DOI: 10.1542/pir.12-7-213 1991;12;213-216 Pediatr. Rev.

Peter E. Mulbury Recurrent Epistaxis

http://pedsinreview.aappublications.orgthe World Wide Web at:

The online version of this article, along with updated information and services, is located on

Print ISSN: 0191-9601. Online ISSN: 1526-3347. Village, Illinois, 60007. Copyright © 1991 by the American Academy of Pediatrics. All rights reserved.trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove

andpublication, it has been published continuously since 1979. Pediatrics in Review is owned, published, Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly

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

The questions below should helpfocus the reading of this article.

1. What are the most common causesof epistaxis in children?

2. What laboratory tests should be in-cluded in the initial evaluation of achild with epistaxis possibly due to ableeding disorder?

3. What are typical clinical findings inpatients with juvenile nasopharyngealangiofibromas? How are these nec-plasms best diagnosed and treated?

4. How are the different causes of ep-istaxis best treated?

EDUCATIONAL OBJECTIVE

Further information about this topiccan be found on a recent “PediatricUpdate” tape (volume 10, issue12). R.J.H.123. The pediatrician should havethe appropriate ability to managethe child with recurrent epistaxis.(Recent Advances, 90/91)

* 1641 East Avenue, Rochester, NY 14610.

pediatrics in review vol. 12 no. 7 january 1991 PIR 213

Recurrent EpistaxisPeter E. Mulbury, MD*

Epistaxis is a common disorderthat may be simple to control or po-tentially life-threatening. The primaryphysician should not only be capableof managing the majority of cases,but he or she should have a knowl-edge of the potential causes thatneed appropriate triage and more ag-gressive treatment.

ANATOMY

The nose serves to warm, humi-dify, and clean the air that webreathe. The least important func-tional component of the nose for hu-mans is the olfactory area high in thenasal vault, medial to the insertion ofthe middle turbinate beneath the crib-nform plate.

The sinuses are paired, air-filled ex-tensions of the nasal cavities lined bymucous membrane. They must beboth ventilated and drained of theirmucoid content. The draining is pro-vided by ciliary action, which movesthe mucous coating medially and thenposteriorly.

The nasal septum merely partitionsthe sides of the nose. The turbinatesare the major anatomical Structureson the nose. There are three of thesescroll-shaped structures on each lat-eral wall of the nasal cavity. The su-perior turbinate is a relatively smallvariable structure, whereas the mid-dle turbinate is composed largely ofethmoid air cells and defines the me-

dial extent of the ethmoid labyrinth.The inferior turbinate is usually a largelinear structure traversing the lengthof the nasal cavity. It is composed ofcontractile sinusoidal blood vessels.The turbinates warm the inspired air,maintain its humidity, and clear partic-ulate matter. In performing thesefunctions, the turbinates vary dra-matically in size, depending upon theenvironmental stimuli. Similarly, theybecome engorged during nasal infec-tions, viral or bacterial. Finally, thereis a “nasal cycle” of engorgement andshrinkage of the turbinates that oc-curs throughout the day.

The arterial supply to the nose ismultiple, involving branches of boththe internal and external carotid sys-tems. In general, the vast majority ofthe supply is projected from posteriorsites. The distribution of the majorblood vessels supplying the mucosaof the septum and the turbinate isillustrated in Figures 1 and 2.

In the past, much attention wasfocused on the Little area, also calledthe Kiesselbach plexus. This area ofthe anterior septum is considered tobe an anastomotic site of several an-tenor vessels. Theoretically, this an-atomical feature accounts for thefinding that a majority of nosebleedsoccur in the anterior 2 to 3 cm of theseptum. It is more likely that this isthe area most irritated by both fingermanipulation and the drying effectsof inspired air.

CAUSES

An overview of the causes of ep-istaxis in the pediatric patient is pro-vided in Table 1.

Digital Manipulation

Most nosebleeds are due to digitalmanipulation and occur in the anteriorthird of the nasal vault. The bleedingsite is almost always at or just pos-terior to the mucocutaneous junc-ture. An anterior deviation of the sep-tum may result in a specific areabeing more vulnerable to drying and,therefore, to crusting and irritation atthat point. From either cause, a dis-tinct excrescence of a vessel or, corn-

monly, a linear vessel running at theinferior aspect of the mucocutaneousjunction may be identified as theprobable source. This area has nosubcutaneous tissue into which theinjured vessel may retract, which isan important local mechanism of he-mostasis in many other areas of thebody.

Ulcer and Perforation

Less commonly, an ulcer throughthe mucosa to the perichondriummay be present in chronic cases. Ex-tension of the erosion into the under-lying cartilage with its meager bloodsupply leads to perforations. Theseseptal perforations whistle withbreathing if the hole is relatively small.More troublesome is the chroniccrusting of these perforations, whichin turn leads to granulation tissue andbleeding.

