Management of Paediatric epistaxis in different age group in a tertiary care centre

This article was written and published back in 2016 when I was working as a teacher at Malda Medical College. Sharing it on the Blog for the first time,

TITLE PAGE: Management of Paediatric epistaxis in different age groups in a tertiary care centre

Type of Article: Research Article

 Abhijit Misra1*, Amrita Basu2, Prabir Kr Mandal2, Nepal Ch Mahapatra1
1Department of Paediatric Medicine, Malda Medical College, West Bengal, India 2Department of Otorhinolaryngology, Malda Medical College, West Bengal, India

ABSTRACT

Background: Epistaxis is a common otorhinological emergency seen in children. Aetiology and treatment differ in different age groups.

Methods: A retrospective study was conducted in a tertiary care hospital and data of pediatric patients (under 18 years) admitted with Epistaxis were divided into three different age groups Gr A (2 years to <5 years), Gr B( 5 to < 12 years) and Gr C (12 years to 18 years) and analyzed.
 

Results: Out of 216 total patients males outnumbered females in all age groups. Trauma including nose picking was the most common cause in all three age groups (54%, 45.4%, and 31% respectively). 2nd most common cause noted was Blood dyscrasia in Gr A (17.5%), idiopathic in Gr B (23.8%), and Gr C (22.5%). Tumours accounted for 11.3% of patients in Gr C. Observation alone (i.e. nasal mucosal hydration, use of topical decongestants, topical antibiotics) were the main intervention needed (70% in Gr A, 50% in Gr B, and 28% in Gr C). Nasal packing and other methods were needed mainly in the older age Groups. 61% of traumatic patients managed with observation alone whereas 55.8% of inflammatory group and 66.7% of blood dyscrasia group needed nasal packing for control of Epistaxis.

Conclusions: Trauma including nose picking is the most common cause of pediatric epistaxis among all age groups and usually managed well with observation alone. Nasal packing and other invasive treatment modalities are mostly needed in older age groups of pediatric patients and those with non-traumatic causes of epistaxis.


INTRODUCTION

Epistaxis is a common problem in paediatric population. Most are spontaneous, anterior and self-limiting. Gently pressing the nasal ala for 5–10 min is usually all that is required. Up to 60% of children will have had at least one nosebleed by age ten. Commonly occur between the ages of 3 and 8 years, the incidence declines in adulthood. However 50% of all adults presenting with epistaxis had epistaxis during childhood.1 Children younger than 2 years rarely present with Epistaxis.2 Epistaxis also occurs more frequently in dry environments such as in the desert or in the winter in the cooler climates, where, the lack of humidity dries the mucosa of the anterior nasal septum. Most often, these nosebleeds tend to be minor and are relatively easily managed with pressure or stop spontaneously.3 Nonetheless; epistaxis may herald a developing neoplasm, particularly if bleeding is predominantly unilateral and is associated with a history of nasal obstruction. The etiological profile of epistaxis has been reported to vary with age and anatomical location .The treatment of epistaxis also requires a systematic and methodical approach, and options vary according to the cause, location, and severity of the haemorrhage.4-9 Very few data are available regarding aetiology and treatment protocols in different paediatric age group. We here, report our experience in a tertiary care hospital about the aetiology, management aspects of this issue. The results of this study will help in planning of preventive strategies and establishment of management protocols.

METHODS

This was a retrospective observational study conducted in a tertiary care hospital in eastern India. Data of paediatric patients (children under 18 years of age) admitted with Epistaxis were collected from hospital records from January 2013 to January 2016. Patient particulars, demographic profile, eiology identified, investigations and treatment needed during hospital stay noted. Children were divided into three different age group Gr A 2years to <5 years, Gr B % to < 12 years and Gr C 12 years to 18 years. Data were then tabulated and analysed.

RESULTS

Total 216 paediatric patients of less than 18 years were admitted during the study period. Males outnumbered females in all the three age groups. Demographic data of the patients were detailed in Table 1. Family history of Epistaxis was present in 14% of Gr A patients compared to 5.7 % in Gr B and 5.6% in Gr C. History of consanguinity noted in 15.8% of Gr A compared to 6.8% in Gr B and 9.8% in Gr C patients.

