Definition And Epidemiology

• Defined as bleeding from nostril, nasal cavity, or nasopharynx warranting medical care.
• Includes severe, persistent, or recurrent bleeding affecting quality of life.
• Recurrent epistaxis defined as five or more episodes per year.
• Accounts for 0.5% of pediatric emergency department visits.
• Peak presentation occurs between 2 and 10 years of age.
• Rare in infants under 2 to 3 years of age; incidence is 1 per 10,000.
• Declines in incidence after puberty.
• More frequent during winter months due to dry air.

Anatomy And Pathophysiology

• Most common bleeding site is anterior nasal septum.
• Area known as Kiesselbach plexus or Little's area.
• Region features convergence of
  • internal carotid branches (anterior and posterior ethmoid arteries) and
  • external carotid branches (sphenopalatine and terminal internal maxillary arteries).
• Superficial mucosal location makes vessels highly vulnerable to mechanical and chemical insults.
• Posterior bleeding arises from posterior sphenopalatine branches, Woodruff plexus, and venous sources.

Etiology And Risk Factors

• Classified clinically as primary (idiopathic) or secondary (identifiable cause).

Age-Specific Etiology

• Children over 2 years: Primarily local factors (trauma, mucosal drying, infections) or systemic clotting disorders.
• Children under 2 years: Requires intensive workup for child abuse, intentional trauma, or severe hematological illness.

Clinical Presentation And Differential Diagnosis

• Occurs without warning; blood flows slowly but freely from nostrils.
• Bleeding often follows physical exercise in children with nasal lesions.
• Nighttime bleeding often swallowed; manifests later as hematemesis or melena.
• Posterior epistaxis presents with copious bleeding; mimics upper gastrointestinal source.
• Unilateral foul-smelling discharge suggests foreign body.
• Profuse, recurrent unilateral bleeding in adolescent males strongly suggests juvenile nasopharyngeal angiofibroma.

Assessment And Evaluation

• Initial stabilization mandates immediate evaluation of airway obstruction and circulatory imbalance.

Clinical History

• Document onset, duration, frequency, and laterality of bleeding.
• Estimate blood loss objectively.
• Inquire regarding easy bruising, bleeding from other sites, or family history of bleeding disorders.
• Elicit history of antithrombotic medications, recreational drugs, or nasal steroid sprays.

Physical Examination

• Assess vitals for tachycardia and hypotension.
• Inspect skin for pallor, jaundice, petechiae, purpura, and telangiectasias.
• Evaluate central nervous system for vision or hearing changes associated with nasopharyngeal masses.
• Palpate abdomen for hepatosplenomegaly signifying malignancy or liver disease.
• Perform anterior rhinoscopy using otoscope with wide-tipped speculum.
• Clear purulent secretions and blood clots to visualize bleeding point.
• Identify transverse nasal crease or Dennie-Morgan folds indicating allergic rhinitis.
• Refer to otolaryngologist for flexible endoscopic evaluation if bleeding point remains unidentified.

Investigations

• Usually self-limited; potentially life-threatening episodes require detailed evaluation.
• Perform full blood count, urgent blood grouping, cross-matching, and coagulation studies for recurrent, prolonged, or significant bleeding.
• Screen for von Willebrand disease in patients with familial bleeding history; standard coagulation profiles may appear normal.

Management

Immediate Resuscitation And First Aid

• Position upright leaning slightly forward; prevents blood aspiration or swallowing.
• Apply firm, constant pressure on caudal soft nose for 5-10 minutes.
• Avoid pinching bony nasal bridge; provides inadequate pressure.
• Apply cold compresses to nose.
• Instruct patient to gently blow nose to evacuate fibrinolytic blood clots if bleeding persists after initial compression.

Pharmacological And Local Therapy

• Administer topical vasoconstrictors (oxymetazoline or phenylephrine 0.25-1%); reapply pressure.
• Cauterize identified anterior bleeding points with topical silver nitrate.
• Avoid simultaneous bilateral septal cauterization; prevents septal perforation.
• Utilize bipolar electrocautery for recurrent epistaxis as alternative to chemical cautery.

Nasal Packing

• Insert anterior nasal pack using absorbable hemostatic agent if pressure and cautery fail.
• Retain anterior packing for 24-48 hours.
• Utilize combined anterior and posterior packing for uncontrolled posterior bleeds.
• Consult otolaryngologist for posterior bleeding management.

Surgical And Advanced Interventions

• Consider minimally invasive transnasal endoscopic sphenopalatine artery ligation for severe, unremitting epistaxis.
• Utilize endovascular embolization to occlude feeding vessels in patients with sinonasal tumors.
• Avoid embolization of ethmoidal arteries; derivation from ophthalmic artery carries blindness risk.
• Administer blood transfusions and specific factor replacement for severe hemorrhage with underlying coagulopathy.

Prevention

• Discourage digital manipulation and nose picking.
• Maintain proper room humidification during dry winter months.
• Apply petrolatum ointment to nasal septum; increases moisture and prevents fissuring.
• Treat underlying allergic rhinitis and nasal infections promptly.
• Discontinue offending medications such as nasal steroid sprays if implicated.