Although this process is the usualcause of septal perforations, the phy-sician must be aware of other etiolo-gies. In the adult, previous surgery orcocaine abuse are concerns; in chil-dren, however, less favorable diag-noses such as vasculitis, granuloma-tous disorder, or lymphoma must beconsidered.

Inflammation

Significant epistaxis may occurwith any acute or chronic inflamma-tory disorder within the nose simplyas a consequence of the resultanthyperernia of the mucosa. Suchcauses include allergy and thechronic purulent rhinitis that may beassociated with adenoidal hypertro-

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

Anteriorethmoidal artery

ethmoidal artery

TABLE 1. Causes of Epistaxis

Bleeding abnormalitiesHemophiliaLeukemiaOsler-Weber-Rendu syndromevon Willebrand syndrome

Digital manipulationInflammatory

ftJlergicBacterial

Adenoid infection or obstruc-tion

Foreign bodySinusitis

DrynessViral

NeoplasticBenign

GranulomasHemangiomasJuvenile nasopharyngeal an-

giofibromaPolyps

MalignantStructural

PerforationSeptal deviationUcer

Traumatic

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

Frontal sinus

Watershed area

Septal branch ofanterior ethmoidal artery

Septalcartilage

Septal branchof superior

labial artery

Sphenoidsinus

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. StLouis, MO: CV. Mosby; 1986:1

Epistaxis

PIR 214 pediatrics in review #{149}vol. 12 no. 7 january 1991

phy or infections.Sinusitisdoes oc-cur in childhood, often secondary toadenoidal obstruction,particularlyinyounger children. When rhinitis is uni-lateral and associated with a foul-smelling discharge, the presence of aforeign body must be ruled out. Fi-nally, abuse of decongestant medi-

cations results in rhinitis medicamen-tosa; thiscondition however, is notcommonly associated with epistaxis.

Bleeding Disorders

Whenever epistaxis s persistentorrecurrent in the absence of an ob-

vious source or cause, considerationof bleeding disorders is in order. Ep-istaxis and excessive bleeding as acomplication of surgery are the twomost frequent symptoms of von Wil-lebrand disease. This disorder is acombination of varying degrees offactor VIII deficiency and a lack ofplatelet adhesiveness. The latter mayonly be apparent in response to chal-lenge with nstocetin. The conditionvaries widely in its expression, fromnormal hemostasis to a definite pro-longation of the bleeding time, partic-ularly in response to challenge.

Factor VIII and IX hemophilias mayalso cause epistaxis. Similarly, epis-taxis and bruising are frequently theearly signs of leukemia. A completeblood count with a differentialandsmear, platelet count, bleeding time,prothrombin time, and partial throm-boplastin time should constitute theinitial workup.

Osler-Weber-Rendu syndrome, al-though not actually a factor defi-ciency, may be grouped with bleedingdisorders. Hereditary telangiectasis,as it is also known, includes multiplemucosal telangiectasias,particularlyof the nose. Telangiectasias also oc-

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

TABLE 2. Epistaxis

Instruments to examine and treatthe nose

CottonFoley catheter (No 14 or No 16,

with a 30-cc Balloon)Nasal speculumNasal vasehine packingSuction tip

Medications for control of epis-taxis

Antibiotic ointmentCautery material (silver nitrateorchromic acidcrystalsonapplicator)

Hemostaticmaterial(Gelfoam,Surgicel,or Helostat)

Topicalanesthesia(4% xylo-caine, pontocaine or 4% co-caine)

Vasoconstrictor (0.25% neosy-nephrine or 4% cocaine)

OTORHINOLARYNGOLOGY

pediatrics in review #{149}vol. 12 no. 7 january 1991 PIR 215

cur throughout the gastrointestinaltract and may cause gastrointestinalbleeding and chronic anemia. Fur-thermore, there may be cyanosis,clubbing, and significant right-to-leftpulmonary shunting.

Benign Tumors

Of great concern are the neoplasticsources of epistaxis in children.These neoplasms do not necessarilycarry a dismal prognosis because be-nign processes constitute the major-ity. Granulomas are usually the resultof chronic irritation or the use of cau-tery.

Polyps are distinctly uncommon inthe pediatric age group, except forthose with cystic fibrosis. These pa-tients frequently develop nasal pol-yps, chronic sinusitis, and asthma. Apolyp may be acutely inflamed oreven strangulated, leading to bleed-ing. A different type of polyp is formedby the herniation of maxillary sinusmucosa through the natural ostium.These then pass through the poste-nor choana (hence the term antralchoanal polyp), presenting with nasalobstruction and a nasopharyngealmass. These masses also may beinfected or strangulated.

