149} vol. 12 no. 7 january 1991 Downloaded from http://pedsinreview.aappublications.org at Indonesia:AAP Sponsored on March 1, 2009

OTORHINOLARYNGOLOGY

cur throughout the gastrointestinal tract and may cause gastrointestinal bleeding and chronic anemia. Furthermore, there may be cyanosis, clubbing, and significant right-to-left pulmonary shunting. Benign Tumors

TABLE

2.

Epistaxis and treat

Instruments to examine the nose

with epistaxis. Adequate suction and light are essential. Other important items are listed in Table 2. Assessment

Cotton Foley catheter (No 14 or No 16, with a 30-cc Balloon) Nasal speculum Nasal vasehine packing
Suction tip Medications for control taxis Antibiotic ointment of epis-

After taking a brief history, the physician usually must combine assessment with the initial stages of treatment. The acute hemorrhage requires immediate attention, and the

Of great concern are the neoplastic sources of epistaxis in children. These neoplasms do not necessarily carry a dismal prognosis because benign processes constitute the majority. Granulomas are usually the result

of chronic

irritation

or the use of cauin for

tery. Polyps are distinctly uncommon the pediatric age group, except

Cautery material (silver nitrate or chromic acidcrystals on applicator) Hemostaticmaterial (Gelfoam, Surgicel,r Helostat) o Topicalanesthesia(4% xylocaine, pontocaine caine) or 4% co-

source of the bleeding may be obscure until certain procedures are done. An attempt must be made to
identify the bleeding source: anterior versus posterior, right versus left. Blood may have passed posteriorly

around the septum and then out the contralateral side. Similarly, unless an
anterior site is controlled, blood will

those with cystic

fibrosis.

These

pa-

tients frequently develop nasal polyps, chronic sinusitis, and asthma. A

Vasoconstrictor
nephrine

(0.25% neosy-

be found in the oropharynx,

suggest-

or 4% cocaine)

polyp may be acutely inflamed or even strangulated, leading to bleeding. A different type of polyp is formed by the herniation of maxillary sinus mucosa through the natural ostium. the amount of Iyrnphoid tissue present, lymphomas are the second most common form of these malignancies.

ing a posterior site. Generally, arterial and posterior bleeding is more copious. Initially, the clots should be cleared

These then pass through

nor choana (hence the

the posteterm antral

Closely
midline

related
reticuloses,

to lymphomas
previously

are
known

and a pledget of cotton soaked in vasoconstrictor and topical anesthetic placed in the anterior nasal cayity. Pressure over the nasal ala by either the patient or the examiner for a minimum of 5 minutes will usually

choanal

polyp), presenting

with nasal
be

obstruction and a nasopharyngeal mass. These masses also may infected or strangulated.

as lethal midline granulomas. These are particularly aggressive necrotizing processes that are additionally difficult to diagnose by biopsy. Olfactory tumors, sarcomas of the bone or

allow

adequate

examination

and
bleeding

identification

of an anterior

Juvenile nasopharyngeal broma is a benign vascular

arising in the lateral

angiofineoplasrn

nasopharynx.

cartilage,
benign Trauma

and degeneration
neoplasms

of usually

site. While waiting

for the vasoconstric-

These

lesions

occur

only in the pu-

all can be found.

bescent male and are hormonally sensitive. Their blood supply is derived from the internal maxillary artery. On initial examination, a naso-

pharyngeal mass and a history of recurrent posterior epistaxis are found.

Biopsy typically is fraught with problems, and diagnosis is made by arteriogram.

Capillary, cavernous, and mixed hemangiomas also may occur in the nasal cavity. Discussion of these conditions is beyond the scope of this article. Malignant
Malignant

The child who sustains trauma to the midface frequently seeks help for epistaxis. Most often, this bleeding is self-limited. The anterior ethmoidal artery enters through the fragile lamma papyracea of the ethmoid bone and can be lacerated by bone fragments. This injury may result in difficult high arterial bleeding. MANAGEMENT EPISTAXIS When tricians agement OF ACUTE

tor to take effect, the examiner may take a more complete history. This should include the amount of bleeding, a family history suggestive of a bleeding disorder, current medications such as aspirin, infection, trauma, and other precipitating factors. Many offices have the capability of obtaining an immediate hematocrit

or complete
when signs

blood

count.
pulse

Similarly,
and blood

appropriate, of more

pressure

are obtained
significant

to look
bleeding.

for

Treatment If an anterior source of bleeding is identified, the vessel or point is then cauterized by applying a silver nitrate stick or bead of chromic acid to the site for 30 seconds. Care should be taken not to cauterize too deeply or over too large an area, but precisely on the targeted site. Ointment or Gelfoam is then applied, and the patient is requested to apply ointment twice
#{149}

Tumors
neoplasms within the na-

sal vault are distinctly uncommon, and may arise from any of the epithehal or connective tissue elements.

a child comes to the pediaoffice with bleeding, manusually is straightforward.

