A 7-year-old girl is brought to the office for a routine health maintenance examination. While in the waiting room, she develops a nosebleed. An assistant pinches the patient's nasal alae against the nasal septum for 10 minutes while the girl is seated and leaning forward. This slows, but does not stop, the flow of blood. Prior to the appointment, the patient was at a summer camp playing outside in hot, dry weather. She has had no recent facial trauma, unusual bruising, or gingival bleeding. Blood pressure is 100/70 mm Hg and pulse is 94/min. On examination, the patient is sitting in a chair, awake, alert, and in no distress. A continuous trickle of blood from her left naris obscures the mucosa. She has no oropharyngeal lesions. Which of the following is the best next step in management of this patient's condition?
Show Explanatory Sources
This patient has ongoing epistaxis that is most likely due to a hot, dry climate and possible minor nasal trauma (eg, undisclosed nose-picking). The anterior nasal septal mucosa is vulnerable to bleeding as it is where the sphenopalatine, greater palatine, anterior ethmoid, and superior labial arteries anastomose (Kiesselbach plexus).
Nostril pinching directly compresses the Kiesselbach plexus and usually readily controls bleeding after 5-10 minutes. However, if anterior epistaxis does not cease, as seen in this patient, topical vasoconstriction is indicated. Oxymetazoline is the preferred agent in children and should be applied with a squirt bottle or cotton pledget. Direct pressure should then be applied again to the nasal alae. Although beneficial in the acute setting, topical vasoconstrictors should not be used for >3 days due to the risk of rebound congestion.
Patients should be advised to moisturize the nasal mucosa with saline sprays or a humidifier to prevent epistaxis due to dry weather. In addition, nose-picking or rubbing should be avoided.
(Choice A) Intranasal corticosteroids treat allergic rhinitis but may cause thinning, dryness, and/or damage of the nasal septum, contributing to epistaxis. Patients should be instructed to spray laterally (away from the nasal septum) to avoid adverse effects and to discontinue if experiencing recurrent epistaxis.
(Choice B) Chemical (silver nitrate) or electrical cautery is indicated if direct compression and topical vasoconstriction are unsuccessful. Simultaneous bilateral cauterization should be avoided due to the risk of septal ulceration and perforation.
(Choice C) Anterior nasal packing (eg, bacitracin-covered sponge) is indicated if direct nostril compression, topical vasoconstriction, and cauterization fail to stop the acute episode of anterior epistaxis.
(Choice D) Posterior epistaxis occurs more frequently in older adults with hypertension and arteriosclerosis and is treated with posterior nasal packing. Although uncommon in children, posterior bleeds can occur with severe nasal trauma or an underlying bleeding disorder and should be suspected if an anterior source is not identified.
Educational objective:
Most epistaxis originates from the Kiesselbach plexus in the anterior nasal septum. Nostril pinching is the first step in management, and a topical vasoconstrictor can be applied if direct compression alone is not effective.