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

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.

Epistaxis Treatment Options: Literature Review

Epistaxis means bleeding from nostrils, nasal cavity or nasopharynx. To summarize the available epistaxis treatment options. Methods: 61 articles published in the last 20 years were included. Duplicate records, irrelevant and inaccessible ones were excluded.  Epistaxis can be treated with first aid measures such as external pressure and ice packing and applying topical agents, e.g. oxymetazoline that stops 65-75% of nosebleeds in A&E. Also, with electrocautery which is more effective and has fewer recurrences (14.5% vs. 35.1%) than chemical cauterization and applying tranexamic acid that promotes hemostasis in 78% of patients, versus 35% and 31% respectively in patients treated with oxymetazoline and nasal packing. Furthermore, nasal packing can be applied with non-absorbable materials, e.g. petroleum jelly, BIPP gauze, PVA nasal tampons (Merocel), Foley catheter, balloons (Rapid-Rhino), absorbable materials, e.g. nasal tampon (Nasopore), and with newer hemostatic materials which are more effective and with fewer complications, e.g. hemostatic gauzes (Surgicel), thrombin matrix (Floseal), gelatin sponge (Spongostan) and fibrin glue. Moreover, epistaxis can be achieved with endoscopic ligation of arteries, mainly SPA, which is more effective than conventional nasal packing (97% vs. 62%), and with endoscopic cauterization which is more effective than ligation. Finally, for intractable cases embolization can be applied using gelatin sponge, foam, PVA and coils with 80% success rate and comparable efficacy and complications to surgical methods. Epistaxis can be dealt with various methods depending on patient's history and available resources. Newer hemostatic agents in combination with endoscopic methods have advantages over traditional methods.

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.

[Epistaxis and anticoagulation therapy: an analysis based on health insurance data from Lower Saxony]

Hintergrund

Die Epistaxis ist ein häufiges Symptom in der Arztpraxis und assoziiert mit verschiedenen Komorbiditäten und Medikamenten, insbesondere Antikoagulanzien. Trotz ihrer Alltäglichkeit gibt es nur wenige Daten zur Häufigkeit ihres Auftretens und möglichen Risikofaktoren.

Methoden

Die Studie untersuchte anhand einer großen Patientenpopulation (AOK Niedersachsen) über 10 Jahre (2007–2016) die Versorgung von Epistaxis in Niedersachsen. Alter bei Diagnose, Begleitmedikation und Komorbiditäten wurden analysiert und die Prävalenz dargestellt.

Ergebnisse

162.167 Versicherte der AOK Niedersachen wurden zwischen 2007 und 2016 aufgrund einer Epistaxis in 308.947 Fällen ärztlich vorstellig. Die meisten Patienten wurden ausschließlich ambulant behandelt (96,6 %). Über den Studienzeitraum stieg die Prävalenz um 21 % (Anstieg von 8,7 auf 9,3 pro 1000 Versicherte/Jahr) bei stabiler Prävalenz für stationäre Vorstellungen (0,2 pro 1000 Versicherte/Jahr). Die höchsten Prävalenzen fanden sich bei Personen bis 20 und über 80 Jahre. In 17,5 % aller Epistaxisfälle wurden Antithrombotika erfasst (9,5 % orale Antikoagulanzien). Über den Studienzeitraum konnte eine erhöhte Verschreibung von Antikoagulanzien (7,7 % in 2007 auf 11,8 % in 2016, insbesondere NOAK) dokumentiert werden.

Schlussfolgerung

Neben der arteriellen Hypertonie, dem männlichen Geschlecht sowie der typischen Altersverteilung bestand auch häufig eine Medikation mit Antikoagulanzien. Über den untersuchten Zeitraum zeigte sich eine Zunahme von Epistaxisfällen bei gleichzeitig ansteigender Verschreibungshäufigkeit von NOAK, nicht jedoch von schweren hospitalisationsbedürftigen Epistaxisfällen. Eine abschließende Beurteilung hinsichtlich eines möglichen kausalen Zusammenhangs muss in weiteren Studien untersucht werden.

Sudden nasal bleeding and brodifacoum: A case of accidental exposure or attempted homicide?

A 50-year-old man was admitted to the emergency department with abrupt massive epistaxis. An accurate anamnesis and physical evaluation could not reveal any other anomalies, while coagulation tests showed potentially life threatening prolonged prothrombin time, with activated partial thromboplastin and thrombin time, with fibrinogen and antithrombin III within limits. Despite the prompt pharmacological and compressive local treatment, bleeding continued and the patient was therefore hospitalized. Highly specific coagulation and toxicological testing-among others high-performance liquid chromatography assessment on plasma-were performed, leading to the unexpected identification of brodifacoum. Police and criminal justice authorities revealed the source of exposure to brodifacoum after several months of investigation, residing in his everyday life. Brodifacoum is a long-lasting anticoagulant, acting as a vitamin K antagonist, and belongs to the family of superwarfarins. Brodifacoum use is authorized as rodenticide in many countries worldwide, but has been reported as cause of severe coagulopathies in humans, both intentional or involuntary, even consumed as a contaminant of herbal drugs, such as cannabis. The original contribution of this case to the knowledges of human brodifacoum intoxication resides in the multidisciplinary approach and the collaborative interplay of clinical and toxicology experts as well as judicial authorities.