Pediatric emergency medicine trisk 0565 0565
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CHAPTER 26 ■ EPISTAXIS
EVA M. DELGADO, FRANCES M. NADEL
INTRODUCTION
Epistaxis (nose bleeding) is a common symptom in young children and may be
alarming to parents due to overestimation of blood loss. It is usually encountered
first at about age 3 years and increases in frequency until peaking again in
adolescence. An orderly approach to the history and physical examination is
necessary to identify the small minority of patients who require emergent
hemorrhage control, laboratory investigation, or consultation with an
otorhinolaryngologist (i.e., an Ear Nose and Throat [ENT] specialist) for further
management.
PATHOPHYSIOLOGY
Minor trauma, nasal inflammation, desiccation, congestion, as well as the rich
vascular supply of the nose, contribute to the frequency of nosebleeds in
otherwise normal children. The nose is also a favored site for recurrent minor
trauma, especially habitual, often absent-minded picking. The nasal mucosa is
closely applied to the perichondrium and periosteum of the nasal septum and
lateral nasal walls giving little structural support to its supply of small blood
vessels. These vessels join to form plexiform networks like Kiesselbach plexus in
Little’s area of the anterior nasal septum, about 0.5 cm from the tip of the nose
and a frequent source of epistaxis blood (see Fig. 118.8 in ENT Emergencies).
DIFFERENTIAL DIAGNOSIS
Local Causes
Epistaxis is most often the result of local predisposing factors including
inflammation, irritation, infection, or trauma ( Table 26.1 ). The most common
causes of epistaxis are found in Table 26.2 . Acute upper respiratory infections,
whether localized as in colds or secondary to more generalized infections such as
measles, infectious mononucleosis, or influenza-like illnesses, contribute to the
onset of epistaxis. Nasal colonization with Staphylococcus aureus may predispose
to a more friable mucosa and to furuncles, both of which can cause epistaxis.
Allergic rhinitis and treatment of this condition with nasal corticosteroids can
lead to epistaxis. Rhinitis sicca refers to desiccation of the nasal mucosa due to
