Viljoen, J

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Epistaxis (Greek for nose bleed) has beenwith humans from the earliest times, oftencausing ill-founded anxiety in patients.The majority of epistaxis episodes inchildren is from local origin and rarelyrequires resuscitation. Although it may beintimidating to the attending physician, itcan be managed effectively with a fewacquired skills. Recurrent nose bleeds arean irritating, sometimes embarrassingproblem to both the child and parent, asthey often occur unexpectedly.EPIDEMIOLOGYIn the USA, 5 - 14% of patients will haveat least one episode of epistaxis per year;only 10% of these patients will see aphysician, only 10% of whom will bereferred to an otolaryngologist.Epistaxis is rarely seen in infants under 2years of age. Approximately 40% ofchildrenwill havepresentedwith at leastone episodeof epistaxisby the ageof 5 years.In the agegroup 6 -10 years theincidenceincreases to56%.Althoughvery littledata isavailable,epistaxisseems to be more prevalent in youngmales.Epistaxis is commonly encountered dur-ing autumn and winter when a lower envi-ronmental humidity and frequently alter-nating temperatures prevail. The higherincidence of upper respiratory tract infec-tions (URTIs) in children during wintermonths also contributes to nose bleeds.ANATOMYThe nasal mucosa has a rich vascular sup-ply originating from the internal andexternal high-pressure carotid systems.1-3The internal carotid artery’s first intracra-nial branch is the ophthalmic artery whicheventually gives rise to the anterior andposterior ethmoid arteries. The externalcarotid artery supplies blood to the nosevia the internal maxillary and facial arter-ies (Fig. 1).JACQUESVILJOENMB ChB, MMed ORL  Private ENTSurgeonLinmed HospitalBenoni andBrooklyn SurgicalCentre andMontana HospitalPretoriaDr Jacques Viljoen isan ear, nose andthroat surgeon in pri-vate practice at theLinmed Hospital,Benoni and MontanaHospital and theBrooklyn SurgicalCentre in Pretoria. Hetakes a keen interestin rhinology, especial-ly aesthetic nosesurgery and the management ofrhino-sinal condition,as well as microscopic earsurgery.Epistaxis in children:approach and managementNose bleeds can be intimidating for the child, theparents and the doctor alike.Fig. 1. Branches of the internal and external carotid artery supplying the nose.MAIN TOPIC664 C M E N o v / D e c  2 0 0 3   Vo l . 2 1   N o . 1 1There are two important areas inthe nose that play a role in epix-taxis:• Kiesselbach's plexus (anteriorbleeds), also known as Little’sarea; located on the anteriornasal septum, formed by ananastomosis between the vesselsillustrated in Fig. 2.• Woodruff ’s plexus (posteriorbleeds); located over the posteri-or middle turbinate, formed byan anastomosis between the ves-sels illustrated in Fig. 3.AETIOLOGY OF EPISTAXISNinety per cent of epistaxis in chil-dren originates from Little’s area inthe anterior part of the nose, oftenbeing either idiopathic or the resultof trauma. Idiopathic epistaxisforms the most common aetiologi-cal category (Table I).Although bleeding may occurspontaneously, it often results fromforceful nose blowing and sneezingwhich increases arterial and venouspressure in the vascularised nasalseptum, which usually accompa-nies allergic rhinitis, viral/bacterialURIs and trauma/sepsis secondaryto foreign bodies.Posterior epistaxis is uncommon inchildren and is usually the result ofbleeding disorders, inflammatorydisorders or neoplasms. Persistentor recurrent epistaxis should raisethe suspicion of bleeding disordersor neoplasms, necessitating furtherinvestigation.The most common causes of epis-taxis in children are outlined inTable I.APPROACH AND MANAGEMENTTaking a proper history and per-forming a thorough systemic exam-ination