What is the differential diagnosis and management for a 15-month-old child presenting with worsening symptoms (epistaxis)?

Differential Diagnosis of Epistaxis in a 15-Month-Old

In a 15-month-old child with epistaxis, the most common causes are digital trauma and nasal mucosal irritation affecting the anterior nasal septum, but you must systematically rule out nasal foreign bodies, coagulopathies, and anatomic abnormalities through targeted history and examination. 1

Primary Differential Considerations

Most Common Causes

• Digital trauma (nose picking) is the leading cause in otherwise healthy toddlers, typically affecting Kiesselbach's plexus on the anterior septum 1
• Nasal mucosal irritation from dry air, upper respiratory infections, or environmental irritants causes fragile, hyperemic mucosa that bleeds easily 2
• Viral upper respiratory infections produce congestion and inflammation that predispose to bleeding 2

Critical "Cannot Miss" Diagnoses

• Nasal foreign body presents with unilateral epistaxis, rhinorrhea, and foul smell in 7% of cases; bleeding occurs in 30% of foreign body cases 1

  • Disk battery foreign bodies are particularly dangerous, causing tissue necrosis and septal perforation in as little as 3 hours 1
  • This diagnosis requires high suspicion in any toddler with unilateral symptoms 1

• Coagulopathy or bleeding disorder should be suspected when there is:

  • Family history of bleeding disorders 1
  • Severe or bilateral recurrent episodes 1
  • Associated bruising, petechiae, or other bleeding manifestations 3
  • Immune thrombocytopenia (ITP) can present with mucosal bleeding including epistaxis in young children 3

Anatomic and Structural Causes

• Adenoidal hypertrophy is the most common acquired anatomic cause of nasal obstruction in infants and children, leading to mouth breathing and potential mucosal trauma 3
• Nasal septal deviation contributes to recurrent bleeding through altered airflow and mucosal trauma 1
• Laryngopharyngeal reflux can cause nasal congestion and inflammation in infants, particularly those with prematurity, neuromuscular disease, or cleft palate 3

Rare but Important Considerations

• Hereditary hemorrhagic telangiectasia (HHT) should be considered with recurrent bilateral nosebleeds or positive family history, though nasal telangiectasias may not be visible yet at 15 months 1, 4
• Nasal tumors are rare in this age group but can present with unilateral obstruction and bleeding 3, 1

Diagnostic Approach

Initial Assessment

• 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, as this is more practical than a nasal speculum at 15 months 1
• Look specifically for: septal deviation, perforation, telangiectasias, masses, and foreign bodies 1

When to Obtain Additional Testing

• Obtain coagulation studies with hematology referral when there is:

  • Positive family history of bleeding disorders 1
  • Severe or bilateral recurrent episodes 1
  • Associated bruising or petechiae suggesting ITP 3

• Nasal endoscopy is indicated for:

  • Recurrent unilateral bleeding 1
  • Bleeding despite prior treatment 1
  • Suspected foreign body not visible on anterior examination 1
  • Nasal endoscopy localizes the bleeding site in 87-93% of cases 1

Imaging Considerations

• Do NOT obtain imaging (CT or plain films) to distinguish acute bacterial sinusitis from viral URI, as they do not contribute to diagnosis 3
• Imaging is not necessary for uncomplicated epistaxis in children 3

Common Pitfalls to Avoid

• Failing to examine for nasal foreign bodies in any toddler with unilateral nasal symptoms—this is a critical miss that can lead to serious complications 1
• Overlooking coagulopathy when epistaxis is accompanied by other bleeding manifestations like petechiae or bruising 3
• Missing disk batteries, which require emergency removal due to rapid tissue destruction 1
• Not considering adenoidal hypertrophy as a contributing factor in this age group, as it is the most common anatomic cause of nasal obstruction in young children 3