Dr YK Amdekar writes on epistaxis, a condition that causes bleeding from the nostrils, nasal cavity or nasopharynx. While it is often the result of benign causes, at times it may represent more serious diseases. In this article, he discusses common investigations, treatment, and management of  the condition.

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Causes of epistaxis 

Fragile capillaries in the anterior part of the nose are vulnerable to rupture due to extreme environmental temperatures and are one of the most common benign causes of epistaxis. Nose pricking may also lead to epistaxis and so may accidental injuries to the nose or head, from a basal skull fracture. A foreign body in the nostril may present with epistaxis as well. Massive epistaxis may be confused with hemoptysis or hematemesis - though classically, blood dripping from the posterior nasopharynx is due to epistaxis.

Epistaxis may be the manifestation of an underlying haematological or vascular disorder. Common haematological diseases include platelet disorders (destruction or lack of production of platelets or platelet dysfunction in spite of normal amount of platelets) and coagulation disorders (congenital or acquired deficiency of coagulation factors). Vascular disorders include vasculitis and different types of vascular malformations. Hypertension is not the cause of epistaxis in children as hypertension is mostly acute unlike in adults in whom chronic progressive hypertension may present with epistaxis.

Clinical approach

The first step is to make sure that it is blood. Many times, a blood-stained kerchief is shown to the doctor as evidence of blood. Rarely, a child can intentionally cheat the parents and doctors. The next step is to locate an exact site in the nasal cavity. History should find out whether epistaxis was unilateral or bilateral, time taken to stop bleeding, bleed recurred again within a short time, relation to environment or injury, any accompanying symptoms such as fever, bleeding from other sites, past history of similar episodes and family history of bleeding disorder.

Physical examination should first ensure that the child is hemodynamically stable and then start with an inspection of the nasal cavity, if necessary with a speculum. During the active episode, the local examination may not be possible unless bleeding stops but throat examination may reveal dripping of blood from the nasopharynx. In such a case, firm pressure should be applied over the nostril for two minutes to stop bleeding. If it fails or takes time to control bleeding, further evaluation or referral is mandatory. Bleeding is easily controlled by pressure in common benign causes and physical examination should rule out the presence of the foreign body. Physical examination should focus on abnormal findings such as sick look, purpura, and ecchymosis, bleeding from other sites, hepatosplenomegaly or lymphadenopathy.

Investigating epistaxis

Tests are necessary only when one suspects haematological or pathological vascular causes of bleeding. Sick child, bleeding from other sites, difficulty in controlling bleeding and presence of abnormal physical findings are pointers to justify further evaluation with relevant tests. The haemoglobin level can estimate the degree of blood loss. Besides CBC, platelet count and PT / PTT are basic screening tests to give a clue to the type of bleeding disorder.

Further tests can define subtypes such as bone marrow in case of low platelet count and coagulation factor assessment and liver function tests in case of coagulation defects. In case of suspicion of vasculitis, special tests may be required.

Management of epistaxis

1. Usually, firm pressure over the nostrils controls bleeding. However, if it fails, topical epinephrine 1:10000 and 4% lidocaine may help to control bleeding.
2. Nasal packing with gauze has been a traditional method that is now replaced with balloons, tampons or compressed sponge.
3. Specific treatment is necessary in case of haematological or vascular causes.

In summary, occasional epistaxis in a healthy child may often be a benign problem and does not call for any specific intervention. However, it could be the first and only a single manifestation of haematological or vascular disorder that would need proper evaluation.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.