INTRODUCTION — Epistaxis is common in children. Childhood nosebleeds are rarely severe and seldom require hospital admission [1]. Nonetheless, frequent minor nosebleeds can be both bothersome and alarming for parents and children.
The epidemiology and etiology of epistaxis in children will be reviewed here. The evaluation and management of epistaxis in children are discussed separately. (See "Evaluation of epistaxis in children" and "Management of epistaxis in children".)
EPIDEMIOLOGY — There is limited evidence regarding the prevalence of nosebleeds in children. One 1979 study found that 30 percent of children younger than 5 years and 56 percent of children aged 6 to 10 years had had at least one nosebleed [2]. The incidence of epistaxis declines in adulthood, but approximately one-half of all adults with epistaxis had nosebleeds during childhood [3]. Epistaxis is rare in children younger than 2 years (approximately 1 per 10,000) and should prompt consideration of trauma (intentional or unintentional) or serious illness (eg, thrombocytopenia) [4-6]. Some pediatric healthcare providers believe that when a young baby bleeds from the nose, or is reported to have had a nosebleed, that child abuse must be considered [7,8].
Epistaxis that occurs in children younger than 10 years usually is mild and originates in the anterior nose, whereas epistaxis that occurs in individuals older than 50 years is more likely to be severe and to originate posteriorly [9].
Data from the National Hospital Ambulatory Medical Care Survey indicate that epistaxis accounted for <1 percent of all emergency department visits between 1992 and 2001 [10]. Overall, there were approximately two emergency department visits for epistaxis per 1000 population annually. The age-related frequency was bimodal with one peak in individuals younger than 10 years (4 per 1000 population) and a second peak in those 70 to 79 years.
An increased incidence of epistaxis occurs during hot or cold weather and when ambient humidity is low, all of which make the nasal septal mucosa dry and friable, and predisposed to bleeding, even with minor trauma as may occur with nose rubbing, blowing, or sneezing [10-12]. Increased atmospheric pollutant concentrations (in the form of airborne particulate matter and atmospheric ozone) also can irritate the nasal respiratory epithelium, leading to increased incidence of epistaxis [13].
ANATOMY — The nose is a highly vascular structure [14]. These qualities enable the nose to filter, humidify, and warm inhaled air, but also predispose it to bleeding.
One of the most vascular areas of the nose is Kiesselbach's plexus in the anterior nasal septum (figure 1). Kiesselbach's plexus (also called Little's area) is formed by the anastomosis of terminal vessels from the internal and external carotid arteries. Specifically, the septal branch of the anterior ethmoidal artery; the lateral nasal branch of the sphenopalatine artery; and the septal branch of the superior labial branch of the facial artery all end in Kiesselbach's plexus (figure 1). In addition, the branches of the sphenopalatine artery supply the posterolateral wall and posterior choana; these vessels are the most likely source of posterior nosebleeds.
PATHOPHYSIOLOGY — The nasal mucosa provides little anatomic support or protection for the underlying blood vessels. Any factors that cause congestion of the nasal vessels, or drying or irritation of the nasal mucosa, increase the likelihood of bleeding.
ETIOLOGY
Overview — Nosebleeds in children have a variety of etiologies, ranging from self-limited mucosal irritation to life-threatening neoplasms (table 1). Common causes of nosebleeds in children include mucosal dryness, trauma, foreign body, and rhinitis (allergic, infectious, or related to mucosal irritation). Less common, but important causes of nosebleeds to remember include bleeding disorders and other systemic diseases, tumors, and post-traumatic pseudoaneurysm of the internal carotid artery or carotid-cavernous sinus fistulae.
Several classification schemes have been used to categorize nosebleeds. One categorizes the bleeding according to site: anterior versus posterior. Anterior nosebleeds, usually arising from Kiesselbach's plexus (figure 1), are most common (accounting for approximately 90 percent of nosebleeds in children) and are almost always self-limited [9]. Anterior nosebleeds usually result from mucosal dryness, trauma, or irritation, although many cases are idiopathic.
