What is the appropriate workup for a pediatric epistaxis (nosebleed)?

From the Guidelines

The workup for pediatric nosebleeds should begin with a thorough history and physical examination, focusing on determining if the nosebleed is anterior or posterior, and considering the patient's age, with children under 3 years typically not requiring evaluation 1. The initial assessment should include questions about frequency, duration, severity, associated symptoms, trauma, foreign bodies, medication use, and family history of bleeding disorders.

• The physical examination should include vital signs, assessment of hemodynamic stability, visualization of the nasal cavity, and examination for signs of systemic disease.
• For most uncomplicated anterior nosebleeds, direct pressure by pinching the soft part of the nose for 10-15 minutes is the first-line treatment, with patients sitting upright, leaning slightly forward, and breathing through the mouth 1.
• If bleeding persists, chemical cautery with silver nitrate can be considered, but only after identifying the bleeding site, and topical vasoconstrictors like oxymetazoline may help temporarily 1.
• Nasal packing with absorbable materials like Surgicel or Gelfoam can be used if other measures fail, and laboratory testing is not routinely needed for isolated, easily controlled nosebleeds but should be considered for recurrent, severe, or bilateral episodes 1.
• Imaging studies are rarely needed unless there's suspicion of a mass, foreign body, or structural abnormality, and referral to an otolaryngologist is warranted for posterior bleeds, recurrent episodes, suspicion of underlying pathology, or failed initial management 1.
• It is essential to consider the possibility of nasal foreign bodies, especially in children, as delay in diagnosis can result in morbidity, including nasal infection, sinusitis, and nasal septal perforations or synechiae 1.
• Nasal endoscopy may be indicated to exclude foreign bodies or to evaluate for intranasal pathology, particularly if bleeding was unusually difficult to control or if clinical symptoms or signs exist alerting the clinician to additional bleeding sites 1.

From the Research

Pediatric Nosebleed Workup

• The workup for pediatric nosebleeds typically involves an assessment of vital signs, mental status, and airway patency 2.
• Compressive therapy is often the first step in controlling anterior epistaxis, and may be supplemented with oxymetazoline nasal spray or application of cotton soaked in oxymetazoline or epinephrine 1:1,000 2.
• Directive nasal cautery, typically using silver nitrate, can be used to control localized continued bleeding or prominent vessels that are the suspected bleeding source 2.
• Topical therapy, such as tranexamic acid, may also be effective in achieving hemostasis in patients with epistaxis 3, 4.
• However, the evidence for the use of tranexamic acid in pediatric patients is limited, and most studies have focused on adult populations 3, 5, 4.

Treatment Options

• Oxymetazoline has been shown to be effective in achieving hemostasis in patients with epistaxis, and may be superior to tranexamic acid in some cases 5, 6.
• Tranexamic acid, on the other hand, has been shown to reduce the risk of re-bleeding in patients with epistaxis, although the evidence is primarily based on adult studies 3.
• The choice of treatment will depend on the individual patient's needs and the severity of the nosebleed.

Considerations

• Posterior epistaxis is more likely to require hospitalization and may need nasal packing, which can be associated with pain and a risk of aspiration if dislodged 2.
• Patients with posterior packing often require referral to otolaryngology or the emergency department for definitive treatments 2.
• Further research is needed to determine the most effective treatment strategies for pediatric nosebleeds, particularly in terms of the use of tranexamic acid and other topical therapies 3, 5, 4.