Epidemiological characteristics of pediatric epistaxis presenting to the emergency department

Pediatric Epistaxis-Effectiveness of Conservative Management

OBJECTIVES

Epistaxis is an emergency medical condition that sometimes requires admission to the emergency department. Pediatric epistaxis differs from epistaxis in the older population in terms of etiology, severity, and management. Our objective was to identify the distinctive features of pediatric epistaxis and determine the appropriate management.

METHODS

This was a retrospective study of 231 medical records of children (<18 years old) with epistaxis of a total of 1171 cases in the general population who presented to our medical center's emergency department between 2013 and 2018.

RESULTS

Among 231 admissions, 10 children (4.3%) presented more than once. Male patients accounted for the majority of cases (64.5%), and the average age was 9.4 years. Two children were treated with aspirin because of cardiac valve disease. Anterior bleeding was detected in 101 cases (43.7%), whereas posterior origin was observed in 8 cases (3.5%). In 122 cases (52.8%), there was no active bleeding observed. Nose injury was the cause of epistaxis in 24 cases (10.4%), and 16 admissions (6.9%) followed nasal surgical interventions. Nineteen children (8%) had abnormal coagulation tests, and 7 patients (3%) received blood transfusions. Chemical cauterization was performed in 89 cases (39.3%), and anterior packing was needed in only 9 cases (3.9%). Nine children required hospitalization (3.9%), and 2 needed surgical intervention to control bleeding. Compared with the adult population, there were significantly fewer cases of active bleeding, recurrent epistaxis, anterior packing, or need for hospitalization in the pediatric population.

CONCLUSIONS

Epistaxis is significantly less severe in the pediatric population, with only a few cases requiring major intervention. Endoscopic examination of the entire nasal cavity and routine coagulation tests are not mandatory unless there is a history of recurrent epistaxis, known coagulopathy, antiplatelet/anticoagulation therapy, or a suspicion of juvenile idiopathic angiofibroma. We suggest using absorbable packs, which offer advantages over cauterization or nonabsorbable packs.

Nasal Disorders

Nasal obstruction, rhinorrhea, and epistaxis are common presenting concerns in primary care clinics. Nasal disorders affect the quality of life for many children and families. Rarely, these complaints may represent a life-threatening condition among infant obligate nasal breathers or cases of unusual pathology. The most common causes of rhinorrhea and nasal obstruction vary by age and include physiologic, infectious, allergic, foreign body, irritant, and traumatic causes. Less commonly, children may have congenital malformations, sinonasal masses, or autoimmune disease. The most common causes of epistaxis are inflammatory, environmental, and traumatic causes and medication misuse, but rarely, children may have predisposing anatomic, hematologic, or vascular abnormalities or even sinonasal tumors. In this article, we provide a thorough review of the common nasal disorders treated every day in primary care clinics and mention briefly some of the rare but serious cases that may be overlooked without considering a full differential diagnosis.

Influence of meteorological variables on the frequency of visits and hospital admission for epistaxis in a city with a cold semi-arid climate (Lorca, Spain)

BACKGROUND AND OBJECTIVES

Epistaxis is a common emergency for otorhinolaryngologists. Although the aetiological factors have been widely studied, they remain subject to debate. The role of meteorological variables has been discussed in recent years, but results have been inconsistent. Given a lack of prior data, the aim of our study was to identify the meteorological variables that influence the frequency of visits and hospital admission for epistaxis in a city with a cold semi-arid climate in Spain.

METHODS

Case-control study.

CASES

patients who attended the accident and emergency department of a secondary level hospital for epistaxis over a 9-year period (2011-2019). Controls were established by simple random sampling among emergency rooms visits in general (patients who attended the same centre over the same period of time). Sociodemographic, clinical and meteorological variables were all taken into account.

RESULTS

2749 patients in the epistaxis group and 2764 in the control group. There were significant differences in the epistaxis group, with a higher proportion of male (62.85%) and older patients. Univariate and multivariate analysis revealed that the daily minimum temperature and maximum wind speed were factors significantly associated with the onset of epistaxis. In addition, logistic regression analysis showed that decreases in minimum temperature and increases in maximum wind speed were associated with an increase in epistaxis (p < 0.01). No association was found between hospital admission and the weather conditions.

CONCLUSION

Our findings suggest that low minimum temperatures and high wind speeds are associated with the number of visits to hospital accident and emergency departments for epistaxis, but not with hospital admission.

Environmental Risk Factors for Pediatric Epistaxis vary by Climate Zone

INTRODUCTION AND OBJECTIVE

Prior studies have provided variable results regarding environmental risk factors for epistaxis. These studies were conducted in varying climate zones, which may explain discrepancies in results. The objective of this study is to investigate correlations between season, temperature, and humidity on frequency of pediatric epistaxis across climate zones.

METHODS

Children seen in the outpatient setting for epistaxis were identified from the 2007-2010 IBM MarketScan database. Climate zones were assigned according to International Energy Conservation Code (IECC) classification, where temperature zones in the United States and territories were assigned on an ordinal scale from 1 (tropical) to 8 (subarctic), and humidity zones were categorized as moist, dry, or marine. The control population was a sample of all well-child visits matched by age and county.

