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International Journal of Pediatric Otorhinolaryngology xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
An update on management of pediatric epistaxis Neel Patel a,b , John Maddalozzo a,c, Kathleen R. Billings a,c, * a Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Otolaryngology – Head and Neck Surgery, 225 East Chicago Ave, Box #25, Chicago, IL 60611, USA b University of Illinois Hospital and Health Sciences System, Department of Otolaryngology – Head and Neck Surgery, 1855 West Taylor St, Suite 2.42, Chicago, IL 60612, USA c Northwestern University Feinberg School of Medicine, Chicago, IL, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 15 April 2014 Received in revised form 1 June 2014 Accepted 5 June 2014 Available online xxx
Objective: To evaluate the work-up and treatment of pediatric epistaxis in an outpatient clinical setting, with a focus on the diagnostic utility and associated costs of nasal endoscopy and adjunctive laboratory data. Study design: Retrospective, case series. Methods: Children under 18 years of age seen in an outpatient clinical setting at a tertiary care hospital between 2004 and 2012 for the primary diagnosis of epistaxis were identified. Patient characteristics were analyzed from a statistical and cost perspective. Results: A total of 175 patients with epistaxis were included. One hundred twenty-two (69.7%) were male, with a mean overall age of 9.1 years (range 5 months to 17.9 years). The duration of bleeding ranged from 0.25 to 84 months (mean 11.5 months). Nasal endoscopy was performed in 123 (70.2%) patients. Three (2.4%) had nasal polyps, and 1 (0.8%) a juvenile nasopharyngeal angiofibroma. The average age of patients with nasal masses was significantly older (16.2 years versus 10.4 years, p = 0.008). Of 131 patients with available blood work, laboratory values demonstrated anemia in 27 (20.6%) patients, elevated partial thromboplastin time in 5 (3.8%), and an abnormal platelet function analysis in 1 (0.8%) patient. Those with anemia were statistically younger (p = 0.001), than those with either normal labs or abnormal coagulation studies. Epistaxis resolved in 88/135 (65.2%) who had follow-up visits. Conclusion: The majority of pediatric epistaxis cases resolved with nasal mucosa hydration. Nasal endoscopy can be reserved for teenaged patients with epistaxis, and routine laboratory screening may be useful in select cases based on the clinical judgment. ã 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Epistaxis Pediatric epistaxis Epistaxis management
1. Introduction Epistaxis (nosebleed) is a common pediatric problem, although it is rare before 2 years of age. It is reported to affect 30% of children aged 0–5 years, and over 50% of children 5 years and older [1] and is a common reason for parents to seek medical attention for their children. Most nosebleeds arise from the anterior septum in a richly vascular region called the Kiesselbach's plexus. When this area is exposed to drying or minor trauma, bleeding can arise. Most children can be managed with nasal ointments and saline solution with some requiring additional intervention such as cautery.
* Corresponding author at: Ann and Robert H. Lurie Children's Hospital, Division of Otolaryngology – Head and Neck Surgery, 225 East Chicago Ave, Box #25, Chicago, IL 60611, USA. Tel.: +1 312 227 6230; fax: +1 312 227 9414. E-mail addresses: [email protected] (N. Patel), [email protected] (J. Maddalozzo), [email protected] (K.R. Billings).
No consensus exists on the standard work-up and treatment for pediatric epistaxis. A previous review of pediatric epistaxis by one of the co-authors provided a general approach including a history and physical exam, including anterior rhinoscopy, complete blood count, coagulation profile and computed tomography (CT) of the sinuses. The study showed that CT imaging is not indicated in the initial work up of pediatric epistaxis [2]. Laboratory testing for anemia and coagulation disorders and flexible nasal endoscopy (FNE) continues to be part of the practice paradigm for some otolaryngologists when assessing patients with epistaxis. Recurrent epistaxis may be the first sign of coagulopathy and may lead to anemia [3–5]. Epistaxis raises an additional concern of a nasal cavity or nasopharyngeal mass, such as a juvenile nasopharyngeal angiofibroma (JNA) in an adolescent male [6]. Identifying those patient characteristics suggestive of an increased risk for these hematologic concerns and/or nasal masses becomes important to the otolaryngologist when assessing the average patient with epistaxis. The goal of this study was to assess our current trends in
http://dx.doi.org/10.1016/j.ijporl.2014.06.009 0165-5876/ ã 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: N. Patel, et al., An update on management of pediatric epistaxis, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.06.009
