Epistaxis, also called nosebleeds or nasal bleeding, is a common symptom after the first year and up to puberty, causing considerable anxiety to the sufferer as well as the parents. In our experience, it occurs in 10% of children. In a vast majority of the cases, blood loss is small. Of course, it appeals quite large to the parents. Moreover, the episode is frequently transient, stopping spontaneously or after application of little pressure.
Irrespective of the basic cause of bleeding, the fact remains that the site of epistaxis usually is the antero-inferior part of the cartilaginous nasal septum which has a rich vascular plexus (Kiesselbach plexus, area or triangle the anastomotic site for a number of terminal arterioles 0.5 cm within the nose and above the nasal floor) followed by the mucosa lining the anterior portion of the Notably, even in such bleeding disorders as leukemias, purpuras or hemophilia, this is the usual location of epistaxis.
In clinical history-taking, it is vital to determine if there has been any sort of physical injury to the nose with special reference to nose picking. Is the patient a habitual nose picker? Any history of foreign body, overexposure to solar radiation, allergic rhinitis, upper respiratory catarrh, pertussis, cystic fibrosis, etc.? Enquire if the subject is suffering from such diseases as uremia, hypertension, or liver disorder. A child who manifests epistaxis along with throbbing headache may well be suffering from hypertension. Any relationship with menses?
When you encounter epistaxis in association with bleeding from one or more additional sites, remember to exclude blood dyscrasias like leukemias.
A careful search for a bleeding disorder in family members (say, in maternal uncles in case of hemophilia A) points to a genetically determined etiology.
The most important part of physical examination is detailed and careful examination of the nose for deformity, a bleeding point, a telangiectasia spot over Kiesselbach’s area, congestion or pallor of mucosa, foreign body, polyp, ulceration, etc. Is there any evidence of sinusitis in the form of local sinus tenderness and/ or purulent discharge oozing out of the sinus opening in the nose. Look for purpuric lesions over skin or active bleeding from other sites. What is the blood pressure? Any organomegaly, particularly with reference to liver, spleen and lymph glands?
Nose picking is the most common cause of epistaxis in childhood. The location of trauma is usually the anterior portion of the nasal septum, about the Kiesselbach’s area. The bleeding spot can frequently be inspected after cleaning the area of the clots. A careful examination may reveal presence of dried blood under the patient’s fingernails. This kind of nosebleed is termed epistaxis digitorum.
Nasal trauma, say from other causes like a hard blow over the nose, may cause laceration of the mucosa, deformity and fracture in association with epistaxis.
Basal skull fracture may manifest as epistaxis with CSF rhinorrhea.
As and when recurrent epistaxis accompanies unilateral nasal obstruction, foul discharge, particularly in a child with older sibling who is in the habit of inserting nuts, beads, crayons, plastic pieces or similar objects into the patient’s nose during play, a foreign body must be suspected. A careful examination usually enables visualization of the foreign body.
Though this factor as a cause of epistaxis has generally been neglected in the western literature, there is little doubt that it is an important and common cause of recurrent epistaxis in India and other tropical countries.
Solar radiation induces, sudden nosebleed in individuals with very thin-walled anastmotic vessels over the Kiesselbach’s area
Recurrent epistaxis in association with manifestations of nasal obstruction, including mouth breathing, hyposmia, postnasal drip, persistent cold and sneezing should arouse suspicion of nasal polyposis. Visualization of pedunculated hypertrophied edematous nasal mucosa confirms the diagnosis.
Incidence of nasal polyposis is particularly high in cystic fibrosis.
Upper Respiratory Infection/Allergy
Such states as adenoidal hypertrophy/adenitis, allergic rhinitis, atrophic rhinitis, hypertrophic rhinitis, sinusitis, etc. may be accompanied by epistaxis.
In nasal diphtheria, besides blood-stained and mucopurulent discharge, the anterior nares show excoriation. Whereas in acute form toxemic symptoms are dominant, a grayish-white membrane is the hallmark of chronic form.
Physical and Emotional Stress and Strain
Violent exertion, vigorous blowing, sneezing, paroxysmal and forceful cough as in pertussis or cystic fibrosis, excitement, etc. are also known to foster nosebleeds.
Congenital Vascular Defect
Rendu-Osler-Weber disease, which usually manifests with epistaxis, is characterized by presence of telangiectasia on nasal mucosa (septum and turbinates) as also on oral mucosa, on skin and under fingernails. Family history is usually positive for epistaxis/telangiectasia. The cause of bleeding is increased capillary fragility. There is no defect/deficiency of platelets or coagulation factors.
Hypertension, uremia, cirrhosis of liver, rheumatic fever, acute nephritis, anemia, enteric fever, measles, etc. may well be complicated by epistaxis.
In leukemias, purpuras, hemophilia von willebrand disease and DIC, epistaxis may be the presenting features. Remaining features of these bleeding disorders aided by specific investigations help to reach the precise diagnosis.
Remaining Causes of Epistaxis
Tuberculosis, syphilis, leprosy, fungal infections, tumors, puberty, high altitude, scurvy, vitamin K deficiency, sickle-cell disease, brucellosis, prolonged use of phenylephrine nasol drops, juvenile angiofibroma of the nasopharynx, lymphoepithelioma, etc.