Epistaxis

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Epistaxis is common and affects >10% of us in our lifetimes. Children present with epistaxis for a number of reasons, many different to adults. Unfortunately, physics underpins most of these causes.

The nose is a very vascular part of the head and neck, owing to its function in humidifying air as it is breathed in. The nasal mucosa becomes engorged in response to dryness and low temperatures to make air more comfortable to breathe in. This response is more noticeable in patients who are ethnically extracted from tropical and equatorial climates.

Sagittal view of nose showing blood supply of inner aspect
Anatomy of the nasal vessels

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 – branches of the External Carotid artery.

These aren’t necessarily directly relevant to the management of paediatric epistaxis but do become important in some very special circumstances.

These arteries form a plexus in Little’s area called Kiesselbach’s plexus – Conveniently located approximately as far as a person can put their index finger inside their nostril.

Nose picking

The most common cause in children, but surprisingly common in adults too. 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 can 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 eg 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 already 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 out one side compared to the other and result 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 an inspection of the nose 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, who 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 which can affect their nose. This, in conjunction with thrombocytopaenia and nasal cannulae, NG tubes, and turbulent airflow can cause a very difficult to treat epistaxis. ENT may use Floseal – a haemostatic semi-solid matrix made of human recombinant thrombin. Do not pack or instrument the nose as this 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 as to 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 there is blood still trickling down the pharynx or not. 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 which…well…burns! Some departments have 1% lidocaine spray but this can also sting as it hits the mucosa so ideally squirt it onto some cotton wool with some 1:10000 adrenaline before applying it to the nose for 5 minutes then remove it prior to 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. Make sure they don’t try to rub it in with their finger or a cotton bud. Simply insert the tip of the nozzle 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 both your sake and the child and their parents.

Sit the child upright, attach monitoring, and raise the bed so you don’t injure your back. Get PPE on. This means gloves, 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 which is where the bleeding is likely to be coming 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. If you happen to have pre-mixed 5% lidocaine with 0.5% phenylephrine, this is even better. Make some pea-sized balls with the cotton wool and soak in the anaesthetic and adrenaline mixture. Gently place 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 some ice and place over the forehead or pop a cube inside the mouth to aid vasoconstriction and stimulate the diving reflex – this will reduce the cardiac output a little and facilitate haemostasis.

Do we have silver nitrate and do I know how to use it?

Do I need to pack the nose?

Do I need to call ENT?

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 for resection of the tumour endoscopically. They will also have pre-operative embolization. This can be done for the sphenopalatine branch but there is a risk of stroke and blindness if the branches of the internal carotid are inadvertently embolised.

Some common pitfalls:

Not using anaesthetic – this 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. The nitric acid burns anything it comes into contact with so after cauterising, place some cotton wool inside the nose to soak up the excess. Similarly, the silver hydroxide can also dribble down the nose and cause an unsightly but temporary black tattoo.

Naseptin – This contains chlorhexidine and arachis oil. Whilst the arachis oil is boiled to sterilise it, caution should be taken in those with severe peanut allergy in case of anaphylaxis. Chlorhexidine is similarly allergenic – 2% of healthcare workers are sensitive to chlorhexidine, and 0.2% of the general population.

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