Anna K. Schlechter, MD, Katherine E. Remick, MD, FACEP, FAEMS, FAAP; and Stanley H. Inkelis, MD, FAAP
A 3-year-old boy is brought to the office on a winter day. He has had 4 nosebleeds in the past week as well as a cold with rhinorrhea and cough, which began the day before the first nosebleed. The nosebleeds occur at night or during sleep and stop spontaneously or with gentle pressure. Other than the cold and nosebleeds, the boy is in good health. He is active, with bruises over both tibias but none elsewhere. The many cuts and scrapes he has had in the past resulted in minimal bleeding. His family has no history of a bleeding disorder or easy bruising.
The child’s physical examination is entirely normal except for a small amount of blood in the left anterior naris.
1. What are the common causes of nosebleeds in children?
2. What systemic diseases are associated with nosebleeds?
3. How should nosebleeds be evaluated in children?
4. How should minor and severe nosebleeds be managed in children?
Nosebleed, or epistaxis, occurs commonly in children, especially in those between 2 and 10 years of age. In most cases, nosebleeds are secondary to local trauma and can be managed by primary care physicians. In rare instances, however, a nosebleed may be difficult to control or may be a manifestation of a serious systemic illness. Referral to an otolaryngologist or a hematologist/oncologist is usually not required except in these situations, and hospitalization is generally unnecessary. Parents and children often are frightened by nosebleeds and frequently overestimate the amount of blood lost. Providing reassurance and a basic understanding of the most common causes are important in allaying anxiety.
Thirty percent of children experience 1 nosebleed by 5 years of age. In children between the ages of 6 and 10 years, the frequency increases to 56%. Nosebleeds are rare in infancy, with an estimated 1 nosebleed per 10,000 patients younger than 2 years. Nosebleeds are infrequent after puberty. They occur much more frequently in the late fall and winter months, when upper respiratory infections (URIs) are common, environmental humidity is relatively low, and the use of heating systems may result in dryness. Nosebleeds are also more common in children who live in dry climates, especially in the presence of a concomitant URI or chronic allergic rhinitis.
Most children with nosebleeds have a history of bleeding at home and have minimal or no bleeding at the time of presentation (Box 90.1). However, children with underlying clotting disorders (eg, hemophilia) may have recurrent nosebleeds and a history of prolonged bleeding, easy bruising, or multiple bruises in uncommon locations such as the gingivae or joints. Less commonly, nosebleeds are among the first manifestations of an undiagnosed malignancy or other systemic illness. In unusual situations, children with gastrointestinal or respiratory tract bleeding may present with blood exiting through the nose. Alternatively, some children with nosebleeds may present with hematemesis, hemoptysis, melena, or anemia. In these cases, a nasal source should be considered.
Box 90.1. Diagnosis of Epistaxis
•Blood in anterior nares, nasopharynx, or mouth
•History of any of the following:
— Frequent digital manipulation (ie, nose picking)
— Upper respiratory infection (recent)
— Allergic rhinitis
— Dry climate
— Foreign body in nose
— Trauma to nose
— Prolonged or difficult-to-stop bleeding, or easy bruising
•Physical examination consistent with any of the following:
— Dry, cracked nasal mucosa
— Foreign body in nose
— Trauma to nose
— Multiple bruises
Nosebleeds are generally categorized by anatomic location as anterior or posterior. Anterior epistaxis is most common, comprising 90% of pediatric nosebleeds, and is almost always self-limited. With anterior nosebleeds, vessels from the anterior portion of the nose rupture, resulting in readily visible blood loss through the nares. With posterior nosebleeds, most of the blood runs into the nasopharynx and mouth, although some blood may exit through the nose as well. Posterior nosebleeds, though uncommon in children, tend to be heavier and more difficult to control, and children have a propensity to become hemodynamically unstable.