Most common cause of Epistaxis identified was trauma including nose picking in all the three age groups (54%, 45.4%, and 31% respectively in Gr A, B and C). 2nd most common cause noted was Blood dyscrasia( including leukemia,haemophilia,thrombocytopenia, thalassemia) in Gr A (17.5%), whereas idiopathic was 2nd most common cause in Gr B (23.8%) and Gr C (22.5%). Tumours including Angiofibroma, polyp accounted for 11.3% of patients in Gr C and nil in other age groups. Inflammatory causes like rhinitis, sinusitis, adenoiditis, allergy and 5 cases of foreign body accounted for rest the cases. (Table 2)

Different treatment modalities needed summarised in Table 3. Observation alone (i.e. nasal mucosal hydration, use of topical decongestants, topical antibiotics and removal of foreign body in selected cases) were the main intervention needed in 48% of overall patients(70% in Gr A, 50% in Gr B and 28% in Gr C). Nasal packing and other methods were needed mainly in the older age Group of patients (Gr B and C). Table 4 summarised the different successful treatment modalities needed for different age group of patients.

61% of traumatic patients managed with observation alone whereas 55.8% of inflammatory group and 66.7% of blood dyscrasia group needed nasal packing for control of Epistaxis. (Table5)

 
Table 6 enlists the average hospital stay needed for different treatment modalities. Observation and electro cauterisation patients needed least no of hospital  stay.Those needing surgery or multiple modalities of treatment for control of Epistaxis .needed maximum number of hospital stay..

DISCUSSION

Epistaxis is a common condition in children. Thirty percent of children under 5 years of age, 56% of those aged 6–10 years, and 64% of those aged 11–15 years, have had a least one episode of epistaxis.10 Males are more commonly affected than females in our study which correlates with other similar studies.11-13In our study family history of Epistaxis was present in  7.9% of total paediatric cases as compared to 10% in a study by Barkowitz,11 26% by Damrose12 and up to 46% by Davies K.1Children in the age group of 2-5 had the highest incidence of positive family history and also the history of consanguinity. This is further supported by the fact that this group had higher incidence of blood dyscrasia, as aetiology of epistaxis.


A committed search for the bleeder as well as a deliberate effort to find the cause of epistaxis is necessary, because too many cases of epistaxis are grouped as idiopathic or primary.14 Most common cause of paediatric epistaxis identified was trauma including nose picking in all the three age groups in our study which is similar to finding in other studies.1,3 Younger patients and those with a previous history of emergency department attendance are more likely to have a bleeding diathesis.15,16 In our study 2nd most common cause noted was Blood dyscrasia in less than 5 year age group patients whereas idiopathic was 2nd most common cause in older children(Gr B and C). Unilateral nosebleeds in association with facial swelling, pain or nasal obstruction are concerning features suggestive of more unusual causes such as tumours. In adolescent males, juvenile nasopharyngeal angiofibroma, a rare highly vascular benign tumour which is locally aggressive, may present with symptoms of painless nasal obstruction with severe epistaxis. 17 Tumours including Angiofibroma accounted for 11.3% of patients in Gr C but nil in other age groups in our study.

Frequency distribution for causes of epistaxis looks unique in children as compared with adults. Therefore, identification of the cause is important, as it strongly reflects the management plan.16 Observation with nasal mucosal hydration, topical antibiotic ointments and nasal decongestants were the main intervention needed in 48% of all patients (70% in Gr A, 50% in Gr B and 28% in Gr C). Nasal packing and other methods were needed mainly in the older age Group of patients (Gr B and C). These findings are similar to the results of the studies by Davies K1 and J F Damrose12.Topical antiseptic cream does appear to assist in reducing the frequency of nosebleeds in clinical practice, and a randomised control trial of 103 children demonstrated that 4 weeks treatment with 0.5% neomycin + 0.1% chlorhexidine cream (Naseptin) is effective (relative risk reduction 47%, absolute risk reduction 26%, number needed to treat 3.8), 18although not statistically significant, according to recent a Cochrane review.

In present study 61% of traumatic patients managed with observation alone whereas 55.8% of inflammatory group and 66.7% of blood dyscrasia group needed nasal packing for control of Epistaxis. In children with epistaxis secondary to underlying haematological coagulopathies, the primary focus is on correcting underlying clotting problems where possible, and/or the use of topical haemostatic agents.19  Patients with nasal mass lesion or with adenoid hyperplasia were managed with surgical removal of the lesion.

Observation and electro cauterisation patients needed least no of hospital stay. Those needing surgery or multiple modalities of treatment for control of Epistaxis, needed maximum number of hospital stay. These observations are in concordance with the literature.3

CONCLUSIONS: Trauma including nose picking is the most common cause of paediatric epistaxis among all age groups and usually managed well with observation alone(i.e. nasal mucosal hydration, use of topical decongestants, topical antibiotics). Nasal packing and other invasive treatment modalities are mostly needed in older age group of paediatric patients and those with non-traumatic causes of epistaxis. Blood dyscrasia is an important cause especially in younger age group and those with recurrent bleeds and needs packing other than transfusion of the deficient product. Tumours should be suspected in adolescent age group with unilateral nasal obstruction and need surgical treatment.8

ACKNOWLEDGEMENTS

Authors are thankful to all the faculty members of the department of Pediatric medicine and Otorhinolaryngology for their cooperation in collecting and analysing the data.