RESULTS

We identified 184,846 unique children seen for epistaxis and 1,897,012 matched controls. Moderate temperature zones were associated with lower odds of epistaxis compared with the hottest and coldest zones. Humidity was associated inversely with epistaxis rates in moderate temperature zones but was not a significant predictor of epistaxis in climates with extreme heat. Additionally, summer was associated with lower odds of epistaxis compared to winter. Interestingly, however, there were significantly higher rates of cautery procedures during summer months, driven largely by increased procedures performed in clinic, as opposed to the operating room or emergency room.

CONCLUSIONS

Environmental risk factors for epistaxis vary by climate zone. The model presented reconciles prior reports and may allow for more personalized clinical management based on regional climate.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:1450-1456, 2024.

Clinical Presentation and Treatment Patterns of Pediatric Epistaxis: A Single-Center Study

BACKGROUND

Epistaxis, commonly known as nose bleeding, is a prevalent condition in pediatric patients, often managed either at home or in clinical settings. This study aimed to explore the differences in the management of pediatric epistaxis between home and clinical settings, focusing on gender distribution, clinical presentations, and treatment methods.

METHODS

A retrospective review was conducted, analyzing pediatric epistaxis cases managed both at home and in clinical settings. Data on gender distribution, clinical presentation, and treatment methods were collected and analyzed. Home remedies, first aid management, and clinical interventions like the use of nasal sprays and septoplasty were evaluated.

RESULTS

The study found significant differences in gender distribution between home (46.2% males) and clinical settings (61% males). Recurrent nasal bleeding was more common in home settings (75%), whereas more complex cases were predominant in clinical settings. Nasal sprays containing decongestants were widely used in clinical settings (62.1%), contrasting with a preference for first aid measures at home. Surgical interventions like septoplasty were occasionally employed in clinical scenarios.

CONCLUSION

The study highlights distinct approaches to managing pediatric epistaxis in home versus clinical settings. It underscores the importance of tailored treatment strategies, considering the severity and frequency of epistaxis episodes. These findings suggest a need for comprehensive guidelines to assist caregivers and healthcare professionals in effective decision-making for pediatric epistaxis management. The study also emphasizes the necessity for ongoing research and education in this area.

Risk Factors and Management Outcomes in Pediatric Epistaxis at an Emergency Department

BACKGROUND

Most cases of pediatric epistaxis are spontaneous and self-resolve. However, a subset of children may experience significant bleeding and require procedural or medical intervention.

OBJECTIVE

We aim to identify risk factors associated with moderate and severe epistaxis in the emergency department (ED) and explore management outcomes.

METHODS

We retrospectively reviewed all patients under 22 years old with epistaxis who presented to our ED between 2013 and 2022. Epistaxis severity was defined as mild (required nasal compression or intranasal medications), moderate (required cautery or packing), or severe (required factor replacement, transfusion, hospital admission, or surgery). We performed univariable and multinomial regression analyses, with risk factors and outcomes analyzed according to severity.

RESULTS

Of 858 visits, 41 (5%) patients had moderate and 67 (8%) had severe epistaxis. Patients with moderate epistaxis were older than those with mild and severe epistaxis (median 15.6 vs. 8.3 vs. 10.7 years, p < 0.001). In regression analysis, moderate epistaxis was associated with older age, prior ED visit within 72 h, and antiplatelet medication use (p < 0.01). Severe epistaxis was associated with bleeding disorders, nasal procedures within 30 days, and anticoagulation medication use (p ≤ 0.001). Bleeding over 30 min prior to arrival was associated with both moderate and severe epistaxis (p < 0.05). Of the 67 patients with severe epistaxis, 10 (15%) required factor replacement, 28 (42%) required transfusion, 52 (77%) required hospital admission, and 5 (7%) underwent surgery.

CONCLUSION

Epistaxis severity is associated with certain risk factors. However, most cases of pediatric epistaxis are mild and do not require intervention or ED evaluation.

Environmental impact on pediatric epistaxis and the utility of diagnostic studies: A single-institutional review

OBJECTIVES

Pediatric epistaxis is a multifactorial disease entity. The objective of this study is to determine the socioeconomic and air-quality contributions to pediatric epistaxis. The study also evaluates the utility of diagnostic lab work as a predictor of bleeding rates and need for operative intervention.

METHODS

A case series of pediatric patients treated in an outpatient Otolaryngology clinic at a tertiary care children's hospital in 2021 for epistaxis was performed. Patients with nasal bone trauma (n = 8), consult while inpatient (n = 7), and those with nasal masses (n = 2) were excluded; 181 patients met inclusion criteria. Demographic, clinical, socioeconomic, and air quality (tropospheric ozone, particulate matter) data were recorded. Associations with persistent bleeding and operative interventions were evaluated using logistic regression, Wilcoxon rank-sum, and Spearman rank correlation.