However,

one should be prepared

for

The most common head and neck malignancy of childhood is rhabdomyosarcoma. Not surprisingly, given

an emergency minimal amount

should one occur. A of equipment should

be available, and many physicians organize a prepared kit for the patient
pediatrics in review

vol. 12 no. 7 january

1991

PIR

215

Downloaded from http://pedsinreview.aappublications.org at Indonesia:AAP Sponsored on March 1, 2009

Epistaxis

daily for 5 days to decrease localized crusting. If control is not gained or if recur-

rence poses

a problem,

an anterior

pack is inserted. If a minimum of pressure seems necessary, or for patients suspected of having a bleeding diathesis, one of the hemostatic agents (Gelfoam, Surgicel, Helostat) is used for the packing. Otherwise, a pack consisting of layers of vasehine gauze is inserted. This gauze should be coated first with an antibiotic ointment to counter the resident bacteria of the nose. If successful, this is left in place for 2 to 3 days.

by the patient. They are particularly useful in the excoriated nose, or in the individual who returns with bleeding after an initial recent successful cauterization. (The authors only experience has been with the Merocel nasal sponges.) An otolaryngologist is capable of better visualization, particularly of the posterior nasal cavity and nasopharynx, than the general pediatrician. Otolaryngologic examination may indude the use of flexible or rigid sco-

pes, infracturing
or simply

the inferior turbinate,

studies.

radiographic

If the source of bleeding

tified, bleeding has ceased,

is not idenand the

history

is consistent

with an anterior

TREATMENT OF SPECIFIC CAUSES OF EPISTAXIS For the patient with epistaxis secondary to nose-picking, the most important treatment is the regular application of an antibiotic ointment. This therapy prevents both the buildup of crust and the attendant itching. This approach applies as well to the patient with crusting due to a septal deviation. Copious use of ointment usually will prevent penetration of the perichondrium in the mucosal ulcerations. Nosebleeds during the nosebleed season, typically during the transitions from fall to winter and from winter to spring, generally are felt to be secondary to drying of the nasal mucosa with secondary hyperemia and crusting. This problem is treated best with regular use of buffered saline nasal sprays.

epistaxis, an alternative is simply to have the patient return if the bleeding recurs. An active bleeding point may then be identified.

If, however, the primary physician is unable to control the bleeding, the
patient should be sent either to an

otolaryngologist or an emergency department. There, appropriate blood samples can be drawn for laboratory studies, and more complete equipment catheter is available. may In emergency situ-

ations with copious pharynx, followed pack. The catheter

bleeding,

a Foley

be placed

in the naso-

by an anterior is passed through

the nose into the oropharynx, inflated with water, and drawn up tightly against the posterior choana. The balloon should be inflated with just

frequency and quantity of epistaxis that is controlled inadequately without surgery. The laser has proven to be a useful tool. A more aggressive approach involves curettage of the nasal mucosa followed by coverage with a split thickness graft. After removal of a granuhoma, the base is cauterized. There is a significant recurrence rate. Bleeding or necrotic pohyps are removed and always sent for pathologic review to rule out other pathologic processes. Unless hemangiomas are associated with unusual problems, they should be treated expectantly as with other pediatric hemangiomas. The juvenile nasopharyngeal angiofibroma is treated with surgery after both hormonal therapy and embohization. Radiation therapy is to be avoided because of the possible induction of a malignant change. Therapy of malignant neoplasms is based on histology, discussion of which is beyond the scope of this article. Most important, however, is the alertness of the examiner to this possibility in unusual situations, particularly in the case of polypoid or pedunculated lesions. Finally, in the instance of nasal trauma resulting in lacerations of the anterior ethmoid artery, packing may frequently fail to stop these high antenor arterial bleeds. Ligation of the artery through an ethmoid type mcision is necessary for control. SUMMARY Epistaxis in the pediatric patient is a relatively common, and usually easily controlled, event. The practitioner should be aware of the anatomy, p0tential causes, and methods of control available for this condition.

enough water palate slightly,

to depress the soft and an anterior pack

In treating
imal cautery

septal perforations,
and ointment are

mmmdi-

is inserted. The patient is then transported to the hospital for admission and studies. An alternative to the formal nasal packing and use of the hemostatic agents discussed above are the relatively new expanding nasal

cated.

Therapy

is directed

at pre-

sponges.

These are inserted

in a dry

compressed state and expanded with either saline or an antibiotic solution. The authors prefer to use the antibiotic solution (such as an antibiotic ear drop solution) to avoid the

reported incidence syndrome. These sponges

of toxic provide

shock gentle

pressure and protection from the drying effects of air, thus decreasing crust formation. They are generally left in place for 3 days and removed
PIR 216 pediatrics in review
#{149}

venting enlargement of the perforation or an increase in the chronic inflammation. Perforations smaller than 1.0 cm are recommended for repair. Larger perforations are better treated with a silastic button, because the incidence of operative failure is so high. Specific antibiotic therapy is indicated with purulent rhinitis. The bacteriology of sinusitis and adenoiditis is similar to that of otitis media. In the case of cystic fibrosis, Gram negative bacteria play a more prominent role. Similar specific replacement therapy is used in the case of bleeding disorders. Osler-Weber-Rendu syndrome usually is associated with a
1991

SUGGESTED
Cummings

READING
Head
C. V.

Neck Go; 1986:1

Montgomery

C et al. Otolaryngology: Surgery. St Louis, MO:

and

Mosby

WW. Surgery of the Upper Respiratory System. 2nd Ed. Philadelphia, PA: Lea and Febiger; 1979:1 Nasal obstruction. Otalaryngol C/in North Am. April 1989;22:2

Non-squamous tumors of the head and neck. Otolaryngo/ C/in North Am. November 1986:19 (No 4) Paparella MM, Shumerick DA. Oto/aryngo/ogy.
Philadelphia, PA: W. B. Saunders Go; 1987:3

vol. 12 no. 7 january

Downloaded from http://pedsinreview.aappublications.org at Indonesia:AAP Sponsored on March 1, 2009

Recurrent Epistaxis Peter E. Mulbury Pediatr. Rev. 1991;12;213-216 DOI: 10.1542/pir.12-7-213

Updated Information & Services Permissions & Licensing

including high-resolution figures, can be found at: http://pedsinreview.aappublications.org Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://pedsinreview.aappublications.org/misc/Permissions.shtml Information about ordering reprints can be found online: http://pedsinreview.aappublications.org/misc/reprints.shtml

Reprints

Downloaded from http://pedsinreview.aappublications.org at Indonesia:AAP Sponsored on March 1, 2009