Paediatric epistaxis: diagnosis and management

Epistaxis in a Pediatric Outpatient Clinic: Could It be an Alarming Sign?

Introduction Epistaxis is a common presentation among children.

Objective To investigate the suitability of a simple tool of assessment for patients with epistaxis that could guide in subgrouping those with possible bleeding tendencies who may need further assessment.

Methods Children who presented to a tertiary outpatient clinic with epistaxis of an unknown cause were recruited. They underwent thorough clinical assessment and answered the pediatric bleeding questionnaire and the epistaxis severity score. All patients underwent complete blood count as well as coagulation profile, and confirmatory diagnostic tests were performed as needed.

Results Among the 30,043 patients who presented to the outpatient clinic over a year, 100 children had epistaxis, with an estimated annual frequency of 1 in 300. A total of 84% of the patients were younger than 12, and nearly half of these were younger than 6 years. Seventy-six patients had recurrent epistaxis, and 12 had systemic comorbidities. A significant higher percentage of patients presented with epistaxis in the hot months of the year. A total of 90% of the patients presented anterior bleeding, and the majority were treated with nasal compression only. Forty-three patients presented with epistaxis only; 37 of them were diagnosed as idiopathic epistaxis, and 6 had local causes. Fifty-seven patients presented with other bleeding manifestations, 47 of whom had a definite bleeding disorder and the other 10 had undiagnosed bleeding tendency. Those with other bleeding manifestations showed a higher frequency of positive family history of epistaxis; of being referred from a primary care physician; of having alarming low platelet count, and of presenting less seasonal variability. A bleeding score ≥ 2 showed significant value in suspecting an underlying systemic pathology as a cause of epistaxis.

Conclusion The pediatric bleeding questionnaire is a useful and simple tool in the identification of pediatric patients who need further diagnostic testing to detect any underlying bleeding tendency.

Use of Cryotherapy for Managing Epistaxis in the First Aid Setting: A Scoping Review

Epistaxis, or nosebleed, is bleeding from the nostril(s), nasal cavity, or nasopharynx. Anterior nasal bleeding is the most common location for spontaneous nontraumatic epistaxis and is commonly treated with manual compression to the nasal alae. Cryotherapy is also routinely recommended in conjunction with manual compression in the first aid and ED setting. We performed a scoping review on behalf of the International Liaison Committee on Resuscitation First Aid Task Force guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR). We searched Embase, Cochrane, and PubMed databases for published studies, without date restrictions, and we searched the gray literature using Google.com and Google Scholar. The websites of selected resuscitation councils were searched for guidelines relating to the management of epistaxis. References from included studies were hand-searched. Our published and gray literature search identified 1255 and 61,315 records, respectively. After removing duplicates and following selection criteria, we included 21 records from the published literature and 11 records from the gray literature. Our scoping review found that most of the published studies and website documents focused on managing nontraumatic epistaxis in the first aid setting. They provide recommendations for the use of cryotherapy based on expert opinion or indirect evidence extrapolated from cryotherapy-associated changes in nasal submucosal temperature, nasal blood flow, and nasal blood volume in healthy subjects (three studies). We did not identify any prospective, randomized trials comparing the efficacy of cryotherapy as an intervention for nontraumatic epistaxis in the first aid setting. The limited literature identified in this scoping review does not support the development of a systematic review but highlights the need for future research to better understand the role of cryotherapy in the first aid setting.

Evaluation of neutrophil/lymphocyte ratio and platelet/lymphocyte ratio in recurrent epistaxis in childhood: case controlled study

Introduction

the aim of this study was to investigate the possible relationship of neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) and routine hematological parameters with recurrent epistaxis in children.

Methods

İn this retrospective case-controlled study, 294 patients aged between 2 and 18 years who applied to the Tokat State Hopital Ear Nose Throat Clinic due to recurrent epistaxis between January 1^st 2013 and December 31^st December 2017 and 329 sex-and age-matched controls were investigated.

Results

NLR was 1.45±0.75 in the study group and the 1.35±0.7 in the control group. There was no significant difference between the groups (p>0.05). PLR values were found significantly (p<0.05) higher in the study group than in the control group (103,21±29.57 vs. 97,3±30.38). Red Blood Cell Distribution Width (RDW) values were found significantly (p<0.05) lower in the study group than in the control group (39,56±2,87 and 38,92±2,46).

Conclusion

the increase of PLR, an inflammatory marker, in epistaxis supports the effect of inflammatory factors in the etiology of epistaxis. However, more study in future is needed to support this.

Emergency Department care of childhood epistaxis

OBJECTIVE

The aim of this review is to determine an efficient and safe primary strategy care for paediatric epistaxis.

DATA SOURCES

We searched PubMed and Cochrane databases for studies referenced with key words 'epistaxis AND childhood'. This search yielded 32 research articles about primary care in childhood epistaxis (from 1989 to 2015). Bibliographic references found in these articles were also examined to identify pertinent literature. We compared our results to the specific management of adult epistaxis classically described in the literature.

RESULTS

Epistaxis is one of the most common reasons for referral of children to a hospital ENT outpatient department. The bleeding usually originates from the anterior septum, as opposed to adults. Crusting, digital trauma, foreign bodies and nasal colonisation with Staphylococcus aureus have been suggested as specific nosebleed factors in children. Rare aetiologies as juvenile nasopharyngeal angiofibroma appear later during adolescence. There are different modes of management of mild epistaxis, which begin with clearing out blood clots and bidigital compression. An intranasal topical local anaesthetic and decongestant can be used over 6 years of age. In case of active bleeding, chemical cauterisation is preferred to anterior packing and electric cauterisation but is only feasible if the bleeding site is clearly visible. In case of non-active bleeding in children, and in those with recurrent idiopathic epistaxis, antiseptic cream is easy to apply and can avoid 'acrobatic' cauterisation liable to cause further nasal cavity trauma.

CONCLUSIONS

Aetiologies and treatment vary with patient age and the existence or not of active bleeding at the time of the examination. Local treatments are usually easy to perform, but physicians have to ponder their indications depending on the possible complications in order to inform parents and to know paediatric epistaxis specificities.