Posterior nose bleeds are unusual in children and usually due to significant nasal trauma. Posterior bleeds usually arise from the posterolateral branches of the sphenopalatine artery (figure 1).
Another classification scheme considers whether bleeding arises from local or systemic conditions (table 1). Local causes of bleeding, which predominate in children, include trauma, mucosal irritation or drying, anatomic abnormalities, and nasopharyngeal masses.
Systemic causes of epistaxis include bleeding disorders (eg, inherited or acquired factor deficiencies, platelet disorders, or disorders of vessels), medications, neoplasms, inflammatory disorders, and hypertension.
Local causes
Trauma
●Nose picking – In children, trauma to the septum due to nose picking is common, and parents and patients should be routinely queried about the frequency of nose picking when evaluating a child for nosebleeds. (See "Evaluation of epistaxis in children".)
●Facial and head trauma – Blunt facial trauma leading to nasal fractures are due most commonly to auto accidents, sports injuries, intended injuries and home injuries and may result in significant bleeding [15]. The anterior ethmoidal artery, which enters the nasal cavity through the fragile lamina papyracea of the ethmoid bone, can be lacerated by bone fragments in mid-face trauma. Massive epistaxis after head injury is suggestive of internal carotid pseudoaneurysm [16], but this entity also may present initially with mild epistaxis or with recurrent epistaxis that does not respond to conservative management and may occur weeks after the injury [16-21]. Pseudoaneurysm of the cervical internal carotid artery has also been reported in a child after a deep neck space infection [22]. Carotid-cavernous sinus fistulae can also result from blunt head trauma and can lead to intracranial hemorrhage, blindness, cranial nerve palsy and stroke [23]. Child abuse may also be a cause of epistaxis, particularly in the child younger than 2 years of age [7,24,25].
●Foreign body – When epistaxis is unilateral and accompanied by foul-smelling nasal drainage, a foreign body must be presumed present until proven otherwise [26]. The foreign body can cause mucosal irritation, laceration, and/or ulceration. If the foreign body has been in the nose for only a short time (minutes to hours), its attempted removal by the patient or parent may be the cause of the nosebleed [27]. If the foreign body has been in place for several days, the fetid nasal drainage will commonly be blood-stained. Nasal foreign bodies most frequently are found in the floor of the nose just below the inferior turbinate [28]. Common nasal foreign bodies include beads, rubber erasers, paper wads, pebbles, marbles, beans, peas, nuts, sponges, and chalk.
Button batteries are a less common but more serious nasal foreign body which may present with epistaxis. These require immediate removal to prevent permanent septal perforation. (See "Diagnosis and management of intranasal foreign bodies", section on 'Timing'.)
●Postoperative – Postoperative epistaxis may occur after adenoidectomy, sinus surgery, septal surgery, rhinoplasty, and/or turbinectomy [29]. Postoperative epistaxis can occur up to two weeks post-operatively and in most cases will resolve spontaneously. Otolaryngology intervention occasionally is needed to control the bleeding. (See "Management of epistaxis in children".)
●Nasotracheal intubation and nasogastric tube placement – Nasotracheal intubation and nasogastric tube placement may tear the nasal mucosa.
●Barotrauma – Barotrauma, as occurs with scuba diving, may contribute to epistaxis in patients with upper respiratory infection or allergy. (See "Complications of SCUBA diving", section on 'Sinus barotrauma'.)
Mucosal irritation — Irritation of the nasal mucosa may be caused by a number of factors, including changes in humidity, allergies, viral or bacterial upper respiratory infections, chronic rhinitis with frequent nose blowing and increased vascularity and friability of the nasal mucosa, chronic usage of nasal sprays or drying agents, intentional or unintentional exposure to irritant inhalants or substances of abuse (eg, tobacco smoke, cocaine, heroin, volatile inhalants) [30].