are imperative to rule outthe possibility of the bleeding beingthe result of systemic disease orbleeding disorders (petechiae, pur-pura, ecchymosis, hepatospleno-megaly), which will necessitate fur-ther investigations. Up to one-thirdof habitual nose bleeds in childrenmay be due to a blood dyscrasia.5A positive family history and pro-longed partial thromboplastin time(PPT) are useful predictive crite-ria. Resuscitation is seldomrequired in children and alwayssignifies more complex cases.A. Non-surgical managementAs the majority of epistaxis inchildren originates from the anteri-or caudal septum, venous bleedingwill often cease with pinching ofthe nostrils in an upright position.Fresh blood and clots should beremoved with suction. Topicalvasoconstrictors, packing and cau-terisation will stop the bleedingeffectively in 85% of cases. It isoften difficult to locate the sourceof the bleeding and there is littlegain in random cautery ofKiesselbach’s plexus on the nasalseptum. Chemical cautery anddiathermy have proved to be equally effective,6 and uncompli-cated idiopathic epistaxis can besuccessfully managed with topicalapplication of mupirocin(Bactroban), fusidic acid (Fucidin)or neomycin (Naseptin) for 30days.7-9 Systemic and topicaloestrogens are reserved for theFig. 2. Blood supply of the nasal septum.Fig. 3. Blood supply of the lateral wall of the nose.MAIN TOPICC M E N o v / D e c  2 0 0 3   Vo l . 2 1   N o . 1 1   665management of hereditary haemor-rhagic telangiectasis and shouldnot be used routinely in the man-agement of general epistaxis.10Diathermy under local anaesthesiacan be a traumatic experience to achild and is generally not recom-mended, at least not without seda-tion. Simultaneous diathermy ofboth sides of the nasal septum isnot recommended as it may resultin septal perforation.Since posterior epistaxis is uncom-mon, it is seldom necessary toutilise balloon tamponade in chil-dren, although the relative ease ofinsertion renders it useful. Anypatient receiving a posterior packshould be hospitalised. Posteriorpacking is left in the nose for 2 - 3days, constantly reducing the vol-ume of the balloon to avoid localtissue necrosis.It is most important to be ade-quately equipped to manage epis-taxis effectively and with confi-dence, and the following items willprove useful (Fig. 4):• Headlamp• Cocaine — 5% solution• Gloves, gown, mask • 14F Foley’s catheter• Suction apparatus• K-Y gel• McGill sucker• Elastoplast (25 mm wide)• Nasal speculum• 5 ml syringe• Tongue depressor• Bismuth iodoform paraffin paste(BIPP)• Tilley’s forceps/bayonet forceps• 20 mm ribbon gauze• Cotton patties (Codman patties)• Merocel• Gauze• Balloon tampon• Scissors• Kidney dish.The method of anteroposteriorpacking is as follows (Fig. 5):• Suction the nose.LocalAcquiredInfectiveAcuteViralBacterialFungalChronicSpecificTuberculosisInflammatoryRhinosinusitis (allergic/vasomotor)Nasal polyposis (cystic fibrosis, allergies)TraumaIatrogenicFacialDigital (nose picking)Foreign body/ rhinolithSurgery (carotid aneurysm)Idiopathic (refer to mild recurrent nose bleeds)Little’s areaSuperior part of noseMiddle meatusWoodruff’s plexusNeoplasticBenignHaemangiomaMalignantLymphomaDrug-inducedRhinitis medicamentosa (topical decongestants/cocaine)InhalantsTobaccoEnvironmentalHigh altitudeRapid temperature alterationsDry conditionsGeneral1. Bleeding disordersA. CoagulopathiesInherited: coagulation factor deficiencies, i.e. factor VII (haemophil-ia A, B) and factor IX deficiencyAcquired: anticoagulants, chronic liver disease, vitamin K deficiencyB. Platelet disordersThrombocytopenia: congenital acquired — marrow failure; aplasia,drugs, infiltration,  hypersplenism, massive blood lossPlatlet dysfunction: congenital — Von Willebrand's diseaseacquired — myeloproliferative disease/leukaemiaC. Blood vessel disorders: congenital — hereditary haemorrhagictelangiectasis acquired — vitamin C deficiencyD. Hyperfibrinolysis: congenital — alpha-2 antiplasmin deficiency2. Drugs (see 1B)AspirinAnticoagulantsChloramphenicolMethotrexateImmunosuppressionDipyrimadole3. Neoplasms (see 1B)4. IdiopathicInflammatory disordersWegener’s5. OthersHIVAdapted from Scott-Brown's Otolaryngology 6th ed. , volume 4, chapter 18.1,4Table I. Most common causes of epistaxis in childrenMAIN TOPIC666 C M E N o v / D e c  2 0 0 3   Vo l . 