RESULTS

Of the 181 patients, 75 (41.4%) were female. Forty-six of 181 (25.4%) had associated allergic symptoms. Twenty-six patients had allergy testing; 14/26 (53.8%) of these had positive results. Re-bleeding was more common in those with allergic symptoms (OR: 2.42, 95% CI: 1.22-4.78, p = 0.01). Patients with re-bleeding lived in counties with more days with ozone over the US standard (median 5 days, range 0-32 days) compared with those with no re-bleeding (median 3 days, range 0-32 days, p = 0.007). There was also an association between the number of visits for re-bleed and percent below poverty level (ρ = 0.259, p = 0.03) as well as the number of days with particulate matter levels over the US standard (ρ = 0.343, p = 0.01). Coagulopathy was present in 9/54 (16.7%) patients, with the majority being Von Willebrand disease (5/54, 9.3%). Easy bruising was not significantly associated with positive lab results.

CONCLUSIONS

Environmental pollution, living in a zip code with more residents below the poverty level, and allergic rhinitis were positively associated with recurrent epistaxis. Understanding the geographic background of presenting patients may help direct workup and treatment options.

Comparing recurrence between cautery techniques in pediatric epistaxis

OBJECTIVE

To compare the risk of recurrent epistaxis between children treated with silver nitrate (SN) in the office or electrocautery (EC) in the operating room (OR).

METHODS

Patients aged 2-18 diagnosed with epistaxis (ICD R04.0) in 2018 and treated with SN or EC were retrospectively reviewed. Epistaxis laterality, history of nasal trauma, and personal or family history of a bleeding disorder were recorded. Patients with prior cautery or epistaxis secondary to a procedure were excluded. Recurrence was defined as initial encounter after cautery with documented epistaxis. Patients were followed up into 2022 to track onset of recurrence. Time to recurrence between SN and EC was compared with hazard curves with predictors for recurrence analyzed via Cox's proportional hazard regression.

RESULTS

Among 291 patients cauterized for epistaxis, 62 % (n = 181) received SN compared to 38 % (n = 110) who underwent EC. There was significantly higher risk of recurrence when treated with SN compared to EC (Hazard ratio 2.45, 95 % CI: 1.57-3.82, P < 0.0001). Median time to recurrence was not statistically different between techniques (6.39 months (SN) (IQR: 2.33, 14.82) vs. 4.11 months (EC) (IQR: 1.18, 20.86), P = 0.4154). Complication rates were low for both groups (1.16 % (SN) vs. 0 % (EC), P > 0.05).

CONCLUSION

Among patients with epistaxis, risk of recurrence is significantly higher in those cauterized with SN compared to EC. Time to recurrence is not significantly different between cautery techniques.

Age Distribution of Epistaxis in Outpatient Pediatric Patients

Objectives: Little is known about the prevalence of epistaxis in children. Existing reports focus on hospitalized children or those presenting to an emergency department. To better understand pediatric epistaxis in clinical practice, we sought out a searchable, representative outpatient database and examined the incidence of epistaxis in children of different ages. Methods: A cross-sectional analysis of data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from the years 2007 to 2011 was performed. The NHAMCS is a Centers for Disease Control and Prevention-curated national sample of data from visits to non-federally employed office-based physicians and health centers. We queried the NHAMCS to determine the cumulative incidence of epistaxis in children of different age groups. The International Classification of Diseases Ninth Revision code 784.7 was chosen to identify epistaxis. Comparisons of rates were performed using the chi-squared test. A P-value of <.05 was considered statistically significant. Results: In total, 55,435,691 children [27,816,237 (50.2%) males, 55,435,691 (77.2%) white] were included. The overall cumulative incidence rate of epistaxis was 2.4/1000 children. Children in the 3- to 5-year range had the highest cumulative incidence of epistaxis (5.0/1000), followed by those in the 6 to 8 (3.0/1000), 9 to 11 (2.0/1000), 0 to 2 (1.9/1000), 12 to 14 (1.6/1000), and 15 to 17 (0.5/1000) year ranges (P < .001). Conclusion: Pediatric epistaxis is common in the office setting (2.4 per 1000 children)-and well above emergency department estimates (1.7 per 1000 people). Children between the ages of 3 to 5 years have the highest cumulative incidence. Epistaxis is sufficiently unusual in infants and the late teens that alternative causes for nasal bleeding should be included in the differential diagnosis.

Clinical Characteristics and Risk Factors for Allergic Rhinitis in Children with Epistaxis

Background

Epistaxis is frequently observed in children with allergic rhinitis. However, few studies have addressed the clinical characteristics and risk factors for allergic rhinitis in children with epistaxis. This study aimed to describe the factors associated with allergic rhinitis in children with epistaxis.

Methods

In total, we recruited 80 children (aged 3-14 years) who presented with epistaxis at a tertiary hospital between January 2014 and January 2022. The follow-up duration was at least 3 months, and we performed a multivariate logistic regression analysis to identify the risk factors for allergic rhinitis.