More than 90% of nosebleeds in children are anterior and easily controlled. Anterior bleeding originates approximately 0.5 cm from the tip of the nose, known as the Kiesselbach area. This area is a confluence of small vessels supplied by the anterior and posterior ethmoidalarteries, the sphenopalatine artery, and the septal branches of the superior labial artery (Figure 90.1). The mucosa covering the Kiesselbach area is thin and friable, providing little structural support to the small vessels supplying the nasal mucous membrane.
The congestion of vessels located in the Kiesselbach area as the result of URIs or drying of the mucosa secondary to low environmental humidity makes this area susceptible to bleeding. Viral respiratory infections, such as infectious mononucleosis and influenza, may predispose children to nosebleeds because of the local inflammatory effect of such infections. Nosebleeds in children with these infections are more common in areas of low environmental humidity. Even in the absence of URI-like symptoms, however, children may experience nosebleeds in such environments, especially in the winter, when inhaling dry, hot air from heating systems causes desiccation of the nasal mucosa (ie, rhinitis sicca). Nosebleeds also occur more commonly in children who have nasal colonization with Staphylococcus aureus. It is postulated that S aureus replaces existing flora and results in inflammation and new vessel formation.
Figure 90.1. Vascular supply of the nasal septum. Note the confluence of vessels that forms the Kiesselbach plexus.
Posterior nosebleeds are unusual in children and are most commonly associated with trauma. If bleeding is vigorous or poorly controlled with anterior nasal packing or involves both nares, a posterior source is likely to be responsible. Posterior nosebleeds generally arise from the turbinate or nasal wall. Significant bleeding, usually from a branch of the sphenopalatine artery, may occur. Because of the posterior location, children often present with symptoms other than frank epistaxis (eg, hematemesis, hemoptysis, melena, anemia).
Trauma from nose picking and inflammation of the nasal mucosa from a URI are by far the most common causes of nosebleed in children. Repetitive, habitual nose picking (ie, epistaxis digitorum) results in the formation of friable granulation tissue that bleeds when congested blood vessels are traumatized. As the nasal mucosa dries, crust formation and cracking may occur. Bleeding may occur spontaneously or from nose rubbing, but more often it results from forceful nose blowing and sneezing, which increase venous pressure in the more vascularized nasal septum.
Foreign bodies may cause direct trauma or pressure necrosis to the vessels of the nasal mucosa. Toddler-age children may place small toys, beads, pebbles, or food items into the nares. Button batteries are particularly troublesome and should be removed immediately to avoid septal perforation. Children with unilateral epistaxis with purulent or foul-smelling nasal drainage should be evaluated for a foreign body. External trauma secondary to falls or blunt force can cause tears to the nasal mucosa or nasal fractures. If bleeding from mucosal vessels occurs but the mucosa remains intact, a septal hematoma may occur. Thus, it is important to carefully examine the nasal septum. Abscess formation or septal perforation may occur if the septal hematoma is not drained. Non-accidental trauma, specifically asphyxiation, should be considered in any child younger than 2 years with a nosebleed.
Allergic rhinitis with inflammation and subsequent drying also may result in nosebleeds. Airborne environmental pollutants have been associated with increased inflammation of the nasal mucosa. Children with allergic rhinitis who take decongestants or use topical nasal decongestants or topical nasal steroid sprays may have an increased likelihood of experiencing nosebleeds. In addition, the dispenser tip of these sprays may traumatize the already dry and friable mucosa, causing the nose to bleed.
Although nosebleeds are usually benign conditions, they may be among the first signs of serious illness. Persistent or recurrent nosebleeds with no obvious cause should raise the suspicion of bleeding disorders (see Chapter 99). Thrombocytopenia is the most common coagulation defect that results in nosebleeds. Idiopathic thrombocytopenic purpura is the thrombocytopenic disorder most frequently associated with nosebleeds. Leukemia, aplastic anemia, and HIV infection also should be considered and ruled out in children with nosebleeds and thrombocytopenia. Platelet aggregation disorders also may be a cause of recurrent nosebleeds.
