What Causes Nosebleeds?

Patient Presentation
A 7-month-old male living in the upper-Midwest came to clinic in January after his mother found several spots of dried blood the size of a nickel on his sheets and dried blood on his nose when he awoke in the morning.
He had a great deal of clear-yellowish rhinorrhea for 3 days. He was afebrile and was having some problems breast-feeding because of the rhinorrhea.
His mother was using saline and bulb-suction frequently to clear his nose. She also was using a humidifier near his bed. He was otherwise well.
The past medical history and review of systems were negative.
The pertinent physical exam revealed an infant with obvious copious mucopurulent discharge from his nose. His vital signs and growth parameters were normal.
He had increased tearing of his eyes. Tympanic membranes were grey with splayed light reflexes and normal mobility. His mouth was negative.
His nose showed a small amount of dried blood around the entrance to the right nares. He had marked erythema of the anterior nose with several pinpoint areas of previous hemorrhage on the nasal septum.
His mouth, skin and lung examinations were normal.
The diagnosis of epistaxis secondary to rhinorrhea, dry environment and trauma due to bulb suctioning was made. His mother was counseled to use some petroleum jelly on the anterior nares 2-3 times per day with a cotton-tipped applicator or her little finger to promote healing.
She was also counseled about the likelihood that the epistaxis could recur because of the nasal anatomy, and how she could try to stop the bleeding at home if it was a problem.
She was also counseled about when to call or return to clinic and about upper respiratory infections in general.

The nose has a rich vascular supply. The Kiesselbach plexus, or Little area, is located on the anterior septum forming a vascular plexus that is easily traumatized.
This is the most common location causing epistaxis in the anterior nose.

Epistaxis is a common complaint whose cause is often easily identifiable and usually easily treated. However, parents may be quite distressed because their “child is bleeding” and may feel inadequate to stop it or feel that it happens too frequently.
Epistaxis often will spontaneously resolve or will resolve with direct pressure to the nose. These nosebleeds usually require no further treatment.

Active bleeding should be treated by placing the child in the upright position leaning slightly forward with a basin or tissue to capture the blood.
Direct pressure by external compression to the mid- to anterior nose for 5-10 minutes (with no let up at any time of the compression, i.e. “no-peeking”) often will resolve the epistaxis.
If bleeding does not resolve, then cotton pledgets with a vasoconstrictor such as phenylephrine 0.25% can be inserted into the nares and again direct pressure applied.
If the bleeding continues, cauterization with silver nitrate sticks can be used, applying the stick for no longer than 3 seconds to the bleeding site or sites. As cauterization can be difficult in children, consultation with otolaryngology is often needed.

If bleeding continues the nose will need to be packed. There are various options including absorbable materials such as Gelfoam® and non-absorbable antibiotic-impregnated petroleum gauze strips.
Packings are usually removed in 3-4 days. Other options include occlusion with a balloon such as a Foley catheter (especially if the location is in the posterior nose).
If packing is necessary, otolaryngology should be consulted and the child should also have prophylactic antibiotics as there is an increased risk of sinusitis with packing.
Surgical management with septoplasty or arterial ligation is sometimes necessary.
Hospitalization is usually not necessary but children who are hemodynamically unstable need treatment and monitoring, and those with posterior packing need frequent monitoring so are often hospitalized.
Children with a systemic illness such as a blood dyscrasia or oncological disease are also frequently hospitalized for overall management.

Learning Point
The differential diagnosis of epistaxis includes:

  • Environmental irritants – dry air, sudden changes in barometric pressure
  • Trauma – often due to nose picking or blunt external trauma, and one of the most common causes of epistaxis
  • Foreign body
  • Blood dyscrasias – coagulopathy, platelet dysfunction, sickle cell anemia, thrombocytopenia
  • Drug – anticoagulants, decongestant abuse, aspirin, non-steroid anti-inflammatory drugs, drugs of abuse especially inhaled
  • Idiopathic – up to 10% of cases
  • Infections
    • Diphtheria
    • Influenza
    • Measles
    • Mononucleosis
    • Pertussis
    • Streptococcal disease – scarlet fever, rheumatic fever
    • Syphilis
    • Tuberculosis
    • Typhoid fever
    • Rhinitis
    • Sinusitis
    • Upper respiratory infection
  • Nasal anatomy – nasal polyps, nasal septal deviation, nasal septal perforation, telangiectasia
  • Oncological diseases – localized (angiofibroma, angioma, granuloma, papilloma) or disseminated
  • Systemic disease – renal or hepatic disease in terminal stages, hypertension
  • Vascular anomalies – hemangioma, Osler-Weber-Rendu

Questions for Further Discussion
1. What history questions should make the physican think about a serious underlying cause for epistaxis?
2. What physical examination finding should make the physican think about a serious underlying cause for epistaxis?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for these topics: Nose Disorders and Common Cold and at Pediatric Common Questions, Quick Answers for this topic: Colds

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Stockman JA, Corden TE, Kim JJ. Pediatric Book of Lists: A Primer of Differential Diagnosis in Pediatrics. Mosby Year-Book, New York, NY, 1991;261-262.

Inkellis SH. Epistaxis in Pediatrics a Primary Care Approach. Berkowitz C. ed. W.B. Saunders Co. Philadelphia, PA. 1996;191-195.

Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1998:169-70.

Nguyun QA. Epistaxis. eMedicine.
Available from the Internet at http://www.emedicine.com/ent/topic701.htm (rev. 11/24/2007, cited 1/3/2008).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    February 4, 2008