What are the common and uncommon causes of pediatric recurring epistaxis (nosebleeds) and how are they diagnosed?

Pediatric Recurrent Epistaxis: Causes and Diagnostic Approach

For children with recurrent epistaxis, begin with anterior rhinoscopy to identify local causes, then perform nasal endoscopy for recurrent unilateral bleeding or bleeding despite prior treatment, and obtain coagulation studies (CBC, PT, PTT) with hematology referral when there is a positive family history of bleeding or severe/bilateral recurrent episodes. 1, 2

Common Causes

Local/Anatomic Factors

• Digital trauma and nasal mucosal irritation are the most frequent causes in otherwise healthy children, typically affecting Kiesselbach's plexus on the anterior nasal septum 1, 3
• Nasal foreign bodies present with unilateral epistaxis, rhinorrhea, and foul smell in 7% of cases; bleeding occurs in 30% of foreign body cases either from the object itself or during removal 1
• Nasal septal deviation can contribute to recurrent bleeding through altered airflow and mucosal trauma 1
• Rhinitis and nasal inflammation causing crusting and mucosal fragility 3

Systemic Causes

• Coagulopathies are diagnosed in approximately one-third (33%) of children referred for recurrent epistaxis evaluation 2
  • Von Willebrand disease is the most common, found in 33 of 178 children (18.5%) in one large series 2
  • Platelet aggregation disorders 2, 4
  • Thrombocytopenia 2
  • Mild factor deficiencies (VIII, VII, IX, XI) 2

Uncommon but Critical Causes

Life-Threatening Conditions Requiring Urgent Diagnosis

• Juvenile nasopharyngeal angiofibroma occurs in adolescent males, presenting with unilateral, unprovoked, profuse epistaxis in 60-76% of cases; examination of the posterior nasal cavity and nasopharynx is mandatory in adolescent males with these symptoms 1
• Nasal malignancies present with unilateral nasal obstruction (66.7%) and epistaxis (55%); these may not be visible on anterior rhinoscopy and delayed diagnosis can cause life-threatening bleeding 1
• Disk battery foreign bodies can cause tissue necrosis and septal perforation in as little as 3 hours 1

Hereditary Hemorrhagic Telangiectasia (HHT)

• Assess for nasal and oral mucosal telangiectasias in children with recurrent bilateral nosebleeds or positive family history 1
• HHT occurs in 1 in 5,000-18,000 individuals and is often underdiagnosed or diagnosed late 1
• Nosebleeds are the main symptom in >90% of HHT patients 1

Diagnostic Testing Algorithm

Initial Evaluation

Perform anterior rhinoscopy on all patients after removing any blood clot to identify the bleeding source 1

• Use an otoscope in young children for visualization 1
• Look for septal deviation, perforation, telangiectasias, masses, and foreign bodies 1

Indications for Nasal Endoscopy

Perform or refer for nasal endoscopy when: 1

• Recurrent nasal bleeding despite prior treatment with packing or cautery
• Recurrent unilateral nasal bleeding
• Difficult to control epistaxis
• Concern for unrecognized pathology
• Adolescent males with unilateral, profuse bleeding (to exclude juvenile nasopharyngeal angiofibroma)

Nasal endoscopy localizes the bleeding site in 87-93% of cases and can identify posterior sources not visible on anterior rhinoscopy 1

Laboratory Testing for Coagulopathy

Order screening tests when: 2, 4, 5

• Positive family history of bleeding (strongest predictor, p=0.023) 2
• Severe or bilateral recurrent epistaxis 4
• Multiple emergency room visits for epistaxis 5
• Younger age at presentation 5
• Other bleeding symptoms (gingival bleeding, easy bruising, menorrhagia) 2

Initial laboratory panel: 2, 4, 5

• Complete blood count (CBC) with platelet count
• Prothrombin time (PT)
• Activated partial thromboplastin time (PTT)

Critical caveat: Standard coagulation studies (PT, PTT) only reveal 20% of bleeding disorders in children with recurrent epistaxis 5. A prolonged PTT is predictive (median 33.1 vs 30.5 seconds in those with coagulopathy, p=0.012) 2, but comprehensive hematology evaluation with specialized testing (von Willebrand factor antigen and ristocetin cofactor, factor VIII coagulant, platelet aggregation studies) is required to diagnose the majority of bleeding disorders 4, 5.

When to Refer to Hematology

Refer for comprehensive evaluation when: 2, 4, 5

• Abnormal screening coagulation studies
• Positive family history of bleeding
• Severe recurrent epistaxis requiring cauterization or surgery
• Clinical suspicion despite normal screening tests (10.6% of children with severe recurrent epistaxis have a bleeding disorder) 5

Key Clinical Pitfalls

Do not miss nasal foreign bodies in children with unilateral symptoms—delay in diagnosis causes morbidity including infection, sinusitis, and septal perforation, with disk batteries causing necrosis within 3 hours 1

Do not rely solely on PT/PTT screening—these tests miss 80% of bleeding disorders in children with recurrent epistaxis; comprehensive hematology evaluation is essential when clinical suspicion exists 5

Do not dismiss unilateral bleeding in adolescent males—always examine the posterior nasal cavity and nasopharynx to exclude juvenile nasopharyngeal angiofibroma, as delayed diagnosis can result in life-threatening bleeding 1