DECLARATIONS

Funding: none

Conflict of interest: none declared

Ethical approval: not needed

REFERENCES

1. Davies K, Batra K, Mehanna R, Keogh I. Pediatric epistaxis: epidemiology, management & impact on quality of life. Int J Pediatr Otorhinolaryngol. 2014 Aug;78(8):1294-7.
2. N. McIntosh, J.Y. Mok, A. Margerison. Epidemiology of oronasal haemorrhage in the first 2 years of life: implications for child protection. Pediatrics 120 (2007); 1074–1078.
3. Anish K Gupta, Sandip Jain, Devinder Pal Singh, Ashwani Jindal, Kuldeep Singh. Epistaxis: Management Protocol As Per Etiology. Clinical Rhinology: An International Journal September-December 2009;2(3):43-46.
4. Ciaran SH, Owain H. Update on management of epistaxis. The West London Medical Journal 2009; 1:33-41.
5. Walker TWM, Macfarlane TV, McGarry GW. The epidemiology and chronobiology of epistaxis: an investigation of Scottish hospital admissions 1995-2004. Clin Otolaryngol. 2007; 32:361-5.
6. Pope LER, Hobbs CGL. Epistaxis: an update on current management. Postgrad Med J.2005; 81:309-314.
7. Nash CM, Field SMB. Epidemiology of Epistaxis in a Canadian Emergency Department. Israeli Journal of Emergency Medicine 2008; 8:24-28.
8. Pallin DJ, Chng Y, McKay MP, Emond JA, Pelletier AJ, Camargo CA. Epidemiology of epistaxis in US emergency departments, 1992 to 2001.Ann Emerg Med. 2005; 46:77-81.
9. Bernius M, Perlin D. Pediatric ear, nose, and throat emergencies. Pediatr Clin North Am. 2006; 53:195.
10. Petruson B. Epistaxis in childhood. Rhinology 1979; 17:83–90.
11. N.J. Brown, R.G. Barkowitz. Epistaxis in healthy children requiring hospital admission. Int. J. Pediatr. Otolaryngol. 68 (2004); 1181–1184.
12. J.F. Damrose, J. Maddalazzo. Pediatric epistaxis. Laryngoscope 116 (2006); 387–393.
13. S. Loughran, E. Spinou, W.A. Clement, R. Cathcart, H. Kubba, N.K. Geddes. A prospective, single blind, randomized controlled trial of petroleum jelly/ vaseline for recurrent pediatric epistaxis. Clin. Otolaryngol. 29 (2004); 266–269.
14. Watkinson JC. Epistaxis In: Scott-Brown’s Otorhinolaryngology 6th ed. Vol. 4, Oxford Boston: Butterworth-Heinemann; 1997: 4/18/ 1-17.
15. Elden L,Reinders M, Witmer C. Predictors of bleeding disorders in children with epistaxis: Value of preoperative tests and clinical screening. Int J Pediatr Otorhinolaryngol. 2012;76:767–71.
16. Magy S. Abdel Wahab, Hesham Fathy, Rania Ismaila, Nancy Mahmoud. Recurrent epistaxis in children: When should we suspect coagulopathy? The Egyptian Journal of Otolaryngology 2014; 30:106–111.
17. Siddiq S, Grainger J.Fifteen-minute consultation: investigation and management of childhood epistaxis. Arch Dis Child Educ Pract Ed. 2015 Feb;100(1):2-5. doi: 10.1136/archdischild-2013-304931. Epub 2014 Jul 17.
18. Kubba H,MacAandie C, Botma M, et al. A prospective single-blind randomized controlled trial of antiseptic cream for recurrent epistaxis in childhood. Clin Otolaryngol2001;26:465–8.
19. Qureishi A, Burton MJ. Interventions for recurrent idiopathic epistaxis (nosebleeds) in children. Cochrane Database Syst Rev 2012;(9):CD004461.

Healthwealthbridge  Disclaimer health information provided on this blog is for general awareness and doesn’t in any way replace a doctor’s professional medical advice. Kindly consult your doctor in case of any decision regarding your health, and diet.

Previously published in International Journal of Contemporary Pediatrics in 2016 Management of pediatric epistaxis in different age group in a tertiary care centre .