Results

Among the 80 children examined, 57 (71.25%) had allergic rhinitis. Epistaxis mainly occurred in autumn in children with allergic rhinitis; in contrast, it mostly occurred in summer in children without it (P = 0.029). Mites are common allergens for allergic rhinitis in children with epistaxis; the univariate analysis revealed significant differences between allergic-rhinitis group and nonallergic-rhinitis group in the number of allergens (P  <  0.001) and total IgE (P  <  0.001). The difference in severity of nasal symptoms between the two groups was statistically significant and included nasal obstruction (P  <  0.001), rhinorrhea (P  <  0.001), sneezing (P  <  0.001), and nasal itching (P  <  0.001). After adjusting for potential confounders, the severity of rhinorrhea symptoms was found to be associated with an increased risk of allergic rhinitis in children with epistaxis (odds ratio: 3.86; 95% confidence interval: 1.61-9.26; P = 0.003).

Conclusions

Observing the onset season, number of allergens, total IgE, and nasal symptoms in cases of epistaxis could suggest the presence of associated allergic rhinitis and reduce the number of missed diagnoses; antiallergic drugs could help control epistaxis in these cases.

Environmental factors differentially affect epistaxis among preschool and school-aged children

Introduction

Environmental factors are closely associated with pediatric epistaxis. Whether this association differs according to age has not been previously reported. Therefore, we tried to evaluate the differences in associations between environmental factors and epistaxis in children of different ages.

Methods

A total of 20,234 patients with epistaxis who visited the hospital between January 1, 2002, and December 31, 2015, were enrolled in this study. The patients were divided into two groups according to their ages: preschool-aged (<6 years) and school-aged children (6-18 years). Daily, monthly, and yearly data on environmental factors were collected. We performed a stepwise logistic regression to identify the potential environmental risk factors for epistaxis in each age group.

Results

The mean number of epistaxis cases per month in both groups was highest in September. The cases were lowest in February in preschool-aged children and in November in school-aged children. Temperature, humidity, maximum wind speed, and sunshine duration were associated with epistaxis in preschool-aged children. Average wind speed, particulate matter (>10 μm diameter), temperature, humidity, sunshine duration, and sulfur dioxide concentration were associated with epistaxis in school-aged children.

Conclusion

This study indicates that the differences in environmental risk factors for epistaxis are associated with the patient's age.

Outcome of childhood epistaxis with treatment of allergic rhinitis: a randomized controlled study

The purpose of this study is to (1) to determine if treatment of underlying allergic rhinitis (AR) in children will affect epistaxis outcome, (2) to compare efficacy of three outpatient AR treatment regimens in epistaxis outcomes, and (3) to investigate potential factors in the pathogenesis of epistaxis with underlying AR. A single-blind randomized-controlled study was conducted in the Otolaryngology clinic in KK Women's and Children's Hospital. Sixty children aged below 18 years with underlying untreated AR, with first presentation of epistaxis, were randomized to three different AR treatments: treatment 1, antihistamine (20 patients); treatment 2, nasal steroid spray (20 patients); and treatment 3, both antihistamine and nasal steroid spray (20 patients). Epistaxis severity and frequency were assessed. Pre-treatment, 95% of patients within each of the three treatment groups described epistaxis symptoms. Post-treatment, there was improvement in epistaxis outcome (resolution of epistaxis) with 20% (4/20), 40% (8/20), and 60% (12/20) of patients in treatment groups 1 (antihistamine), 2 (nasal steroid spray), and 3 (combined therapy) respectively, who reported resolution of epistaxis. Treatment regimens containing nasal steroid spray resulted in greater improvement of epistaxis severity and frequency. Combined therapy (treatment 3) resulted in the best epistaxis outcome at 1-month follow-up. Majority (90%) reported nose-picking/rubbing behavior.

CONCLUSIONS

Intranasal corticosteroids are superior to oral antihistamines in relieving itch or rhinorrhea in AR. Intranasal corticosteroids may be important in treating epistaxis with underlying AR, because digital trauma from itch/rhinorrhea-related nose-picking/rubbing frequently leads to epistaxis. Results from this study will be important to primary and emergency physicians, community pediatricians, and pediatric allergists and otolaryngologists.

WHAT IS KNOWN

• Childhood epistaxis commonly co-exists with allergic rhinitis (AR), causing significant symptoms and distress to patients. • There are currently no studies reporti ng on epistaxis outcome aft er treatment of underlying AR.

WHAT IS NEW

• This is a single-blind randomized-controlled study of 60 children aged below 18 years with underlying untreated AR, with first presentation of epistaxis to a children's hospital in Singapore Patients were randomized to three different regimens to treat AR: treatment 1, antihistamine; treatment 2, nasal steroid spray; and treatment 3, both antihistamine and nasal steroid spray. • Treatment regimens containing nasal steroid spray improved epistaxis outcomes, with combined therapy of antihistamine and nasal steroid spray resulting in the best outcome for resolution of epistaxis among the three treatment regimens.

[Epidemiology and modern methods of treatment of non-traumatic nosebleeds]

Data on the detection incidence of nosebleeds (NBs) of non-traumatic origin in the population show considerable variability in statistical indicators, and NBs treatment and consequences depend on the localization of hemorrhage source, the volume of blood loss, patient's general condition, the presence and nature of comorbid pathology and a number of other factors. There are some differences in the choice of NBs treatment options, evaluation of their clinical and economic efficiency, which indicates the need to analyze and systematize the results of such studies.