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working up pediatric epistaxis, emphasizing patient characteristics associated with abnormal laboratory and FNE data. 2. Material and methods Approval was obtained from the Institutional Review Board at Ann and Robert H. Lurie Children's Hospital of Chicago. This is a retrospective case series of consecutive patients below 18 years of age seen for the primary diagnosis of epistaxis by the two senior authors in an outpatient clinical setting between January 2004 and December 2012. The patients were identified using a database filter with “epistaxis” (ICD-9 code 784.7) as the primary diagnosis or reason for visit. Three hundred fifty-nine patients with this diagnosis were identified. Exclusion criteria included patients seen initially in the emergency department [3], initially as inpatients [2], with a known coagulopathy [7], and significant medical histories [6]. There were 178 patients seen for a single visit who did not undergo nasal endoscopy or laboratory testing, and who were not included for further analysis. The remaining 175 patients, who had follow-up, nasal endoscopy, or laboratory work up were included in the study. The frequency and duration of epistaxis, medical history, family history, associated symptoms, physical exam findings, nasal endoscopy findings, laboratory values, treatment instituted, and treatment outcomes were recorded. The general work up included a thorough history, physical examination, FNE and laboratory screening including a complete blood count, prothrombin time (PT), and activated partial thromboplastin time (PTT) with reference to the international normalized ratio (INR). Some patients also underwent a platelet function analysis (PFA). Anemia was defined as a hemoglobin 38.4 s, and an abnormal PFA as >200 s. Patient characteristics associated with abnormal laboratory results and abnormal FNE were analyzed statistically. A cost analysis of the expenditure associated with laboratory and endoscopic assessments was performed. All the categorical data was expressed in frequencies and percentages. Chi-square analysis was used to look at comparisons between categorical data and the frequency of FNE and laboratory testing. Continuous data was described using mean and standard deviation for normally distributed data, and median and interquartile range for non-normally distributed data. If continuous variables were normally distributed a t-test was used to compare patients who had or did not have FNE, and an analysis of variance was used to compare the laboratory data (normal versus anemia and/or coagulation abnormalities). If the data was not normally distributed, Mann–Whitney was used to compare those who had or did not have FNE, and Kruskal–Wallis was used to compare the laboratory data. A p value of 4 follow up visits. Initial follow up appointments were 2–4 weeks after the first visit. The longest follow up time was 5 years and 10 months. There were 122 (69.7%) males and 53 (30.3%) females with a mean age of 9.1 years (range 0.42–17.9 years, standard deviation 4.4 years), and median age of 8.2 years. The median age of male patients was 7.0 years, and females 10.9 years, which was statistically significant (p = 0.002). Nasal trauma, 8 blunt and 9 digital, was reported in 17
(9.7%) patients, with no statistical difference in age (p = 0.58) or duration of bleeding (p = 0.92) (Table 1). The most common associated symptom (Fig. 1) was nasal obstruction in 82 (46.9%) patients. Bleeding duration was reported in 121 (69.1%) patients, with a mean of 12.0 months (range 0.25–84 months), and a median of 6.0 months (standard deviation 15.2 months). The duration of bleeding when divided by gender was not statistically significant (p = 0.752) (Table 1). Eighty-five (70.2%) patients reported a duration less than or equal to 12 months duration, 22 (18.1%) for 12–24 months, and 14 (11.5%) patients reported nosebleeds for greater than 24 months. Otitis media, allergic rhinitis, sinusitis, and asthma were the most common medical conditions reported (Fig. 2). There was a reported family history of bleeding tendencies or coagulopathy in 9 (5.1%) patients. Twelve (12.6%) patients had family members with recurrent epistaxis. A maternal history of hereditary hemorrhagic telangiectasia (Osler–Weber–Rendu) was reported in 1 (0.6%). The difference in median age with or without a family history of epistaxis was not significant (p = 0.77), although the duration of bleeding was significantly longer for those with a family history compared to those without (12 versus 5 months, p = 0.015) (Table 1). None of the children with a family history of bleeding disorders were found to have a coagulopathy, although 3 were anemic. A total of 135 (77.1%) patients had at least one follow-up visit (Table 2). Of these, 88 (65.2%) patients reported resolution of epistaxis at the first follow-up visit. All the patients were started on varying methods of nasal mucosal hydration (emollient, saline spray, and/or humidity). Recommended emollients included nasal Table 1 Pediatric epistaxis variables analyzed by age and duration of bleeding. Variable
Median diagnosis age (years)
Male Female p-value
7.02 10.85 0.002*
6.00 5.00 0.752
Negative family history Positive family history p-value
8.15 9.16 0.773
5.00 12.00 0.015*
No trauma Trauma p-value
8.2 6.62 0.576
6.00 6.00 0.920
No mass on endoscopy 10.38 Nasal mass on 16.21 endoscopy 0.008* p-value
Epistaxis duration (months)
4.00 9.00 0.976
No cautery Cautery p-value
7.41 10.65 0.005*
3.00 12.00 0.009*
Normal labs Anemia Coagulopathy p-value
9.79 5.86 10.22 0.004*
5.50 6.00 6.00 0.734
Normal labs Anemia p-value
9.79 5.86 0.001*
Normal labs Coagulopathy p-value
9.79 10.22 0.727
Anemia Coagulopathy p-value
5.86 10.22 0.040*
*
Significant value.