Juvenile nasopharyngeal angiofi-broma is a benign vascular neoplasrnarising in the lateral nasopharynx.These lesions occur only in the pu-bescent male and are hormonallysensitive. Their blood supply is de-rived from the internal maxillary ar-tery. On initial examination, a naso-pharyngeal mass and a history of re-current posterior epistaxis are found.Biopsy typically is fraught with prob-lems, and diagnosis is made by arte-riogram.

Capillary, cavernous, and mixedhemangiomas also may occur in thenasal cavity. Discussion of these con-ditions is beyond the scope of thisarticle.

Malignant Tumors

Malignant neoplasms within the na-sal vault are distinctly uncommon,and may arise from any of the epithe-hal or connective tissue elements.The most common head and neckmalignancy of childhood is rhabdo-myosarcoma. Not surprisingly, given

the amount of Iyrnphoid tissue pres-ent, lymphomas are the second mostcommon form of these malignancies.Closely related to lymphomas aremidline reticuloses, previously knownas lethal midline granulomas. Theseare particularly aggressive necrotiz-ing processes that are additionallydifficult to diagnose by biopsy. Olfac-tory tumors, sarcomas of the bone orcartilage, and degeneration of usuallybenign neoplasms all can be found.

Trauma

The child who sustains trauma tothe midface frequently seeks help forepistaxis. Most often, this bleeding isself-limited. The anterior ethmoidalartery enters through the fragile lam-ma papyracea of the ethmoid boneand can be lacerated by bone frag-ments. This injury may result in diffi-cult high arterial bleeding.

MANAGEMENT OF ACUTEEPISTAXIS

When a child comes to the pedia-trician’s office with bleeding, man-agement usually is straightforward.However, one should be prepared foran emergency should one occur. Aminimal amount of equipment shouldbe available, and many physicians or-ganize a prepared kit for the patient

with epistaxis. Adequate suction andlight are essential. Other importantitems are listed in Table 2.

Assessment

After taking a brief history, the phy-sician usually must combine assess-ment with the initial stages of treat-ment. The acute hemorrhage re-quires immediate attention, and thesource of the bleeding may be ob-scure until certain procedures aredone. An attempt must be made toidentify the bleeding source: anteriorversus posterior, right versus left.Blood may have passed posteriorlyaround the septum and then out thecontralateral side. Similarly, unless ananterior site is controlled, blood willbe found in the oropharynx, suggest-ing a posterior site. Generally, arterialand posterior bleeding is more copi-ous.

Initially, the clots should be clearedand a pledget of cotton soaked invasoconstrictor and topical anes-thetic placed in the anterior nasal cay-ity. Pressure over the nasal ala byeither the patient or the examiner fora minimum of 5 minutes will usuallyallow adequate examination andidentification of an anterior bleedingsite.

While waiting for the vasoconstric-tor to take effect, the examiner maytake a more complete history. Thisshould include the amount of bleed-ing, a family history suggestive of ableeding disorder, current medica-tions such as aspirin, infection,trauma, and other precipitating fac-tors. Many offices have the capabilityof obtaining an immediate hematocritor complete blood count. Similarly,when appropriate, pulse and bloodpressure are obtained to look forsigns of more significant bleeding.

Treatment

If an anterior source of bleeding isidentified, the vessel or point is thencauterized by applying a silver nitratestick or bead of chromic acid to thesite for 30 seconds. Care should betaken not to cauterize too deeply orover too large an area, but preciselyon the targeted site. Ointment or Gel-foam is then applied, and the patientis requested to apply ointment twice

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

Epistaxis

PIR 216 pediatrics in review #{149}vol. 12 no. 7 january 1991

daily for 5 days to decrease localizedcrusting.

If control is not gained or if recur-rence poses a problem, an anteriorpack is inserted. If a minimum of pres-sure seems necessary, or for patientssuspected of having a bleeding dia-thesis, one of the hemostatic agents(Gelfoam, Surgicel, Helostat) is usedfor the packing. Otherwise, a packconsisting of layers of vasehine gauzeis inserted. This gauze should becoated first with an antibiotic oint-ment to counter the resident bacteriaof the nose. If successful, this is leftin place for 2 to 3 days.

If the source of bleeding is not iden-tified, bleeding has ceased, and thehistory is consistent with an anteriorepistaxis, an alternative is simply tohave the patient return if the bleedingrecurs. An active bleeding point maythen be identified.

If, however, the primary physicianis unable to control the bleeding, thepatient should be sent either to anotolaryngologist or an emergency de-partment. There, appropriate bloodsamples can be drawn for laboratorystudies, and more complete equip-ment is available. In emergency situ-ations with copious bleeding, a Foleycatheter may be placed in the naso-pharynx, followed by an anteriorpack. The catheter is passed throughthe nose into the oropharynx, inflatedwith water, and drawn up tightlyagainst the posterior choana. Theballoon should be inflated with justenough water to depress the softpalate slightly, and an anterior packis inserted. The patient is then trans-ported to the hospital for admissionand studies.