●Allergic rhinitis – Allergic rhinitis is another cause of nosebleeds in children; sneezing, nose rubbing, and treatment with nasal corticosteroids may exacerbate or precipitate epistaxis in these children [30-32]. One study found that children with allergic rhinitis (defined by nasal symptoms and a positive skin test to common inhalant allergens), had more nosebleeds than their peers without allergic rhinitis (20 percent compared with: 10 percent in those with only nasal symptoms; 3 percent in those with only a positive skin test; and 2 percent in those with neither nasal symptoms nor a positive skin test) [33]. (See "Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis" and "Allergic rhinitis: Clinical manifestations, epidemiology, and diagnosis" and "Pharmacotherapy of allergic rhinitis".)
●Infection – Viral and bacterial upper respiratory infections, including sinusitis, and systemic illnesses that are accompanied by nasal congestion result in inflammation of the nasal mucosa, with increased likelihood of bleeding. Nasal colonization with Staphylococcus aureus appears to play a prominent role in leading to the mucosal irritation associated with childhood epistaxis. In one study, 24 of 42 (57 percent) children with epistaxis had S. aureus cultured from their anterior nasal cavities, compared to 6 of 19 (24 percent) children with no history of nasal bleeding [34].
Local skin infections (eg, staphylococcal furuncles), also may cause epistaxis. Nasal tuberculosis is a rare, chronic, granulomatous infection that can cause nasal obstruction and epistaxis [35]. Epistaxis is one of the most common spontaneous bleeding features of dengue hemorrhagic fever in children, occurring in 25 percent of affected patients [36-38].
Tumors — Neoplasms of the nasal cavity usually cause unilateral symptoms such as intermittent epistaxis, foul discharge, nasal obstruction, or change in smell sensation. Severe bleeding is uncommon, except in patients with vascular tumors such as juvenile nasopharyngeal angiofibroma.
Benign localized neoplasms that can cause epistaxis in children include juvenile nasopharyngeal angiofibromas, hemangiomas, and pyogenic granulomas, and inverting papillomas [31]. Malignant neoplasms of the nose, sinuses, or nasopharynx are rare but important causes of epistaxis in children. They include rhabdomyosarcoma, mesenchymal chondrosarcoma, non-Hodgkin’s lymphoma, and nasopharyngeal carcinoma [39-42].
●Juvenile nasopharyngeal angiofibroma – Juvenile nasopharyngeal angiofibroma is a histologically benign tumor that is markedly vascular and can cause severe epistaxis (image 1) [43]. It occurs primarily in adolescent males [44]. The lesions arise in the lateral nasopharynx and are hormonally sensitive [44]. Their blood supply is derived from the internal maxillary artery. Although juvenile nasopharyngeal angiofibroma is a benign tumor, it can cause severe problems through local invasion of adjacent structures.
The clinical features of juvenile nasopharyngeal angiofibroma were described in a review of 120 cases from the Mayo Clinic [45]. The mean patient age was 15 years (range 7 to 29 years). The triad of nasal obstruction, epistaxis, and nasal drainage was the most common combination of signs and symptoms; serous otitis media and diminished hearing also may be present [44-46]. The tumors may bulge into the nasal cavity, but often require examination of the nasopharynx to be identified [45].
The diagnosis is usually confirmed by computed tomography or magnetic resonance imaging with contrast that shows a vascular enhancing nasopharyngeal mass with involvement and widening of the pterygomaxillary fissure [45,47]. Intranasal biopsy of these lesions should be avoided because of the risk of life-threatening bleeding [48].
●Lobular capillary hemangioma (Pyogenic granuloma) – Lobular capillary hemangioma, also known as Pyogenic granuloma or granuloma telangiectaticum, is a benign tumor associated with capillary proliferation. Pyogenic granuloma often, but not always, occurs after a history of trauma [49,50]. (See "Pyogenic granuloma (lobular capillary hemangioma)".)