OBJECTIVE

To analyze data on prevalence and current treatment approaches of non-traumatic nosebleeds.

MATERIAL AND METHODS

The search for publications (articles and related abstracts) on the subject of the study, presented in the PubMed database, has been conducted. The choice of material was made according to the following key words: non-traumatic nosebleeds, causes, incidence, methods of stopping nosebleeds.

RESULTS

The literature data show a significant prevalence of NBs in the population, their potential hazard to the life of patient and the importance of clinical and demographic characteristics of persons for determining treatment tactics in each case. In practical terms, primary and secondary NBs should be distinguished. In case of primary NB, the use of coagulation and nasal packing is recommended after determining the place of bleeding. In secondary NB it is necessary to establish its cause in order to assess risk factors and apply appropriate topical or systemic drug therapy. The so-called difficult (difficult-to-treat) NBs deserve special attention. As a rule, these cases involve bleeding from the posterior parts of nose. The analysis of publications shows a high (90%) efficacy of surgical interventions, used as first-line treatment. Effectiveness of embolization in such cases was 75% and of anterior/posterior nasal packing was 62%.

CONCLUSION

The literature data show a significant prevalence of nosebleeds in the population and their potential hazard to the life of patient. The existing differences in the assessments of treatment options for this pathology, their clinical and economic efficiency are the basis for further research, in particular, to clarify the causes of nosebleeds' occurrence and recurrence, the impact of treatment methods on quality of patients' life.

Effects of Nasal Pathologies in Paediatric Epistaxis

Objectives: The aim of this study was to investigate the effects of nasal pathologies in paediatric patients with recurrent epistaxis. Methods: A total of 100 (61 boys, 39 girls) patients aged 2–17 years (mean age: 8.9 ± 3.6 years) were included in this study. Anterior rhinoscopy and flexible nasal endoscopy were used to examine all the patients. The epistaxis duration, treatment in active epistaxis by parents, medical history, medical treatment and interventions were recorded. The location of the epistaxis site, nasal mucosa type, the presence of nasal vestibulitis, nasal septum deviation location and type, adenoid size and the degree of inferior turbinate hypertrophy were recorded. Results: The deviation was present in 31 (62%) patients with recurrent epistaxis and in 14 (28%) patients without epistaxis. The presence of deviation was significantly higher in the epistaxis group than control group (p = 0.001). The nasal mucosa type was friable mucosa in 37 (74%) patients, vascularised mucosa in 11 (22%) patients and friable – vascularised mucosa in 2 (4%) patients in recurrent epistaxis group. A significant relationship was detected between nasal mucosa type and age, the presence of the deviation, deviation location, Mladina type in epistaxis group (p = 0.005, p = 0.004, p = 0.008, p = 0.015). Conclusion: Nasal septum deviation, inferior turbinate hypertrophy and nasal mucosa type are associated with paediatric recurrent epistaxis.

Are laboratory evaluations required in every case admitted to the pediatric emergency department with epistaxis?

BACKGROUND

Epistaxis is a mostly self-limiting condition common among children and is rarely severe. In this study, it was aimed to evaluate the incidence, demographic characteristics, causes of bleeding and treatment methods of patients who presented to the pediatric emergency department (PED) with epistaxis, and to determine in which cases a laboratory test should be used.

METHOD

Admitted to Gazi University Faculty of Medicine, PED which provides trauma care and is a tertiary hospital, from 1 January 2019 to 31 December 2019, 452 patients aged 0-18 years who presented with epistaxis for any reason or secondary to systemic disease were analysed retrospectively.

RESULTS

The annual incidence was found at 1.23%. The median age was 5.25 years, 258 of the cases (57.1%) were male. It was found that the cases most frequently applied to the hospital in the autumn months (37.6%). Sixty of the patients (13.3%) had a chronic disease and 54 (11.9%) had a history of drug use. Bleeding time was less than 5 minutes in 75.2% and 84.4% of the bleeding was unilateral. Nasal bleeding is local in 73.4%; 4.7% of them developed because of systemic reasons. The most common cause of epistaxis; while they were trauma at the first 10 years of age, they were idiopathic causes after the age of 10 years. In 434 (96%) of the patients, epistaxis spontaneously stopped and there was no need for additional treatment.

CONCLUSION

As a result of this study, it was concluded that laboratory tests should be performed in cases with chronic disease history, bilateral bleeding, active bleeding and nontraumatic epistaxis. The situation that causes epistaxis in the childhood age group should be determined with a good history and physical examination, laboratory tests should not be used in every patient.

Clinical Practice Guideline: Nosebleed (Epistaxis)

OBJECTIVE

Nosebleed, also known as epistaxis, is a common problem that occurs at some point in at least 60% of people in the United States. While the majority of nosebleeds are limited in severity and duration, about 6% of people who experience nosebleeds will seek medical attention. For the purposes of this guideline, we define the target patient with a nosebleed as a patient with bleeding from the nostril, nasal cavity, or nasopharynx that is sufficient to warrant medical advice or care. This includes bleeding that is severe, persistent, and/or recurrent, as well as bleeding that impacts a patient's quality of life. Interventions for nosebleeds range from self-treatment and home remedies to more intensive procedural interventions in medical offices, emergency departments, hospitals, and operating rooms. Epistaxis has been estimated to account for 0.5% of all emergency department visits and up to one-third of all otolaryngology-related emergency department encounters. Inpatient hospitalization for aggressive treatment of severe nosebleeds has been reported in 0.2% of patients with nosebleeds.

