An update on management of pediatric epistaxis

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Abstract

Objective

To evaluate the work-up and treatment of pediatric epistaxis in an outpatient clinical setting, with a focus on the diagnostic utility and associated costs of nasal endoscopy and adjunctive laboratory data.

Study design

Retrospective, case series.

Methods

Children under 18 years of age seen in an outpatient clinical setting at a tertiary care hospital between 2004 and 2012 for the primary diagnosis of epistaxis were identified. Patient characteristics were analyzed from a statistical and cost perspective.

Results

A total of 175 patients with epistaxis were included. One hundred twenty-two (69.7%) were male, with a mean overall age of 9.1 years (range 5 months to 17.9 years). The duration of bleeding ranged from 0.25 to 84 months (mean 11.5 months). Nasal endoscopy was performed in 123 (70.2%) patients. Three (2.4%) had nasal polyps, and 1 (0.8%) a juvenile nasopharyngeal angiofibroma. The average age of patients with nasal masses was significantly older (16.2 years versus 10.4 years, p = 0.008). Of 131 patients with available blood work, laboratory values demonstrated anemia in 27 (20.6%) patients, elevated partial thromboplastin time in 5 (3.8%), and an abnormal platelet function analysis in 1 (0.8%) patient. Those with anemia were statistically younger (p = 0.001), than those with either normal labs or abnormal coagulation studies. Epistaxis resolved in 88/135 (65.2%) who had follow-up visits.

Conclusion

The majority of pediatric epistaxis cases resolved with nasal mucosa hydration. Nasal endoscopy can be reserved for teenaged patients with epistaxis, and routine laboratory screening may be useful in select cases based on the clinical judgment.

Introduction

Epistaxis (nosebleed) is a common pediatric problem, although it is rare before 2 years of age. It is reported to affect 30% of children aged 0–5 years, and over 50% of children 5 years and older [1] and is a common reason for parents to seek medical attention for their children. Most nosebleeds arise from the anterior septum in a richly vascular region called the Kiesselbach's plexus. When this area is exposed to drying or minor trauma, bleeding can arise. Most children can be managed with nasal ointments and saline solution with some requiring additional intervention such as cautery.

No consensus exists on the standard work-up and treatment for pediatric epistaxis. A previous review of pediatric epistaxis by one of the co-authors provided a general approach including a history and physical exam, including anterior rhinoscopy, complete blood count, coagulation profile and computed tomography (CT) of the sinuses. The study showed that CT imaging is not indicated in the initial work up of pediatric epistaxis [2]. Laboratory testing for anemia and coagulation disorders and flexible nasal endoscopy (FNE) continues to be part of the practice paradigm for some otolaryngologists when assessing patients with epistaxis. Recurrent epistaxis may be the first sign of coagulopathy and may lead to anemia [3], [4], [5]. Epistaxis raises an additional concern of a nasal cavity or nasopharyngeal mass, such as a juvenile nasopharyngeal angiofibroma (JNA) in an adolescent male [6]. Identifying those patient characteristics suggestive of an increased risk for these hematologic concerns and/or nasal masses becomes important to the otolaryngologist when assessing the average patient with epistaxis. The goal of this study was to assess our current trends in working up pediatric epistaxis, emphasizing patient characteristics associated with abnormal laboratory and FNE data.

Section snippets

Material and methods

Approval was obtained from the Institutional Review Board at Ann and Robert H. Lurie Children's Hospital of Chicago. This is a retrospective case series of consecutive patients below 18 years of age seen for the primary diagnosis of epistaxis by the two senior authors in an outpatient clinical setting between January 2004 and December 2012. The patients were identified using a database filter with “epistaxis” (ICD-9 code 784.7) as the primary diagnosis or reason for visit. Three hundred

Participants

Of the 359 patients initially identified with epistaxis, 175 patients who had either follow-up, FNE, or laboratory work up were analyzed. Regarding follow up, 59 patients had 1 follow up visit, 110 had 2–4 follow up visits, and 6 had >4 follow up visits. Initial follow up appointments were 2–4 weeks after the first visit. The longest follow up time was 5 years and 10 months. There were 122 (69.7%) males and 53 (30.3%) females with a mean age of 9.1 years (range 0.42–17.9 years, standard

Discussion

The majority of pediatric epistaxis is venous and arises from the anterior septum where a network of vessels (Kiesselbach's plexus) lie under a thin mucosal lining that can become dry and excoriated [1]. The etiology of epistaxis is broad and predicting which children are at risk for an underlying neoplasm or bleeding disorder can be a challenge. This study aims to identify characteristics, like age and duration of bleeding, that might be associated with these underlying causes of epistaxis,

Conclusion

The outpatient evaluation and management of pediatric epistaxis continues to evolve. The choice of laboratory screening with blood counts and bleeding parameters should be based on the clinician's judgment, while taking into account the patient's clinical presentation, symptoms and age. Patients found to have abnormalities should be properly referred for further work up. FNE should be incorporated into a patient's work up when a combination of age, gender, symptoms and physical exam are

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