Pediatric emergency medicine trisk 0566 0566
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the use of heating systems in cold winter climates with low ambient humidity. It
is this hot, dry air that increases the risk of epistaxis. Rhinitis sicca is also
important to consider in the differential of a child with dependence on any
respiratory device that instills dry air into the nares such as nasal cannula, nasal
noninvasive ventilation, or other similar systems.
Inspection may reveal a nasal foreign body, which is sometimes suspected by
history of insertion or by reports of chronic or recurrent unilateral epistaxis
accompanied by mucopurulent drainage or foul breath. Also discoverable by
examination are telangiectasias (Osler–Weber–Rendu disease), hemangiomas, or
evidence of other uncommon tumors that cause nosebleeds. Juvenile
nasopharyngeal angiofibromas may be seen in adolescent boys with nasal
obstruction, mucopurulent discharge, and severe epistaxis. These benign tumors
may bulge into the nasal cavity, sometimes causing problems by invading
adjacent structures. A rare childhood malignant tumor, nasopharyngeal
lymphoepithelioma, may cause a syndrome of epistaxis, torticollis, trismus, and
unilateral cervical lymphadenopathy. Other rare local causes of epistaxis include
nasal diphtheria and granulomatosis with polyangiitis (formerly known as
Wegener’s).
Systemic Causes
Children rarely present with a nosebleed as their only manifestation of a more
systemic disease, though there are several conditions that can increase the risk for
epistaxis ( Table 26.1 ). In children with severe or recurrent nosebleeds, a
concerning family history, or constitutional signs and symptoms, the physician
should consider a systemic process. Von Willebrand disease and platelet
dysfunction are two of the more common systemic diseases that cause recurrent
or severe nosebleeds. Less common systemic factors include hematologic
diseases such as leukemia, hemophilia, and clotting disorders associated with
severe hepatic dysfunction or uremia. Arterial hypertension rarely is a cause of
epistaxis in children. Increased nasal venous pressure secondary to paroxysmal
coughing, which can occur in pertussis or cystic fibrosis, occasionally may cause
nosebleeds. Vicarious menstruation refers to a condition occasionally found in
adolescent girls in whom monthly epistaxis related to vascular congestion of the
nasal mucosa occurs concordant with menses and is presumably related to cyclic
changes in hormone levels. Nosebleeds in infants, especially preambulatory
children, are rare, and one should consider the possibility of child abuse,
asphyxiation, or some systemic disorder.
EVALUATION AND DECISION
