Rare in infancy, common in children older than 2 yr of age.
Incidence decreases after puberty.
The most common site of bleeding is the Kiesselbach plexus, an area in the anterior septum
Thin mucosa in this area, as well as the anterior location,
make it prone to exposure to dry air and trauma.
ETIOLOGY:sunflower:
There is often a family history of childhood epistaxis.
Susceptibility is increased during respiratory infections and in the winter when dry air irritates the nasal mucosa, resulting in formation of fissures and crusting.
Epistaxis can be classified into primary or secondary .
digital trauma
foreign bodies
dry air, and inflammation, including upper respiratory tract infections,sinusitis, and allergic rhinitis (Table below:point_down:
)
chronic use of Nasal steroid spray
significant gastroesophageal reflux rarely present with epistaxis secondary to mucosal inflammation.
Severe bleeding may be encountered with congenital vascular abnormalities, such as hereditary hemorrhagic telangiectasia ( varicosities, hemangiomas
The family
history may be positive for abnormal bleeding (epistaxis or other sites);
specific testing for von Willebrand disease is indicated because the
prothrombin time or partial thromboplastin time may be normal
despite having a bleeding disorder.
in children with thrombocytopenia, deficiency of clotting
factors, particularly von Willebrand disease
Hypertension, renal failure, or venous congestion.
Recurrent epistaxis despite cauterization is associated with mild coagulation disorders.
Nasal polyps or other intranasal
growths may be associated with epistaxis.
May be the initial presenting symptom in juvenile nasal angiofibroma, which occurs in adolescent boys.
CLINICAL MANIFESTATIONS:safety_vest:
Epistaxis usually occurs without warning, with blood flowing slowly
but freely from one nostril or occasionally from both.
With nasal lesions, bleeding might follow physical exercise
When bleeding
occurs at night, the blood may be swallowed and become apparent only
when the child vomits or passes blood in the stools.
Posterior epistaxis
can manifest as anterior nasal bleeding or, if bleeding is copious, the patient might vomit blood as the initial symptom.
TREATMENT:stuffed_flatbread:
Most nosebleeds stop spontaneously in a few minutes.
The nares should be compressed
the child kept as quiet as possible, in an upright position with the head tilted forward to avoid blood trickling back into the throat.
Cold compresses applied to the nose can also help.
If these measures do not stop the bleeding:point_right:local application of a solution of oxymetazoline (Afrin or Neo-Synephrine) (0.25-1%) may be
useful.
If bleeding persists, an anterior nasal pack may need to be
inserted
If bleeding originates in the posterior nasal cavity, combined anterior and posterior packing is necessary.
After bleeding is under controland if a bleeding site is identified its obliteration by cauterywith silver nitrate may prevent further difficulties.
Because the septal cartilage derives its nutrition from the overlying mucoperichondrium
only one side of the septum should be cauterized at a time to reduce the chance of a septal perforation. During the winter, or in a dry environment, a room humidifier, saline drops, and petrolatum (Vaseline)
applied to the septum can help to prevent epistaxis.
Antiseptic cream
(e.g., mupirocin) significantly increases the proportion of children who have complete resolution of bleeding at 8 wk compared to no treatment. Ointments prevent infection, increase moisture, decrease
bleeding, and are commonly used in clinical practice. However, the combination of silver nitrate cautery and antiseptic nasal cream is superior to antiseptic cream alone.
Patients with severe epistaxis despite conservative medical measures should be considered for surgical ligation techniques or embolization.
In patients with severe or repeated epistaxis, blood transfusions may be necessary. Otolaryngologic evaluation is indicated for these children and for those with
bilateral bleeding or with hemorrhage that does not arise from the Kiesselbach plexus.
Secondary epistaxis should be managed by identification of the cause, application of appropriate nasal therapy, and
correct systemic medical management
Hematologic evaluation (for coagulopathy and anemia), along with nasal endoscopy and diagnostic imaging, may be needed to make a definitive diagnosis in cases of
severe recurrent epistaxis. Replacement of deficient clotting factors may be required for patients who have an underlying hematologic disorder
Profuse unilateral epistaxis associated with a nasal mass in an adolescent boy
near puberty might signal a juvenile
nasopharyngeal angiofibroma.
CT with contrast medium enhancement and MRI are part of the initial evaluation; arteriography, embolization, and extensive surgery may be needed.
Surgical intervention may also be needed for bleeding from the
internal maxillary artery or other vessels that can cause bleeding in the
posterior nasal cavity.
PREVENTION:peanuts:
The discouragement of nose picking
attention to proper humidification of the bedroom during dry winter months helps to prevent many nosebleeds.
Prompt attention to nasal infections and allergies is
beneficial to nasal hygiene.
Prompt cessation of nasal steroid sprays prevents ongoing bleeding.
Nelson 20:crystal_ball: