What is the workup and treatment for an 11-year-old male with recurrent epistaxis (nosebleeds)?

Workup and Treatment for Recurrent Epistaxis in an 11-Year-Old Male

For an 11-year-old male with recurrent epistaxis, the clinician should perform anterior rhinoscopy to identify the source of bleeding, followed by appropriate treatment including nasal compression, topical vasoconstrictors, and nasal moisturization, with referral for nasal endoscopy if bleeding persists despite treatment. 1, 2

Initial Assessment

History

• Frequency and severity of nosebleeds
• Unilateral vs bilateral bleeding
• Triggers (digital trauma, dry air, allergies)
• Family history of bleeding disorders
• Use of medications that may affect bleeding 1

Physical Examination

1. Anterior rhinoscopy is essential to identify the bleeding source after removal of any blood clots 1

   • Most pediatric epistaxis originates from Kiesselbach's plexus in the anterior nasal septum 3
   • Look for signs of digital trauma, crusting, or foreign bodies

2. Vital signs to assess for hemodynamic stability

   • Blood pressure
   • Heart rate
   • Respiratory rate

First-Line Treatment

1. Nasal compression

   • Apply firm, sustained compression to the lower third of the nose for at least 5 minutes 2
   • Patient should breathe through mouth and spit out any blood
   • This simple measure controls most anterior nosebleeds in children

2. Topical vasoconstrictors

   • Oxymetazoline nasal spray has a 65% success rate in controlling epistaxis 2
   • Apply with cotton pledget to the bleeding site

3. Chemical cautery

   • Silver nitrate cautery for visible anterior bleeding sites
   • 75% silver nitrate is preferable to 95% as it causes less pain while being more effective 4

Prevention and Home Care

1. Nasal moisturization

   • Apply nasal saline gel or spray 1-3 times daily 2
   • Use a humidifier at bedside to maintain a humid environment 2

2. Behavioral modifications

   • Avoid digital trauma (nose picking) 2
   • Avoid vigorous nose blowing 2
   • Teach proper technique for managing minor bleeds at home

When to Escalate Care

Indications for Nasal Endoscopy

• Refer for nasal endoscopy if the patient has: 1
  • Recurrent nasal bleeding despite prior treatment with packing or cautery
  • Recurrent unilateral nasal bleeding (to rule out juvenile nasopharyngeal angiofibroma)
  • Bleeding that is difficult to control
  • Concern for unrecognized pathology contributing to epistaxis

Indications for Laboratory Testing

• Persistent or severe epistaxis
• Family history of bleeding disorders
• Bleeding from multiple sites
• Consider:
  • Complete blood count
  • Coagulation studies (PT/INR, PTT)
  • Von Willebrand factor testing if indicated 1

Advanced Treatment Options

1. Resorbable nasal packing for bleeding not controlled by compression or cautery 2

   • Patient education about type of packing, removal timing, and post-procedure care is essential 1

2. Surgical options for persistent/recurrent bleeding:

   • Endoscopic arterial ligation (97% success rate)
   • Endovascular embolization (~80% success rate) 2

Follow-Up Care

• Schedule follow-up within 3-5 days to assess for recurrence 2
• Provide clear instructions on when to seek emergency care:
  • Bleeding lasting >30 minutes
  • Signs of hypovolemia
  • Severe or uncontrollable bleeding 2

Important Considerations

• Most pediatric epistaxis cases (94%) are self-limiting or respond to simple measures 3
• Recurrent epistaxis in children is usually idiopathic and anterior in location 4
• Certain medications can induce epistaxis, though this is less common in children 5
• Unilateral recurrent epistaxis in adolescent males should raise suspicion for juvenile nasopharyngeal angiofibroma 1