●Rhabdomyosarcoma – Rhabdomyosarcoma may present with episodic epistaxis. Parameningeal rhabdomyosarcoma can cause nasal, aural, or sinus obstruction with or without mucopurulent or bloody nasal discharge. Other signs and symptoms include middle ear effusion, deep facial pain, and cranial neuropathies, such as sixth nerve palsy [42]. (See "Rhabdomyosarcoma in childhood and adolescence: Epidemiology, pathology, and molecular pathogenesis".)
●Nasopharyngeal carcinoma – Nasopharyngeal carcinoma in children may present with epistaxis, rhinitis, headache, torticollis, trismus, unilateral cervical lymphadenopathy, retrobulbar or ear pain, hearing loss and/or neck pain [41]. (See "Epidemiology, etiology, and diagnosis of nasopharyngeal carcinoma".)
●Inverting papillomas – Inverting (or inverted) papillomas, which grow with an inversion of the epithelium into the connective tissue stroma, are rare in children. They manifest as unilateral red, polypoid masses attached to the lateral nasal wall, middle turbinate, the septum, or the nasal vestibule. Approximately two percent may undergo malignant transformation, which typically occurs in adulthood [51].
Other — Increased nasal venous pressure secondary to paroxysmal coughing as occurs in pertussis or cystic fibrosis occasionally may cause nosebleeds.
Systemic causes — Systemic causes of nosebleeds in children include bleeding diathesis, disorders of blood vessels, medications, neoplasms, inflammatory disorders, and hypertension. Epistaxis is rarely the only manifestation of systemic disease. Systemic disease should be considered in children with constitutional signs and symptoms, severe or recurrent nosebleeds, and a family history of bleeding disorder or other heritable systemic disease.
Bleeding disorders — Bleeding disorders must be considered in children with recurrent, frequent, spontaneous epistaxis and those with a prolonged, difficult-to-control nosebleed [52-54]. Bleeding disorders encompass inherited and acquired disorders of coagulation, platelet disorders, and disorders of blood vessels. (See "Approach to the child with bleeding symptoms".)
One study of 178 children referred to a pediatric hematologist for recurrent epistaxis found 59 children (33 percent) had a bleeding disorder [52]. Of these 59 children, von Willebrand disease was found in 33 (56 percent), platelet aggregation disorders in 10, thrombocytopenia in 7, mild factor VIII deficiency in 3, Bernard-Soulier syndrome in 2, factor VII deficiency in 1, factor IX deficiency in 1, factor XI deficiency in 1, and coagulation inhibitor in 1. Of the historic data collected, only a family history of bleeding was found to be predictive of a bleeding disorder. Children with bleeding disorders had a longer median partial thromboplastin time (PTT) of 33.1 versus 30.5 seconds.
In another prospective study, 36 children with five or more nosebleeds per year and 35 control children who were admitted for minor elective surgery were evaluated for mild bleeding disorders [54]. Two children with epistaxis were found to have type I von Willebrand disease.
Over 50 percent of children with von Willebrand disease will experience epistaxis. The frequency of bleeding is higher in von Willebrand types 2 and 3 than in type 1 and is associated with the von Willebrand factor levels [55].
People with blood group O have a lower expression of von Willebrand factor and thus a relative bleeding tendency. A retrospective study of White patients with epistaxis admitted to hospitals in the United Kingdom over a six-year period revealed a higher prevalence of blood group O in patients admitted with epistaxis compared with controls. This study suggests that blood group O may be a risk factor for epistaxis [56]. (See "Clinical presentation and diagnosis of von Willebrand disease".)