PURPOSE

The primary purpose of this multidisciplinary guideline is to identify quality improvement opportunities in the management of nosebleeds and to create clear and actionable recommendations to implement these opportunities in clinical practice. Specific goals of this guideline are to promote best practices, reduce unjustified variations in care of patients with nosebleeds, improve health outcomes, and minimize the potential harms of nosebleeds or interventions to treat nosebleeds. The target patient for the guideline is any individual aged ≥3 years with a nosebleed or history of nosebleed who needs medical treatment or seeks medical advice. The target audience of this guideline is clinicians who evaluate and treat patients with nosebleed. This includes primary care providers such as family medicine physicians, internists, pediatricians, physician assistants, and nurse practitioners. It also includes specialists such as emergency medicine providers, otolaryngologists, interventional radiologists/neuroradiologists and neurointerventionalists, hematologists, and cardiologists. The setting for this guideline includes any site of evaluation and treatment for a patient with nosebleed, including ambulatory medical sites, the emergency department, the inpatient hospital, and even remote outpatient encounters with phone calls and telemedicine. Outcomes to be considered for patients with nosebleed include control of acute bleeding, prevention of recurrent episodes of nasal bleeding, complications of treatment modalities, and accuracy of diagnostic measures. This guideline addresses the diagnosis, treatment, and prevention of nosebleed. It focuses on nosebleeds that commonly present to clinicians via phone calls, office visits, and emergency room encounters. This guideline discusses first-line treatments such as nasal compression, application of vasoconstrictors, nasal packing, and nasal cautery. It also addresses more complex epistaxis management, which includes the use of endoscopic arterial ligation and interventional radiology procedures. Management options for 2 special groups of patients-patients with hereditary hemorrhagic telangiectasia syndrome and patients taking medications that inhibit coagulation and/or platelet function-are included in this guideline. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not intended to be a comprehensive, general guide for managing patients with nosebleed. In this context, the purpose is to define useful actions for clinicians, generalists, and specialists from a variety of disciplines to improve quality of care. Conversely, the statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients.

ACTION STATEMENTS

The guideline development group made recommendations for the following key action statements: (1) At the time of initial contact, the clinician should distinguish the nosebleed patient who requires prompt management from the patient who does not. (2) The clinician should treat active bleeding for patients in need of prompt management with firm sustained compression to the lower third of the nose, with or without the assistance of the patient or caregiver, for 5 minutes or longer. (3a) For patients in whom bleeding precludes identification of a bleeding site despite nasal compression, the clinician should treat ongoing active bleeding with nasal packing. (3b) The clinician should use resorbable packing for patients with a suspected bleeding disorder or for patients who are using anticoagulation or antiplatelet medications. (4) The clinician should educate the patient who undergoes nasal packing about the type of packing placed, timing of and plan for removal of packing (if not resorbable), postprocedure care, and any signs or symptoms that would warrant prompt reassessment. (5) The clinician should document factors that increase the frequency or severity of bleeding for any patient with a nosebleed, including personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, or intranasal drug use. (6) The clinician should perform anterior rhinoscopy to identify a source of bleeding after removal of any blood clot (if present) for patients with nosebleeds. (7a) The clinician should perform, or should refer to a clinician who can perform, nasal endoscopy to identify the site of bleeding and guide further management in patients with recurrent nasal bleeding, despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding. (8) The clinician should treat patients with an identified site of bleeding with an appropriate intervention, which may include one or more of the following: topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents. (9) When nasal cautery is chosen for treatment, the clinician should anesthetize the bleeding site and restrict application of cautery only to the active or suspected site(s) of bleeding. (10) The clinician should evaluate, or refer to a clinician who can evaluate, candidacy for surgical arterial ligation or endovascular embolization for patients with persistent or recurrent bleeding not controlled by packing or nasal cauterization. (11) In the absence of life-threatening bleeding, the clinician should initiate first-line treatments prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications for patients using these medications. (12) The clinician should assess, or refer to a specialist who can assess, the presence of nasal telangiectasias and/or oral mucosal telangiectasias in patients who have a history of recurrent bilateral nosebleeds or a family history of recurrent nosebleeds to diagnose hereditary hemorrhagic telangiectasia syndrome. (13) The clinician should educate patients with nosebleeds and their caregivers about preventive measures for nosebleeds, home treatment for nosebleeds, and indications to seek additional medical care. (14) The clinician or designee should document the outcome of intervention within 30 days or document transition of care in patients who had a nosebleed treated with nonresorbable packing, surgery, or arterial ligation/embolization. The policy level for the following recommendation, about examination of the nasal cavity and nasopharynx using nasal endoscopy, was an option: (7b) The clinician may perform, or may refer to a clinician who can perform, nasal endoscopy to examine the nasal cavity and nasopharynx in patients with epistaxis that is difficult to control or when there is concern for unrecognized pathology contributing to epistaxis.

