Epistaxis In A Child – Important Points in History

Epistaxis which is defined as bleeding from the nose is a common complain seen in children but usually the cause is not serious. A mother or the witness may be alarmed by the symptom and a child presenting with epistaxis needs to be asked following important questions in the history :

1. How old is the patient ?
Nose bleeds are unusual in very young children. In adolescent boys , juvenile nasopharyngeal angiofibroma is a rare benign, highly vascular neoplasm of the nasopharynx that can cause significant bleeding.

2. Was there any trauma to the nose ?
Allergic rhinitis can cause itching and subsequent rubbing of the nose , traumatizing the mucosa. Prior trauma from a direct blow on the nose may cause septal injury and bleeding. A dry environment causes crusting and young children may be prone to picking the nose , irritating septal mucosa. Unilateral foul or purulent discharge suggests a foreign body. In hospitalized patient, indwelling nasal tubes or suction trauma may injure mucosa and promote bleeding.

3. What medications has the patient taken ? Use of NSAIDs promotes bleeding, particularly in children with undiagnosed coagulopathy. Antihistamines may thicken secretions and causes drying and cracking of mucosa. Nasal sprays , particularly those not in an aqueous vehicle or that rely on propellants can traumatize mucosa. patients should be instructed on proper way to spray nasal medications, directing stream away from septum. Herbal or alternative medicine may be associated with bleeding.

4. Is there a history of recent surgeries ?
Procedures requiring nasal intubation can injure mucosa. Adenoidectomy, sinus surgery and repair of nasal fracture among other procedures all carry a small risk of postoperative bleeding.

5. History of bleeding problems ?
Many children have never been surgically challenged therefore it is important to seek information suggesting coagulopathy e.g usnusal or prolonged bleeding with circumcision, umbilical cord separation or dental extraction; unusual bruising with play or immunizations; history of unusal or large bruises in muscles or joints or any family history of bleeding problems.

6. Any systemic illness ?
Renal and hepatic diseases are associated with bleeding problems. Also there may be a possibility of hematological malignancy.

7. Is bleeding unilateral ?
Most bleeding occurs from the anterior septal vessels and may be unilateral or switch from side to side.

8. Is there any blood in the mouth ?
Consider posterior epistaxis if blood is seen entering the posterior orophayrnx when child has not been lying down.

After this detailed history a proper examination and relevant diagnostic workup is needed to reach the final diagnosis and cause of the nasal bleeding.