Epistaxis is common, affecting>10% of us in our lifetimes. Children present with epistaxis for several reasons, many of which differ from those in adults. Unfortunately, physics underpins most of these causes.
The nose is a highly vascular part of the head and neck, owing to its role in humidifying inhaled air. The nasal mucosa becomes engorged in response to dryness and low temperatures to make the air more comfortable to breathe in. This response is more noticeable in patients of ethnic origin from tropical and equatorial climates.
The arteries contributing to the blood supply of the nose include:
Anterior and Posterior Ethmoid arteries – branches of the Internal Carotid artery
The Superior Labial, Sphenopalatine, and Nasopalatine arteries – External Carotid artery branches.
These aren’t necessarily directly relevant to managing paediatric epistaxis, but become important in special circumstances.
These arteries form a plexus in Little’s area called Kiesselbach’s plexus. It is conveniently located about as far as a person can extend their index finger into their nostril.
What causes epistaxis?
Nose picking
It is the most common cause in children, but surprisingly common in adults. Look for the tell-tale white keratinised patch inside the nostril, almost invariably on the anterior septum, at Little’s area. Nose picking can directly traumatise a vessel or cause turbulent flow over an area, drying out the septum and increasing the risk of bleeding.
Allergies
Common airborne allergens, such as house dust mite faeces, grass and tree pollen, and animal antigens, e.g. cat saliva and dog hair, can cause a Type I hypersensitivity reaction in the upper airways. This results in further engorgement of the nasal mucosa and can make fragile vessels bleed again by increasing turbulent airflow through the nose.
Idiopathic
Most people have a deviated nasal septum to some extent. Non-laminar flow over a deviated nasal septum can differentially dry one side compared to the other, resulting in epistaxis.
Blunt force trauma
To differentiate this from simple nose picking, we need to consider a mode of injury which, although more common in adults through falls or assault, is also seen in children who fall whilst playing or as a result of non-accidental injury. Blunt force trauma can result in arterial bleeding from the anterior ethmoid vessels and may be associated with other facial injuries. Acute manipulation of the bones can stop significant bleeding, but sometimes a nose inspection under general anaesthetic is also needed to identify a bleeding point.
Rare causes
Epistaxis can rarely be the first presentation of haematological disease through derangement of clotting, for example, in leukaemia, lymphoma, or haemophilia. Beware the adolescent male who presents with torrential bleeding and unilateral nasal obstruction. He may have a rare vascular tumour centred on the sphenopalatine artery—a juvenile nasal angiofibroma—which accounts for 0.05% of all head and neck tumours. Whilst benign, they are locally aggressive, and in advanced disease, they can involve the internal carotid artery.
Mucositis
Very rarely, children undergoing oncological treatment may develop mucositis that affects the nose. In conjunction with thrombocytopenia, nasal cannulae, NG tubes, and turbulent airflow, this can cause a very difficult-to-treat epistaxis. ENT may use Floseal, a haemostatic semi-solid matrix of human recombinant thrombin. Do not pack or instrument the nose, which will cause more bleeding.
Clinical Assessment
General inspection
Check for signs of distress, anaemia, pallor, cachexia, and lymphadenopathy.
Nasal examination
Check for signs of bleeding – Is this unilateral or bilateral? If you have a cold metal spatula, hold this under the nose to see if it mists equally, assuming the nasal cavities are clear of blood. Evert the tip of the nostril to examine the nasal vestibule. You should be able to see the septum in the midline and the inferior turbinate laterally on either side. The colour of the inferior turbinate can give you an idea of underlying pathology – a bluish, oedematous turbinate suggests venous congestion and is seen in allergy.
Oral examination
The posterior nares open into the nasopharynx, behind the soft palate and uvula. Before and after any nasal intervention, check the posterior pharyngeal wall with a good headlight and tongue depressor to see if blood is still trickling down the pharynx. In drowsy or obtunded patients, this can pose a risk of aspiration.
No active bleeding?
Good news. The bleeding has probably stopped, but might start again. You can inspect the nostrils with an otoscope with a speculum on it. This magnifies, and the lens can also be slid aside to allow you to insert a silver nitrate stick through it if you’re able to see a point to cauterise—don’t do this without some form of topical anaesthetic, as it causes a chemical burn that…well…burns!
Some departments have 1% lidocaine spray, but it can sting when it hits the mucosa, so ideally, squirt it onto cotton wool with 1:10000 adrenaline before applying it to the nose for 5 minutes, then remove it before cautery.
If you don’t know how to cauterise, don’t worry…a Cochrane review found that emollients such as Vaseline or Naseptin ointment were as effective as silver nitrate cautery in stopping paediatric epistaxis. You’re just as likely to succeed by making an outpatient referral to ENT and prescribing some emollient for intranasal use 3-4 times a day until reviewed. Ensure they don’t try to rub it in with their finger or a cotton bud. Insert the nozzle tip into the nostril, squirt, pinch the nostrils together, and sniff.
Resuscitation
So you’ve got an active bleeder?! Worry not…anxiety is contagious, so it’s important to stay calm for your sake and that of the child and their parents.
Sit the child upright, attach the monitoring, and raise the bed so you don’t injure your back. Get PPE on. This means gloves, an apron, goggles, and a mask. Meanwhile, ask someone, if not the child, to pinch the soft part of their nose whilst tipping the head forward. Do this without letting go for 10-15 minutes. This prevents aspiration and compresses the septum, where the bleeding will likely come from. Assess the airway, breathing, and circulation as you would for any other emergency patient.
Get hold of cotton wool balls, 1% lidocaine, and 1:10000 adrenaline. It’s even better if you have pre-mixed 5% lidocaine with 0.5% phenylephrine. Make some pea-sized balls with the cotton wool and soak them in the anaesthetic and adrenaline mixture. Gently place them inside the offending nostril(s) and wait. This will buy you time and allow you to coordinate the rest of your care.
Use this time to ask yourself some questions.
Do I need to cannulate the child? (Probably not)
Where is the ice kept? Fill a glove with ice and place it over the forehead, or pop a cube into the mouth, to aid vasoconstriction and stimulate the diving reflex – this will reduce cardiac output slightly and facilitate haemostasis.
Do we have silver nitrate, and do I know how to use it?
Do I need to pack the nose?
Reassess ABC
When should I refer to ENT?
- Heavy bleeding
- Heavy bleeding in the presence of trauma
- Recurrent epistaxis
- An adolescent male with unilateral nasal obstruction and torrential bleeding
Children with JNAs ultimately go to the operating theatre to resect the tumour endoscopically. They will also have pre-operative embolisation. This can be done for the sphenopalatine branch, but there is a risk of stroke and blindness if the internal carotid artery branches are inadvertently embolised.
Some common pitfalls:
Not using an anaesthetic is one of the most common failings and is very unpleasant for an already traumatised child.
Cautery – It’s great when it works. However, silver nitrate dissociates into nitric acid and silver hydroxide on contact with water. Nitric acid burns anything it comes into contact with, so after cauterising, place some cotton wool inside the nose to absorb any excess. Similarly, the silver hydroxide can dribble down the nose and cause an unsightly but temporary black tattoo.
Naseptin – This contains chlorhexidine and Arachis oil. Whilst arachis oil is boiled to sterilise it, caution is advised for those with severe peanut allergy to avoid anaphylaxis. Chlorhexidine is similarly allergenic – 2% of healthcare workers and 0.2% of the general population are sensitive to chlorhexidine.
