Definition And Epidemiology
Defined as bleeding from nostril, nasal cavity, or nasopharynx warranting medical care.
Includes severe, persistent, or recurrent bleeding affecting quality of life.
Recurrent epistaxis defined as five or more episodes per year.
Accounts for 0.5% of pediatric emergency department visits.
Peak presentation occurs between 2 and 10 years of age.
Rare in infants under 2 to 3 years of age; incidence is 1 per 10,000.
Declines in incidence after puberty.
More frequent during winter months due to dry air.
Anatomy And Pathophysiology
Most common bleeding site is anterior nasal septum.
Area known as Kiesselbach plexus or Little’s area.
Region features convergence of internal carotid branches (anterior and posterior ethmoid arteries) and external carotid branches (sphenopalatine and terminal internal maxillary arteries).
Superficial mucosal location makes vessels highly vulnerable to mechanical and chemical insults.
Posterior bleeding arises from posterior sphenopalatine branches, Woodruff plexus, and venous sources.
Etiology And Risk Factors
Classified clinically as primary (idiopathic) or secondary (identifiable cause).
Category Specific Causes Primary Idiopathic Local Trauma Digital manipulation (nose picking), facial trauma, septal perforation Inflammation & Infection Upper respiratory tract infections, allergic rhinitis, sinusitis, foreign body, nasal diphtheria Neoplasms & Masses Nasal polyps, juvenile nasopharyngeal angiofibroma, rhabdomyosarcoma Hematologic & Coagulopathies Hemophilia, von Willebrand disease, leukemia, immune thrombocytopenia, platelet dysfunction, aplastic anemia, liver disease Medications Anticoagulants, nasal steroid sprays, aspirin, nonsteroidal anti-inflammatory drugs Vascular Anomalies Hemangiomas, hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome) Systemic Conditions Hypertension, pertussis, renal failure
Age-Specific Etiology
Children over 2 years: Primarily local factors (trauma, mucosal drying, infections) or systemic clotting disorders.
Children under 2 years: Requires intensive workup for child abuse, intentional trauma, or severe hematological illness.
Clinical Presentation And Differential Diagnosis
Occurs without warning; blood flows slowly but freely from nostrils.
Bleeding often follows physical exercise in children with nasal lesions.
Nighttime bleeding often swallowed; manifests later as hematemesis or melena.
Posterior epistaxis presents with copious bleeding; mimics upper gastrointestinal source.
Unilateral foul-smelling discharge suggests foreign body.
Profuse, recurrent unilateral bleeding in adolescent males strongly suggests juvenile nasopharyngeal angiofibroma.
Assessment And Evaluation
Initial stabilization mandates immediate evaluation of airway obstruction and circulatory imbalance.
Clinical History
Document onset, duration, frequency, and laterality of bleeding.
Estimate blood loss objectively.
Inquire regarding easy bruising, bleeding from other sites, or family history of bleeding disorders.
Elicit history of antithrombotic medications, recreational drugs, or nasal steroid sprays.
Physical Examination
Assess vitals for tachycardia and hypotension.
Inspect skin for pallor, jaundice, petechiae, purpura, and telangiectasias.
Evaluate central nervous system for vision or hearing changes associated with nasopharyngeal masses.
Palpate abdomen for hepatosplenomegaly signifying malignancy or liver disease.
Perform anterior rhinoscopy using otoscope with wide-tipped speculum.
Clear purulent secretions and blood clots to visualize bleeding point.
Identify transverse nasal crease or Dennie-Morgan folds indicating allergic rhinitis.
Refer to otolaryngologist for flexible endoscopic evaluation if bleeding point remains unidentified.
Investigations
Usually self-limited; potentially life-threatening episodes require detailed evaluation.
Perform full blood count, urgent blood grouping, cross-matching, and coagulation studies for recurrent, prolonged, or significant bleeding.
Screen for von Willebrand disease in patients with familial bleeding history; standard coagulation profiles may appear normal.
Management
Position upright leaning slightly forward; prevents blood aspiration or swallowing.
Apply firm, constant pressure on caudal soft nose for 5-10 minutes.
Avoid pinching bony nasal bridge; provides inadequate pressure.
Apply cold compresses to nose.
Instruct patient to gently blow nose to evacuate fibrinolytic blood clots if bleeding persists after initial compression.
Pharmacological And Local Therapy
Administer topical vasoconstrictors (oxymetazoline or phenylephrine 0.25-1%); reapply pressure.
Cauterize identified anterior bleeding points with topical silver nitrate.
Avoid simultaneous bilateral septal cauterization; prevents septal perforation.
Utilize bipolar electrocautery for recurrent epistaxis as alternative to chemical cautery.
Nasal Packing
Insert anterior nasal pack using absorbable hemostatic agent if pressure and cautery fail.
Retain anterior packing for 24-48 hours.
Utilize combined anterior and posterior packing for uncontrolled posterior bleeds.
Consult otolaryngologist for posterior bleeding management.
Surgical And Advanced Interventions
Consider minimally invasive transnasal endoscopic sphenopalatine artery ligation for severe, unremitting epistaxis.
Utilize endovascular embolization to occlude feeding vessels in patients with sinonasal tumors.
Avoid embolization of ethmoidal arteries; derivation from ophthalmic artery carries blindness risk.
Administer blood transfusions and specific factor replacement for severe hemorrhage with underlying coagulopathy.
Prevention
Discourage digital manipulation and nose picking.
Maintain proper room humidification during dry winter months.
Apply petrolatum ointment to nasal septum; increases moisture and prevents fissuring.
Treat underlying allergic rhinitis and nasal infections promptly.
Discontinue offending medications such as nasal steroid sprays if implicated.
🌱 This is a Digital Garden. Notes are always growing and changing.
These notes are intended for educational purposes only and reflect my personal understanding of the subject. Please cross-reference with standard textbooks and current clinical guidelines.
Authored by Dr. Rubanbalaji 2026