Epistaxis - nosebleed

Epistaxis

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A 9-year-old boy is brought to see you. He has been having recurrent nose bleeds over the last few weeks. They may occur at any time but many of them happen at night, when the child wakes from sleep with blood on the pillow and bedclothes. Mum is concerned as the bleeding seems to last for ages and there are clots present.

Bottom line

The most common causes for epistaxis in this age group are digital trauma/nose picking and allergies

Most bleeds arise from Little’s area on the anterior nasal septum

Bleeding usually stops by applying pressure to the lower/soft part of the nose and prolonged bleeding frequently occurs because people squeeze too high up over the bony part of the nose

Treatment is usually avoidance of the cause along with the topical application of an ointment such as Naseptin

Cautery is not curative and therefore is only indicated for those children for whom the epistaxis is a serious problem

History of recent trauma with subsequent nasal deformity, followed by recurrent heavy intermittent bleeding over the following days, is a reason for urgent referral to ENT for consideration of MUA

 

Where does the bleeding arise from?

The most common site for epistaxis is in Little’s area or Kiesselbach’s plexus; an area on the anterior nasal septum, about 0.5-1 cm inside the front of the nose, where a number of branches of the arteries supplying the nose anastamose.

There are larger arteries further posteriorly in the nose and they can bleed heavily, but it is rare to have such a bleed in the absence of significant trauma.

Causes of epistaxis

1. Nose picking, often politely referred to as ‘digital trauma’ is the most common cause. In children, upper respiratory tract infections are common, leading to a build up of dried mucous and crusts in the nose. These crusts will irritate and the child will pick at the nose, if not consciously when awake often at night when they are asleep. Hence they wake with a bleed.

2. Allergies. These are other common causes for an increase in nasal secretion and crusts building up in the nose. If the patient is allergic to house dust mite they will again suffer from irritation of the nose at night, causing them to pick their nose in their sleep. Nose bleeds are also a frequent presenting feature of nasal allergies, such as hayfever.

3. Nasal Trauma. A fracture of the nasal bones causing deviation of the bones, can rarely tear an underlying nasal artery leading to a significant bleed. These are usually intermittent but very heavy, recurring up to several days after the initial injury. Treatment is through reduction of the nasal bones (manipulation of nasal bones) under general or local anaesthesia.

4. Serious causes. In the absence of evidence for the above, remember serious causes for bleeding including haematological disorders e.g. leukaemias, haemophilias, lymphomas. Though rare in this age group, in teenage boys always consider the possibility of a juvenile nasopharyngeal angiofibroma.

Clinical findings

The findings will depend on the cause as well as the frequency/severity and timing of most recent bleed.

When you examine the nose you are most likely to see hard dried crusts, which may or may not entirely be composed of dried blood. Do not remove these.

If there are signs of fresh bleeding control the bleeding in the manner explained below.

Management of an active bleed

Stay calm, even if it is a heavy bleed. Your anxiety will make the parents anxious which will make the child anxious which will make them bleed more.

Initial assessment is always ABC (airway, breathing, circulation) and deal with these as you usually would.

In the absence if any major concerns, sit the child down, in the parents lap if they are more comfortable there. Warn the child about what you are about to do.

Squeeze the soft part of the lower nose between the thumb and index finger. This should totally occlude both nostrils and be extremely firm pressure, sometimes uncomfortable but not cause pain.

Keep this part of the nose squeezed firmly for a minimum of 10 minutes (you may wish to ask Mum to take over doing this, so you are free to write notes etc).

If there is ice available you could give the child a cube to suck on. This will reduce the temperature in the mouth and blood flow in many of the arteries supplying the nose. Alternatively put some ice in a glove and get the child or Mum to hold it against the top of the nose. This is done in addition to applying pressure and not as an alternative.

If the bleeding persists after 10 minutes, repeat the above steps, always re-assessing ABC.

If the bleeding still persists, it is likely the child will need a formal examination of the nose by an ENT specialist and an immediate referral should be made.

Management of epistaxis, when there is no active bleeding

Do not be tempted to remove the crusts you see in the nose. You are not likely to learn much more and might start a heavy bleed, which will consume a lot of your time as you try to stop it.

By softening the crusts over time, they will gradually lift off and come away from the nose. In addition you want to treat any infections that might be present and therefore a combination treatment, e.g. Naseptin ointment, works best.

Application of a tiny amount of Naseptin ointment to the nostril 3-4 times per day for 10 days to 2 weeks is a usual dose.

At the end of the course of Naseptin it is important to prevent further drying and the regular application of Vaseline to the nostrils will help with this.

Leaving a small bowl of water in the room at night, especially in the hot weather or when the central heating is on, improves the humidity in the room and also helps reduce dryness of the nose.

If the appearances are of nasal allergy, the allergy also needs to be treated. Combining the above steps with a nasal steroid spray is most beneficial.

 

NOTE:

Naseptin contains peanut oil. You should always ask specifically about peanut allergy before prescribing this and only prescribe if it is safe to do so.

Bactroban is a reasonable alternative, but in many centres this is reserved for patients with MRSA.

Referal to ENT

1. If there is a history of recent trauma and subsequent intermittent heavy bleeding.

2. If bleeding persists for more than 20 minutes, despite conservative measures described above.

3. Intermittent recurrent epistaxis: this is not required for most nosebleeds and is often more for peace of mind of the doctor or the parents.

There is no cure for epistaxis, as the blood vessels will keep growing back.

On occasions cautery of the nose (sometimes under local anaesthetic in OPD clinic) is used to control an isolated bleeding point, where the above measures have been unsuccessful.

Repeated cautery, especially in the same area of the nasal septum increases the risk of damage to the underlying nasal septal cartilage, perhaps leading to a nasal septal perforation and no end of trouble including recurrent epistaxis.

 

References

Leong SCL, Roe JJ, Karkanevatos A. No frills management of epistaxis. Emergency Medicine Journal. 2005;22:470-472.

Epistaxis, Life in the Fast Lane.

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About 

Sinéad graduated from UCC, Ireland and moved to Wales to pursue her career in ENT. Working as an ENT consultant in Swansea, Wales since 2007 and has a special interest in Otology and Medical Education, in particular clinical bedside teaching.

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