Endovascular Treatment of Epistaxis

Epistaxis is not uncommon, with up to 60% of the population suffering from at least one episode in their lifetime and as many as 6% presenting for medical attention. An analysis of emergency room (ER) visits in the United States between 2009 and 2011 identified 1.2 million encounters for epistaxis, accounting for 0.32% of ER visits. Approximately 6% of patients will require more aggressive, invasive management in the form of transnasal ligation of the sphenopalatine artery or endovascular embolization. This article reviews the epidemiology, rationale for endovascular treatment, strategy for treatment, endovascular technique, postprocedural follow-up, and complications and their management.

Clinical Practice Guideline: Nosebleed (Epistaxis) Executive Summary

OBJECTIVE

Nosebleed, also known as epistaxis, is a common problem that occurs at some point in at least 60% of people in the United States. While the great majority of nosebleeds are limited in severity and duration, about 6% of people who experience nosebleeds will seek medical attention. For the purposes of this guideline, we define the target patient with a nosebleed as a patient with bleeding from the nostril, nasal cavity, or nasopharynx that is sufficient to warrant medical advice or care. This includes bleeding that is severe, persistent, and/or recurrent, as well as bleeding that impacts a patient's quality of life. Interventions for nosebleeds range from self-treatment and home remedies to more intensive procedural interventions in medical offices, emergency departments, hospitals, and operating rooms. Epistaxis has been estimated to account for 0.5% of all emergency department visits and up to one-third of all otolaryngology-related emergency department encounters. Inpatient hospitalization for aggressive treatment of severe nosebleeds has been reported in 0.2% of patients with nosebleeds.

PURPOSE

The primary purpose of this multidisciplinary guideline is to identify quality improvement opportunities in the management of nosebleeds and to create clear and actionable recommendations to implement these opportunities in clinical practice. Specific goals of this guideline are to promote best practices, reduce unjustified variations in care of patients with nosebleeds, improve health outcomes, and minimize the potential harms of nosebleeds or interventions to treat nosebleeds. The target patient for the guideline is any individual aged ≥3 years with a nosebleed or history of nosebleed who needs medical treatment or seeks medical advice. The target audience of this guideline is clinicians who evaluate and treat patients with nosebleed. This includes primary care providers such as family medicine physicians, internists, pediatricians, physician assistants, and nurse practitioners. It also includes specialists such as emergency medicine providers, otolaryngologists, interventional radiologists/neuroradiologists and neurointerventionalists, hematologists, and cardiologists. The setting for this guideline includes any site of evaluation and treatment for a patient with nosebleed, including ambulatory medical sites, the emergency department, the inpatient hospital, and even remote outpatient encounters with phone calls and telemedicine. Outcomes to be considered for patients with nosebleed include control of acute bleeding, prevention of recurrent episodes of nasal bleeding, complications of treatment modalities, and accuracy of diagnostic measures. This guideline addresses the diagnosis, treatment, and prevention of nosebleed. It will focus on nosebleeds that commonly present to clinicians with phone calls, office visits, and emergency room encounters. This guideline discusses first-line treatments such as nasal compression, application of vasoconstrictors, nasal packing, and nasal cautery. It also addresses more complex epistaxis management, which includes the use of endoscopic arterial ligation and interventional radiology procedures. Management options for 2 special groups of patients, patients with hemorrhagic telangiectasia syndrome (HHT) and patients taking medications that inhibit coagulation and/or platelet function, are included in this guideline. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the working group. It is not intended to be a comprehensive, general guide for managing patients with nosebleed. In this context, the purpose is to define useful actions for clinicians, generalists, and specialists from a variety of disciplines to improve quality of care. Conversely, the statements in this guideline are not intended to limit or restrict care provided by clinicians based upon their experience and assessment of individual patients.