An alternative to the formal nasalpacking and use of the hemostaticagents discussed above are the rel-atively new expanding nasalsponges. These are inserted in a drycompressed state and expandedwith either saline or an antibiotic so-lution. The authors prefer to use theantibiotic solution (such as an antibi-otic ear drop solution) to avoid thereported incidence of toxic shocksyndrome.

These sponges provide gentlepressure and protection from thedrying effects of air, thus decreasingcrust formation. They are generallyleft in place for 3 days and removed

by the patient. They are particularlyuseful in the excoriated nose, or inthe individual who returns with bleed-ing after an initial recent successfulcauterization. (The author’s only ex-perience has been with the Merocelnasal sponges.)

An otolaryngologist is capable ofbetter visualization, particularly of theposterior nasal cavity and nasophar-ynx, than the general pediatrician.Otolaryngologic examination may in-dude the use of flexible or rigid sco-pes, infracturing the inferior turbinate,or simply radiographic studies.

TREATMENT OF SPECIFICCAUSES OF EPISTAXIS

For the patient with epistaxis sec-ondary to nose-picking, the most im-portant treatment is the regular ap-plication of an antibiotic ointment.This therapy prevents both thebuildup of crust and the attendantitching. This approach applies as wellto the patient with crusting due to aseptal deviation. Copious use of oint-ment usually will prevent penetrationof the perichondrium in the mucosalulcerations.

Nosebleeds during the “nosebleedseason,” typically during the transi-tions from fall to winter and from win-ter to spring, generally are felt to besecondary to drying of the nasal mu-cosa with secondary hyperemia andcrusting. This problem is treated bestwith regular use of buffered salinenasal sprays.

In treating septal perforations, mm-imal cautery and ointment are mdi-cated. Therapy is directed at pre-venting enlargement of the perfora-tion or an increase in the chronicinflammation. Perforations smallerthan 1.0 cm are recommended forrepair. Larger perforations are bettertreated with a silastic button, be-cause the incidence of operative fail-ure is so high.

Specific antibiotic therapy is indi-cated with purulent rhinitis. The bac-teriology of sinusitis and adenoiditisis similar to that of otitis media. In thecase of cystic fibrosis, Gram negativebacteria play a more prominent role.

Similar specific replacement ther-apy is used in the case of bleedingdisorders. Osler-Weber-Rendu syn-drome usually is associated with a

frequency and quantity of epistaxisthat is controlled inadequately with-out surgery. The laser has proven tobe a useful tool. A more aggressiveapproach involves curettage of thenasal mucosa followed by coveragewith a split thickness graft.

After removal of a granuhoma, thebase is cauterized. There is a signifi-cant recurrence rate. Bleeding or ne-crotic pohyps are removed and alwayssent for pathologic review to rule outother pathologic processes. Unlesshemangiomas are associated withunusual problems, they should betreated expectantly as with other pe-diatric hemangiomas.

The juvenile nasopharyngeal an-giofibroma is treated with surgeryafter both hormonal therapy and em-bohization. Radiation therapy is to beavoided because of the possible in-duction of a malignant change.

Therapy of malignant neoplasms isbased on histology, discussion ofwhich is beyond the scope of thisarticle. Most important, however, isthe alertness of the examiner to thispossibility in unusual situations, par-ticularly in the case of polypoid orpedunculated lesions.

Finally, in the instance of nasaltrauma resulting in lacerations of theanterior ethmoid artery, packing mayfrequently fail to stop these high an-tenor arterial bleeds. Ligation of theartery through an ethmoid type mci-sion is necessary for control.

SUMMARY

Epistaxis in the pediatric patient isa relatively common, and usually eas-ily controlled, event. The practitionershould be aware of the anatomy, p0-tential causes, and methods of con-trol available for this condition.

SUGGESTED READING

Cummings C et al. Otolaryngology: Head andNeck Surgery. St Louis, MO: C. V. Mosby

Go; 1986:1Montgomery WW. Surgery of the Upper Res-

piratory 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. November1986:19 (No 4)

Paparella MM, Shumerick DA. Oto/aryngo/ogy.Philadelphia, PA: W. B. Saunders Go; 1987:3

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

DOI: 10.1542/pir.12-7-213 1991;12;213-216 Pediatr. Rev.

Peter E. Mulbury Recurrent Epistaxis

 

& ServicesUpdated Information

http://pedsinreview.aappublications.orgincluding high-resolution figures, can be found at:

Permissions & Licensing

http://pedsinreview.aappublications.org/misc/Permissions.shtmlits entirety can be found online at: Information about reproducing this article in parts (figures, tables) or in

Reprints http://pedsinreview.aappublications.org/misc/reprints.shtml

Information about ordering reprints can be found online:

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