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Epistaxis In Children

Epistaxis In Children. Adaobi Okobi, M.D. St. Barnabas Hospital. Learning Objectives. History and Physical Exam Findings Differential Diagnosis Work up Management. Introduction. Nosebleeds account for <1% of ED visits

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Epistaxis In Children

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  1. Epistaxis In Children Adaobi Okobi, M.D. St. Barnabas Hospital

  2. Learning Objectives • History and Physical Exam Findings • Differential Diagnosis • Work up • Management

  3. Introduction • Nosebleeds account for <1% of ED visits • Children <10 years usually have mild nosebleeds that originate anteriorly • Incidence: 4 in 1,000 in children under 10y • Increased incidence in cold weather (low humidity) and with increased air pollutants • Children <2 years rarely get nosebleeds so suspect trauma or serious illness (1/10,000)

  4. Anatomy: Kiesselbach’s Plexus

  5. History • Age • When did the bleeding start? • Unilateral or bilateral? • How much blood loss? • Blood in the mouth or vomitus? • What was done to stop the bleeding? • Trauma? • Foreign body? • Easy bruising or bleeding? • PMHx? • Nasal congestion, discharge or obstruction? • Recent surgery? • Family history? • Medications? • Associated symptoms? • Headache or facial pain • Fever • Organomegaly • Hearing loss • Neck pain • Ecchymosis

  6. Exam • Vital Signs! (especially BP and HR) • Pallor • Petechiae, bruising or gingival bleeding • Hemotympanum • Oropharynx exam • Mucosal telangiectasias or hemangiomas • Enlarged lymph nodes or organomegaly • Icterus • Visual acuity and extraocular movements with history of facial trauma • Pale or bluish nasal mucosa or boggy turbinates

  7. Lab Evaluation • CBC with smear • Blood type and screen/cross-match • PT • PTT • INR (for patients on anticoagulants) • Von Willebrand factor if warranted • CT or MRI if mass is suspected

  8. Differential Diagnosis • Trauma • Nose picking! • Foreign body • Child abuse • NG tube • Nasotracheal intubation • Mucosal Irritation • Dry air • Allergic Rhinitis • Inhaled irritants/drugs • URI • Localized skin or soft tissue infection • Anatomic • Septal deviation • Unilateral choanal atresia with asymmetric airflow • Other • Increased venous pressure from coughing • Medications • Aspirin • Ibuprofen • Anticoagulants • Valproic Acid

  9. Differential Diagnosis (cont’d) • Tumors • Hemangioma • Juvenile NP angiofibroma • Pyogenic granuloma • Rhabdomyosarcoma • NP carcinoma • Inverting papilloma • Granulomatous Disorders • Wegener’s • Sarcoidosis • Tuberculosis • Bleeding Disorders • Platelet disorders • Von Willebrand disease • Hemophilia • Inherited or acquired coagulation disorders • Blood vessel disorders (hereditary hemorrhagic telangiectasia aka Osler Weber Rendu syndrome) • Hypertension

  10. Osler Weber Rendu • Red macular and papular telangiectasias of the lips and tongue

  11. Adapted from UpToDate

  12. Management Compression

  13. Management Vasoconstriction • 0.05% oxymetazoline HCl (Afrin) or 0.25, 0.5 or 1% phenylephrine (20mcg/kg in children up to 25kg) • Side effects: headache, dizziness, dry nasal passage, nasal discharge, arrhythmia • Useful in patient with recurrent benign epistaxis • Chemical cautery with silver nitrate sticks • Electrical cautery works well on a dry surface • Side effects: rhinorrhea and crusting; ulceration and perforation Cautery

  14. Management Matrix sealant • Composed of collagen-derived particles and topical bovine-derived thrombin • Commercially available as Floseal • In a small prospective, randomized controlled trial patients in the Floseal group were found to have better control of their epistaxis than patients in the anterior nasal packing group • Fibrin glue is another option that has fallen out of favor since matrix sealants are available • Apply topical anesthesia and nasal decongestant first if possible • Small risk of toxic shock syndrome associated with packing • Neither prophylactic antibiotics nor impregnation of nasal packing with antibiotic ointment eradicate nasal carriage or are proven to prevent toxic shock syndrome Nasal packing

  15. Nasal Packing

  16. Management: Treatment Failure • Balloon catheter insertion • Embolization of the internal maxillary artery • Surgery (transnasal endoscopy and direct cautery or arterial ligation)

  17. Take Home Points • Initial evaluation should focus on respiratory and hemodynamic stability of the patient • History and physical should focus on the source of the bleeding • Lab evaluation is indicated for patient with frequent recurrent nosebleeds, severe nosebleeds that are difficult to control and patients with a personal or family history of bleeding disorders • CT or MRI is indicated if a mass is suspected • Compression is the first plan of action to stop the bleeding • Other techniques can be administered with the involvement of ENT to stop the bleed

  18. References • Messner, AH, et al. Evaluation of Epistaxis in Children. UpToDate. 2010 • Messner, AH, et al. Management of Epistaxis in Children. UpToDate. 2010 • www.Images.Google.com

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