What Is Epistaxis?

 

I. Introduction 

Epistaxis is common in children. Childhood nosebleeds are rarely severe but frequent minor nosebleeds can be precautious for parents and children. Most of the patients can be managed with direct compression of the nasal alae for 5 to 10 minutes. For more recurrent epistaxis, other techniques might include vasoconstrictor nose drops, cautery with silver nitrate, nasal packing, or balloon catheters.

II. Epidemiology

The incidence of epistaxis declines in adulthood, but approximately one-half of all adults with epistaxis had nosebleeds during childhood. Epistaxis is rare in children younger than 2 years and should consider trauma (intension or unintentional) or serious illness(eg, thrombocytopenia ).
Epistaxis occurs in children younger than 10 years usually in mild and originates in the anterior nose, in contrast, epistaxis that occurs in individuals older than 50 years is more likely to be severe and originate posteriorly.
The increased incidence of epistaxis occurs during hot or cold weather and when the ambient humidity is low, which make the nasal septal mucosa dry and friable, and predisposed to bleeding, even with minor trauma as may occur with nose rubbing, blowing, or sneezing.

III. Anatomy

The nose is a highly vascular structure. One of the most vascular areas of the nose is Kiesselbach’s plexus in the anterior nasal septum. Kiesselbach’s plexus(also called Little’s area) is formed by the anastomosis of terminal vessels from the internal and external carotid arteries.

IV. Pathophysiology 

The nasal mucosa provides little anatomic support or protection for the underlying blood vessels. The cause of nosebleeds can result from the congestion of the nasal vessels, or drying or irritation of the nasal mucosa, increase the likelihood of bleeding.

V. Etiology

Common causes of nosebleeds in children include mucosal dryness, trauma, foreign body, and rhinitis(allergic, infectious, or related to mucosal irritation). Less common causes include bleeding disorders and other systemic diseases, tumors, and post-traumatic pseudoaneurysm of the internal carotid artery or carotid-cavernous sinus fistulae.

Anterior nosebleeds usually result from mucosal dryness, trauma, or irritation, although many cases are idiopathic. Posterior nose bleeds are unusual in children and usually due to significant nasal trauma. Posterior bleeds usually arise from the posterolateral branches of the sphenopalatine artery.

Local causes :
Trauma: Nose picking, Fascial, and head trauma, Foreign body, Postoperative(after adenoidectomy, sinus surgery, septal surgery, rhinoplasty, rhinoplasty, or turbinectomy), Nasotracheal intubation, and nasogastric tube placement may tear the nasal mucosa, Barotrauma (occurs with scuba diving, may contribute to epistaxis in patients with upper respiratory infection or allergy.Allergic rhinitis(sneezing, nose rubbing, and treatment with nasal corticosteroids may exacerbate or precipitate epistaxis in these children), infection (viral and bacterial upper respiratory infection including infection, sinusitis and systemic illnesses accompanied by nasal congestion result in inflammation of the nasal mucosal)

Tumors: neoplasms of the nasal cavity cause unilateral symptoms such as intermittent epistaxis, foul discharge, nasal discharge, or change in smell sensation.
 Juvenile nasopharyngeal angiofibroma: a histologically benign tumor that is markedly vascular and causes severe epistaxis. It occurs primarily in adolescent males. Although juvenile nasopharyngeal angiofibroma is a benign tumor, it can cause severe problems through the local invasion of adjacent structures. The mean patient age was 15 years(range 7 to 29 years). The triad of nasal obstruction, epistaxis, and nasal drainage was the most common combination of signs and symptoms. Serous otitis media and diminished hearing also may be present.
 A lobular capillary hemangioma (pyogenic granuloma) : lobular capillary hemangioma(pyogenic granuloma or granuloma telangiectaticum,is a benign tumor associated with capillary proliferation.
 Rhabdomyosarcoma: It may present with episodic epistaxis. Other signs and symptoms include middle ear effusions, deep facial pain, and cranial neuropathies, such as sixth nerve palsy.
 Inverting papillomas: inverting (or inverted) papillomas, grow with the invasion of the epithelium to the connective tissue stroma, are rare in children. They manifest as unilateral red, polypoid masses attached to the lateral nasal wall, middle turbinate, the septum, or the nasal vestibule.
 Systemic causes: including bleeding diathesis, disorders of blood vessels, medications, neoplasms, inflammatory disorders, and hypertension.
 Bleeding disorders: should be considered in children with recurrent, frequent, spontaneous epistaxis and those with a prolonged,difficult-to-control nosebleed.
 Medications: Antiinflammatory agents ( aspirin, ibuprofen ) and anticoagulants(eg, complex congenital heart disease or thromboembolic disease). Epistaxis related to acquired factor XIII deficiency, and von Willebrand disease.
 Inflammatory disorders: systemic inflammatory disorders, such as granulomatosis with polyangiitis (GPA). The most common presenting symptoms of GPA include persistent rhinorrhea, purulent/bloody nasal discharge, oral and nasal ulcers, polyarthralgia, myalgias, or pain.
 Hypertension: Secondary causes of hypertension that may result in epistaxis include renal disease and systemic corticosteroid therapy.
 Recurrent epistaxis: are related to chronic irritation of the nasal mucosa as may occur from dry air, chronic use of nasal medication for allergic rhinitis, recurrent upper respiratory infection, or inhalation of substances of abuse.

 Recurrent epistaxis also may be presenting symptoms of a bleeding disorder, hereditary hemorrhagic telangiectasia, nasopharyngeal tumor, or post-traumatic pseudoaneurysm of the internal carotid artery.

VI. Management

Most episodes of epistaxis resolve with compression of the nasal alae for 5 to 10 minutes and do not require specialty care. For severe epistaxis, recurrent epistaxis, or local abnormalities such as tumors should have a consultation with an otolaryngologist or other specialties.

Oxymetazoline with 0.05 percent oxymetazoline hydrochloride can help to stop epistaxis. If not available, the minimum dose of phenylephrine is recommended.
Other techniques :

 Cautery: Cauterization is also commonly used for children with recurrent benign epistasis.
 Matrix sealant: a matrix hemostatic sealant composed of collagen-derived particles and topical bovine-derived thrombin.
 Fibrin glue: it provides rapid hemostasis without nasal packing and is painless compared to cauterization or nasal packing.
 Nasal packing: it is tamponade local bleeding.

Advanced techniques :
 Nasal balloon catheters: a single or double-balloon catheter( eg, a Foley catheter, Rapid Rhino, Epistat, Epi-max, Post-stat, or Post-stop) can be inserted.
 Embolization of the internal maxillary artery; can be useful with hereditary hemorrhagic telangiectasia, juvenile angiofibroma, hemangiomas, arterial-venous malformations.
 Operative control: surgery(transnasal endoscopy and direct cautery or arterial ligation )