●Hereditary hemorrhagic telangiectasia – Epistaxis is the most common presenting symptom among patients with hereditary hemorrhagic telangiectasia (HHT, also known as Osler-Weber-Rendu disease) [57,58]. HHT is an autosomal dominant condition, characterized by widespread mucocutaneous telangiectasias (picture 1). Ninety percent of patients with HHT present with epistaxis by age 12 years; bleeding may be mild [58]. Epistaxis in patients with HHT progressively worsens with age and can be difficult to control; the friable lesions appear to bleed more with treatment than without. A high index of suspicion is necessary to make the diagnosis, which should be considered on the basis of family and clinical history in patients with multiple mucocutaneous telangiectasias [59]. The approach to the diagnosis of HHT, including recommendations for genetic testing, is provided separately. (See "Clinical manifestations and diagnosis of hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)".)
Medications — Nosebleeds may be more frequent, or more difficult to control in children taking certain medications, particularly antiinflammatory agents (aspirin, ibuprofen) and anticoagulants (eg, those with complex congenital heart disease or thromboembolic disease). Epistaxis related to acquired factor XIII deficiency, and von Willebrand disease have been reported in children receiving treatment with valproic acid [60,61]. In addition, anticoagulating agents (warfarins and "superwarfarins") are contained in a number of rodenticides, which may be unintentionally ingested by children [62,63].
Inflammatory disorders — Bloody nasal discharge may occur in various systemic inflammatory disorders, such as granulomatosis with polyangiitis (GPA) [60,64]. The most common presenting symptoms of GPA include persistent rhinorrhea, purulent/bloody nasal discharge, oral and/or nasal ulcers, polyarthralgias, myalgias, or pain. (See "Granulomatosis with polyangiitis and microscopic polyangiitis: Clinical manifestations and diagnosis".)
Hypertension — Primary hypertension rarely results in epistaxis in children. Secondary causes of hypertension that may result in epistaxis include renal disease and systemic corticosteroid therapy.
Recurrent epistaxis — In children and adolescents, recurrent nosebleeds usually are related to chronic irritation of the nasal mucosa as may occur from dry air, chronic use of nasal medication for allergic rhinitis, recurrent upper respiratory infection, or inhalation of substances of abuse [31,65]. However, recurrent epistaxis also may be the presenting symptom of a bleeding disorder, hereditary hemorrhagic telangiectasia, nasopharyngeal tumor, or post-traumatic pseudoaneurysm of the internal carotid artery. These disorders must be considered in the appropriate clinical setting (eg, positive family history, mucocutaneous telangiectasias, head trauma, nasopharyngeal mass head trauma). (See "Evaluation of epistaxis in children".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Nosebleeds (The Basics)")
●Beyond the Basics topic (see "Patient education: Nosebleeds (epistaxis) (Beyond the Basics)")
SUMMARY
●Nosebleeds are common in children. Approximately 30 percent of children younger than 5 years and over half of those aged 6 to 10 years have had at least one nosebleed. Nosebleeds are more common during cold weather and when ambient humidity is low. (See 'Epidemiology' above.)
●Most nosebleeds in children originate from the anterior nasal septum, in an area known as Kiesselbach's plexus, which is formed by the anastomosis of terminal vessels from the internal and external carotid arteries (figure 1). (See 'Anatomy' above.)
●Any factors that cause congestion of the nasal vessels or drying or irritation of the nasal mucosa increase the likelihood of nosebleeds. (See 'Pathophysiology' above.)
●Common causes of nosebleeds in children include trauma, dry air, nasal foreign body, and rhinitis (allergic, infectious, or related to mucosal irritation). Nasal colonization with Staphylococcus aureus is commonly found in children with recurrent epistaxis. Less common, but important, causes of nosebleeds to remember include a button battery foreign body, bleeding disorders and other systemic diseases, tumors, and post-traumatic anomalies of the internal carotid artery. (See 'Overview' above.)
●Local, systemic, and recurrent causes of pediatric epistaxis are listed in the table (table 1). (See 'Local causes' above and 'Systemic causes' above and 'Recurrent epistaxis' above.)
