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Epistaxis In Children. Adaobi Okobi, M.D. St. Barnabas Hospital. Learning Objectives. History and Physical Exam Findings Differential Diagnosis Work up Management. Introduction. Nosebleeds account for <1% of ED visits

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epistaxis in children

Epistaxis In Children

Adaobi Okobi, M.D.

St. Barnabas Hospital

learning objectives
Learning Objectives
  • History and Physical Exam Findings
  • Differential Diagnosis
  • Work up
  • Management
  • Nosebleeds account for <1% of ED visits
  • Children <10 years usually have mild nosebleeds that originate anteriorly
  • Incidence: 4 in 1,000 in children under 10y
  • Increased incidence in cold weather (low humidity) and with increased air pollutants
  • Children <2 years rarely get nosebleeds so suspect trauma or serious illness (1/10,000)
  • Age
  • When did the bleeding start?
  • Unilateral or bilateral?
  • How much blood loss?
  • Blood in the mouth or vomitus?
  • What was done to stop the bleeding?
  • Trauma?
  • Foreign body?
  • Easy bruising or bleeding?
  • PMHx?
  • Nasal congestion, discharge or obstruction?
  • Recent surgery?
  • Family history?
  • Medications?
  • Associated symptoms?
    • Headache or facial pain
    • Fever
    • Organomegaly
    • Hearing loss
    • Neck pain
    • Ecchymosis
  • Vital Signs! (especially BP and HR)
  • Pallor
  • Petechiae, bruising or gingival bleeding
  • Hemotympanum
  • Oropharynx exam
  • Mucosal telangiectasias or hemangiomas
  • Enlarged lymph nodes or organomegaly
  • Icterus
  • Visual acuity and extraocular movements with history of facial trauma
  • Pale or bluish nasal mucosa or boggy turbinates
lab evaluation
Lab Evaluation
  • CBC with smear
  • Blood type and screen/cross-match
  • PT
  • PTT
  • INR (for patients on anticoagulants)
  • Von Willebrand factor if warranted
  • CT or MRI if mass is suspected
differential diagnosis
Differential Diagnosis
  • Trauma
    • Nose picking!
    • Foreign body
    • Child abuse
    • NG tube
    • Nasotracheal intubation
  • Mucosal Irritation
    • Dry air
    • Allergic Rhinitis
    • Inhaled irritants/drugs
    • URI
    • Localized skin or soft tissue infection
  • Anatomic
    • Septal deviation
    • Unilateral choanal atresia with asymmetric airflow
  • Other
    • Increased venous pressure from coughing
  • Medications
    • Aspirin
    • Ibuprofen
    • Anticoagulants
    • Valproic Acid
differential diagnosis cont d
Differential Diagnosis (cont’d)
  • Tumors
    • Hemangioma
    • Juvenile NP angiofibroma
    • Pyogenic granuloma
    • Rhabdomyosarcoma
    • NP carcinoma
    • Inverting papilloma
  • Granulomatous Disorders
    • Wegener’s
    • Sarcoidosis
    • Tuberculosis
  • Bleeding Disorders
    • Platelet disorders
    • Von Willebrand disease
    • Hemophilia
    • Inherited or acquired coagulation disorders
    • Blood vessel disorders (hereditary hemorrhagic telangiectasia aka Osler Weber Rendu syndrome)
  • Hypertension
osler weber rendu
Osler Weber Rendu
  • Red macular and papular telangiectasias of the lips and tongue




  • 0.05% oxymetazoline HCl (Afrin) or 0.25, 0.5 or 1% phenylephrine (20mcg/kg in children up to 25kg)
  • Side effects: headache, dizziness, dry nasal passage, nasal discharge, arrhythmia
  • Useful in patient with recurrent benign epistaxis
  • Chemical cautery with silver nitrate sticks
  • Electrical cautery works well on a dry surface
  • Side effects: rhinorrhea and crusting; ulceration and perforation



Matrix sealant

  • Composed of collagen-derived particles and topical bovine-derived thrombin
  • Commercially available as Floseal
  • In a small prospective, randomized controlled trial patients in the Floseal group were found to have better control of their epistaxis than patients in the anterior nasal packing group
  • Fibrin glue is another option that has fallen out of favor since matrix sealants are available
  • Apply topical anesthesia and nasal decongestant first if possible
  • Small risk of toxic shock syndrome associated with packing
  • Neither prophylactic antibiotics nor impregnation of nasal packing with antibiotic ointment eradicate nasal carriage or are proven to prevent toxic shock syndrome

Nasal packing

management treatment failure
Management: Treatment Failure
  • Balloon catheter insertion
  • Embolization of the internal maxillary artery
  • Surgery (transnasal endoscopy and direct cautery or arterial ligation)
take home points
Take Home Points
  • Initial evaluation should focus on respiratory and hemodynamic stability of the patient
  • History and physical should focus on the source of the bleeding
  • Lab evaluation is indicated for patient with frequent recurrent nosebleeds, severe nosebleeds that are difficult to control and patients with a personal or family history of bleeding disorders
  • CT or MRI is indicated if a mass is suspected
  • Compression is the first plan of action to stop the bleeding
  • Other techniques can be administered with the involvement of ENT to stop the bleed
  • Messner, AH, et al. Evaluation of Epistaxis in Children. UpToDate. 2010
  • Messner, AH, et al. Management of Epistaxis in Children. UpToDate. 2010
  • www.Images.Google.com