2 1   N o . 1 1• Remove the tip of the Foley’scatheter distal to the balloon, asit irritates the throat.• Advance the Foley’s catheterthrough the bleeding nasal pas-sage, until it is visible in theoropharynx.• Fill the balloon with 4 ml ofwater, and pull it into thenasopharynx.• Insert BIPP/Vaseline ribbongauze in layers in the nasal pas-sage around the catheter.• While maintaining slight trac-tion on the catheter, wrap the25 mm Elastoplast around thecatheter at the nostril to create aplug.The concurrent use of either lasertherapy or diathermy withendoscopy, has certainly enhancedthe management of epistaxis.11,12Surgical intervention (arterial liga-tion, submucosal resection) andembolisation are reserved as a lastresort and are seldom necessary inchildren.13Patients with the following condi-tions require referral to an ENTspecialist:• Recurrent, troublesome epistaxis• Uncontrollable epistaxis• Posterior epistaxis• haemotympanum• bleeding in nasopharynx/mouth• Identifiable causes requiringspecialist management• facial trauma• polyps• tumours.B. Surgical managementIndications for surgery are as follows:• Failure of medical managementafter 48 hours• Patient refusal of medical man-agement• Need for blood transfusion.Surgical management includes thefollowing:• Arterial ligation• Transmaxillary internal max-illary artery ligation• Anterior/posterior ethmoidartery ligation• External carotid artery liga-tion• Transnasal endoscopicsphenopalatine artery liga-tion.14• Submucosal resection (SMR)/septoplasty.C. EmbolisationEmbolisation of the internal maxil-lary artery is effective and safe. Itwas initially reserved for patients inwhom surgery failed, althoughrecent literature supports emboli-sation as first-line treatment inspecified cases because of safer pro-cedures and increased experience.15References available on request.Fig. 4. Useful items with which to manage epistaxis effectively.Fig. 5. Method of anteroposterior nasal packing.MAIN TOPIC668 C M E N o v / D e c  2 0 0 3   Vo l . 2 1   N o . 1 1MAIN TOPICC M E N o v / D e c  2 0 0 3   Vo l . 2 1   N o . 1 1   669Idiopathic causesBleeding disorderInfectiveTraumaDrug-inducedNeoplasmFLOW DIAGRAM FOR EPISTAXIS MANAGEMENTActive bleedingHistoryClinical examinationAnterior rhinoscopyRigid/flexible nasendoscopyAssess for hypovolaemic shockIdentify site of bleedingAnteriorPosteriorAnteroposteriorSuction and vasconstriction5% cocaine solutionAdrenalinePhenylephrineStop the bleeding Pinch nostrils Assess for hypovolaemicshockResuscitateNasal packingAnterior packingBIPPVaseline gauzeMerocelSurgicelPosterior packingBalloon packingTamponade withBIPP/VaselineRemove packingNasal CauteryElectrocauteryChemical cauteryTrichloracetic acidSilver nitrateSuccessfulUnsucessfulRepackingRemovepackingRebleedingSurgical interventionArterial ligationSubmucosal resectionEndoscopic cauteryRebleedingEmbolisationIdentify causeNo further bleeding No further treatmentOintmentAdviceRefer to haematologistManage accordingly/Refer to ENT surgeon

Epistaxis in children: approach and management

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Epistaxis in children: approach and management

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