ACTION STATEMENTS

The guideline development group made recommendations for the following key action statements: (1) At the time of initial contact, the clinician should distinguish the nosebleed patient who requires prompt management from the patient who does not. (2) The clinician should treat active bleeding for patients in need of prompt management with firm sustained compression to the lower third of the nose, with or without the assistance of the patient or caregiver, for 5 minutes or longer. (3a) For patients in whom bleeding precludes identification of a bleeding site despite nasal compression, the clinician should treat ongoing active bleeding with nasal packing. (3b) The clinician should use resorbable packing for patients with a suspected bleeding disorder or for patients who are using anticoagulation or antiplatelet medications. (4) The clinician should educate the patient who undergoes nasal packing about the type of packing placed, timing of and plan for removal of packing (if not resorbable), postprocedure care, and any signs or symptoms that would warrant prompt reassessment. (5) The clinician should document factors that increase the frequency or severity of bleeding for any patient with a nosebleed, including personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, or intranasal drug use. (6) The clinician should perform anterior rhinoscopy to identify a source of bleeding after removal of any blood clot (if present) for patients with nosebleeds. (7a) The clinician should perform, or should refer to a clinician who can perform, nasal endoscopy to identify the site of bleeding and guide further management in patients with recurrent nasal bleeding, despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding. (8) The clinician should treat patients with an identified site of bleeding with an appropriate intervention, which may include 1 or more of the following: topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents. (9) When nasal cautery is chosen for treatment, the clinician should anesthetize the bleeding site and restrict application of cautery only to the active or suspected site(s) of bleeding. (10) The clinician should evaluate, or refer to a clinician who can evaluate, candidacy for surgical arterial ligation or endovascular embolization for patients with persistent or recurrent bleeding not controlled by packing or nasal cauterization. (11) In the absence of life-threatening bleeding, the clinician should initiate first-line treatments prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications for patients using these medications. (12) The clinician should assess, or refer to a specialist who can assess, the presence of nasal telangiectasias and/or oral mucosal telangiectasias in patients who have a history of recurrent bilateral nosebleeds or a family history of recurrent nosebleeds to diagnose hereditary hemorrhagic telangiectasia syndrome (HHT). (13) The clinician should educate patients with nosebleeds and their caregivers about preventive measures for nosebleeds, home treatment for nosebleeds, and indications to seek additional medical care. (14) The clinician or designee should document the outcome of intervention within 30 days or document transition of care in patients who had a nosebleed treated with nonresorbable packing, surgery, or arterial ligation/embolization. The policy level for the following recommendation about examination of the nasal cavity and nasopharynx using nasal endoscopy was an option: (7b) The clinician may perform, or may refer to a clinician who can perform, nasal endoscopy to examine the nasal cavity and nasopharynx in patients with epistaxis that is difficult to control or when there is concern for unrecognized pathology contributing to epistaxis.

Epistaxis health disparities in the United States pediatric population

OBJECTIVE

Despite epistaxis occurring in up to 60% of the population, few studies have investigated health status disparities in the pediatric epistaxis population. The aim of this study was to evaluate sociodemographic risk factors associated with epistaxis visits for pediatric patients.

METHODS

Data were extracted from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey Outpatient Department from 2001 to 2010. Outpatient visits of children less than 18 years who received a primary, secondary, or tertiary diagnosis of epistaxis (ICD-9CM code 784.7X) were included. Bivariate and stepwise multivariate regressions were conducted to develop a final model for epistaxis visits described by sociodemographics.

RESULTS

Epistaxis visits accounted for 5 ± 0.6 million visits in children less than 18 years. 51% and 33% of children presenting with epistaxis had private insurance and Medicaid, respectively (p = 0.001). 69% of epistaxis visits were evaluated at a pediatric clinic, 18% at an ENT/surgery clinic, and 13% at a general/family medicine clinic (p < 0.0001). After multivariate adjustment, epistaxis visits were associated with older age (p = 0.006). Black children were more likely to present with epistaxis (95% CI 1.3-4.1, p = 0.005) compared to white children. Allergic rhinitis, present in 11% of epistaxis visits, was a significant comorbidity associated with visits (95%CI 1.3-4.6, p = 0.008). Patients were also more likely to present to an ENT/surgery clinic (95% CI 4.5-16.5, p < 0.0001) compared to a general/family medicine clinic.

CONCLUSIONS

Epistaxis visits by children are associated with age, race, and specialty. Targeted interventions to help reduce this common presentation should be developed.

Is the occurrence of pediatric epistaxis related to climatic variables?

OBJECTIVE

To investigate the correlations between multiple meteorological variables and the frequency of epistaxis in the pediatric population.

METHODS

Children diagnosed with epistaxis in 2016 and 2017 were selected from the Outpatient Department of the Children's Hospital of Zhejiang University School of Medicine. The correlations between multiple meteorological factors and the incidence of pediatric epistaxis each month, were analyzed. A Poisson regression model was generated to predict the cases of pediatric epistaxis using both the 2-year study data and the 4-month new data.

RESULTS

There were 6805 cases of pediatric epistaxis (mean age 4.99 years). Contrary to previously reported inverse associations between ambient temperature and presentation rates for patients with epistaxis, a significant strong positive correlation was found between temperature and pediatric epistaxis rates (Pearson's r = 0.801 p < 0.001). A weak negative correlation between humidity and pediatric epistaxis was found, but it was not significant (Pearson's r = -0.225 p = 0.29). A very strong positive correlation between high air visibility and pediatric epistaxis was identified (Pearson's r = 0.909 p < 0.001). The predictions from the Poisson regression model have a mean error rate of 5.70% ± 22.71%.

CONCLUSION

A positive correlation between the frequency of pediatric epistaxis existed for both temperature and air visibility. No significant correlation was found for humidity.

Management of Epistaxis in Children and Adolescents: Avoiding a Chaotic Approach

This article provides an organized foundation that facilitates the management of acute epistaxis and an understanding of features that merit further diagnostic workup. Prompt management, including measures such as holding pressure and using nasal packing, takes precedence over comprehensive diagnostic workup. Severe, recurrent, and posteriorly based bleeds should prompt consideration of alternate interventions and expert consultation.