What is the workup for a 7-year-old with increasing frequency of epistaxis (nosebleeds)?

From the Guidelines

The workup for a 7-year-old with increasing frequency of nosebleeds should begin with a thorough history and physical examination, focusing on identifying the bleeding site and assessing for underlying bleeding disorders, as recommended by the clinical practice guideline for nosebleed (epistaxis) executive summary 1. The history should include questions about the pattern of bleeding (frequency, duration, unilateral vs bilateral), associated symptoms, trauma history, medication use, and family history of bleeding disorders.

• The physical examination should focus on the nasal mucosa using a nasal speculum or otoscope to identify the bleeding site, typically in the anterior septum (Kiesselbach's plexus) 1.
• Initial management includes teaching proper nasal pressure application (pinching the soft part of the nose for 10-15 minutes while leaning forward), humidification with saline nasal spray 2-3 times daily, and petroleum jelly applied to the anterior septum twice daily.
• Laboratory testing is warranted if nosebleeds are severe, recurrent, or accompanied by other bleeding symptoms, and should include a complete blood count, prothrombin time, partial thromboplastin time, and possibly von Willebrand factor testing, as suggested by the clinical practice guideline for nosebleed (epistaxis) 1.
• For persistent bleeding, referral to an ENT specialist may be necessary for potential cauterization of the bleeding vessel. The clinician should document factors that increase the frequency or severity of bleeding for any patient with a nosebleed, including personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, or intranasal drug use 1. The clinician should treat patients with an identified site of bleeding with an appropriate intervention, which may include one or more of the following: topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents 1. The clinician should perform anterior rhinoscopy to identify a source of bleeding after removal of any blood clot (if present) for patients with nosebleeds, and consider nasal endoscopy to examine the nasal cavity and nasopharynx in patients with epistaxis that is difficult to control or when there is concern for unrecognized pathology 1.

From the Research

Workup for Increasing Frequency of Nosebleeds in a 7-year-old

• The clinical evaluation of bleeding and bruising in primary care, as discussed in 2, suggests that a patient history can help determine whether the bruising or bleeding is abnormal.
• A family history of bleeding problems may suggest a hereditary coagulation defect, which is especially important in children who may not have experienced a major bleeding episode, as noted in 3 and 2.
• Initial laboratory testing for a child with recurrent epistaxis may include a complete blood count, peripheral blood smear, prothrombin time (PT), and partial thromboplastin time (PTT), as mentioned in 2.
• According to 3, one-third of children presenting with recurrent epistaxis have a diagnosable coagulopathy, with von Willebrand disease being one of the most common diagnoses.
• The study in 4 suggests that routine coagulation screening of all patients with epistaxis is of little value and only adds to treatment costs and emergency room occupancy times, but coagulation studies are justified in patients with known coagulopathy or chronic liver disease.
• In cases where initial testing does not reveal an etiology in a patient with a high suspicion for a bleeding disorder, the patient should be referred to a hematologist for additional evaluation, as recommended in 2 and highlighted by the knowledge gaps identified in 5.

Laboratory Tests

• Complete blood count (CBC) to check for anemia or thrombocytopenia, as mentioned in 5 and 2.
• Coagulation studies, including prothrombin time (PT) and partial thromboplastin time (PTT), to evaluate the intrinsic and extrinsic coagulation pathways, as discussed in 6 and 2.
• Mixing study to differentiate between factor deficiencies and inhibitors, as noted in 2.
• Vitamin K challenge to assess for vitamin K deficiency, as mentioned in 2.
• Liver function tests to evaluate for liver disease, as recommended in 2.

Special Considerations

• A positive family history of bleeding problems and a prolonged partial thromboplastin time (PTT) are useful predictive data for diagnosing a coagulopathy, as found in 3.
• Medication review to identify pharmacologic causes of bleeding or bruising, as discussed in 2.
• Physical examination findings, such as mucocutaneous bleeding or hemarthroses, can suggest underlying conditions, as mentioned in 2.