The most commonly inherited bleeding disorder associated with nosebleeds is von Willebrand disease, an autosomal-dominant bleeding disorder characterized by varying degrees of factor VIII deficiency and platelet dysfunction (ie, decreased platelet adhe-siveness). Hemophilia (factor VIII, IX, or XI deficiency), factor VII deficiency, Glanzmann thrombasthenia, and Bernard-Soulier syndrome are other inherited bleeding disorders that may result in nosebleeds. Hepatic disease, severe vitamin K deficiency, or malabsorption syndrome are associated with acquired coagulopathy, of which nosebleed may be a presenting sign. Administration of valproic acid has been associated with acquired von Willebrand disease and nosebleeds.
Nosebleeds may be a manifestation of hereditary or acquired blood vessel disorders. Hereditary hemorrhagic telangiectasia (ie, Osler-Weber-Rendu disease) is an inherited autosomal-dominant disease with multiple mucosal telangiectasias, especially in the nose. Because telangiectasias are deficient in muscular and connective tissue, they may rupture spontaneously and bleed profusely. An association between migraine headaches and recurrent nosebleeds has also been reported.
Neoplasms, particularly malignancies, are uncommon causes of nosebleeds in children. Although nasal polyps generally are benign, they usually occur in association with cystic fibrosis or allergies. Capillary, cavernous, and mixed hemangiomas may occur in the nose and be a source of bleeding. Juvenile nasopharyngeal angiofibroma occurs almost exclusively in adolescent males who present with nasal obstruction and bleeding. Rhabdomyosarcoma, lymphoma, and squamous cell carcinoma of the nose, sinuses, or nasopharynx are rare causes of nosebleeds in the pediatric population.
Drugs such as aspirin and nonsteroidal anti-inflammatory drugs, which interfere with platelet function, and warfarin and heparin, which inhibit clotting factors, increase the risk for nasal hemorrhage with minor trauma, infection, or inflammation. Unintentional ingestion of these medications should be suspected if they are accessible to the child. Snorting cocaine or heroin may cause nasal septal perforation and nosebleeds. Some complementary and alternative therapies, such as Ginkgo biloba, may also be associated with abnormal bleeding.
Hypertension is rarely associated with nosebleeds in children. Wegener granulomatosis and lethal midline granuloma are rare idiopathic inflammatory diseases in children that result in nasal tissue destruction and bleeding. Nosebleeds during menstruation, that is, vicarious menstruation, may be secondary to hormonal changes that result in vascular congestion of the nasal mucosa.
A thorough history often reveals the etiology of the nosebleed (Box 90.2). Information concerning the side of the nose from which the bleeding occurred, amount of bleeding, measures used to stop the bleeding, and time required to stop the bleeding may be helpful to quickly assess the severity of the nosebleed.
Box 90.2. What to Ask
•Does the child pick his or her nose?
•Has the child suffered any trauma recently?
•Is there suspicion of non-accidental trauma?
•Has the child recently had an upper respiratory infection?
•Has the child recently had any systemic viral or bacterial illness?
•Does the child have any allergies?
•Is the child exposed to dry conditions (eg, dry climate, dry heat, dehumidified air)?
•Has the child put or tried to put foreign objects in his or her nose?
•Is there a history of easy bruising or prolonged, difficult-to-stop bleeding in the child or family?
•Does the child or anyone in the family use any aspirin, aspirin-containing medications, nonsteroidal anti-inflammatory drugs, or warfarin?
•Does the child or any family member use cocaine, heroin, inhalants, or any other drugs of abuse?
•Does the child or any family member use complementary and alternative therapies, such as Ginkgo biloba?
•Which side of the nose was bleeding? Was it bilateral?
•How extensive was the bleeding?
•Did the child spit out or swallow blood? Was there blood in the mouth?
•What measures were used to stop the bleeding? How long did it take to stop the bleeding?
•Was this the first nosebleed? If nosebleeds are recurrent, how often do they occur and how long do they last?