Please cite this article in press as: N. Patel, et al., An update on management of pediatric epistaxis, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.06.009
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3
Dry nose Fever Weakness Dizziness Easy bruising Headache Cough Facial Pain URI Snoring Nasal Obstruction None
0
10
20
30
40
50
60
70
80
90
# of Patients Fig. 1. Common symptoms associated with pediatric epistaxis.
100 90
# of Patients
80 70 60 50 40 30 20 10 0
History Fig. 2. Medical history of pediatric epistaxis patients.
saline gel, petroleum jelly or antibiotic ointment. In the emollient group, 54/81 (66.7%) patients reported resolved bleeding, while 17/34 (50.0%) of the non-emollient group had resolved. Fourteen (10.4%) patients were treated with silver nitrate (AgNO3) cautery to the nasal septum, and 12 (85.7%) reported resolution at first follow-up. Patients who received cautery were significantly older and had significantly longer duration of symptoms compared to those who did not (10.7 versus 7.4 years, p = 0.005 and 9 versus 3 months, p = 0.009, respectively) (Table 1).
Table 2 An analysis of treatment strategies and their outcomes for patients presenting with epistaxis. Treatment
Resolved epistaxis (n = 88)
Unresolved epistaxis (n = 47)
Emollient (n = 81) Non-emollient (n = 34) Silver nitrate (n = 14)
54 (66.7%) 17 (50.0%) 12 (85.7%)
27 (33.3%) 17 (50.0%) 2 (14.3%)
3.2. Diagnostic findings FNE was performed in 123 (70.3%) patients. The majority of abnormalities identified were benign (Fig. 3). Four (3.3%) patients were found to have nasal masses, including 3 with nasal polyps. Only 1 (0.8%) patient demonstrated a worrisome mass, which was eventually diagnosed as a JNA. The average age of patients with nasal masses (polyps or JNA) was significantly older when compared to those with no masses (16.2 versus 10.4 years, p = 0.008), but there was no statistical difference in duration of epistaxis (p = 0.98) (Table 1). The patient diagnosed with the JNA underwent embolization and resection of the mass, and the patients with polyps were treated medically. Laboratory results were available for 131 (74.9%) patients (Fig. 4). Laboratory evaluations consisted of a CBC, PT/INR, and PTT. A PFA was available for 17 patients and abnormal in 1. Newly identified laboratory abnormalities were found in 33 (25.2%) patients, with anemia in 27 (20.6%) patients. Five (3.8%) patients were identified as having an isolated elevated PTT. On further hematologic work up, 1 was found to have a positive lupus
Please cite this article in press as: N. Patel, et al., An update on management of pediatric epistaxis, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.06.009
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60
34
# of Patients
24
5
4
3
2
1
1
1
1
Fig. 3. Flexible nasal endoscopy findings of patients presenting with epistaxis.
anticoagulant. A single (0.8%) elevated PFA was identified in a patient with a history of DiGeorge syndrome, although the result was only mildly elevated at 209 s. There was no statistically significant difference (p = 0.73) in duration of bleeding between the 3 groups: normal, anemic, coagulopathic, although there was a difference when looking at age (Table 1). Median age of anemic patients was significantly younger (5.9 years) when compared to those with normal labs (9.8 years), and to those with abnormal coagulation studies (10.2 years), with a p-value of 0.001 and 0.04, respectively. There was no significant age difference in those with normal labs and abnormal coagulation studies (p = 0.73). 3.3. Associated costs The cost of laboratory testing at our institution includes $144 for a CBC, $94 for a PT/INR, $118 for a PTT, and $259 for a PFA. If no laboratory testing had been performed, a saving of $51,039 would have resulted. Charges for nasal endoscopy at our institution have a variety of costs depending on the nature of the examination: nasal endoscopy (CPT 31231) $939, nasopharyngoscopy (CPT 92511) $769, and flexible fiberoptic laryngoscopy (CPT 31575) $570. This means charges for FNE ranged from $70,100 to $115,497 for 123 patients examined by these methods.
Elevated PT/INR 1%
Elevated aPTT 4%
Elevated PFA 1%
Anemia 20% Normal 74%
# of Patients = 131 Normal = 97 Anemic = 27 Elevated PTT = 5 Elevatd PT/INR = 1* Elevated PFA = 1
*One patient had both an elevated PTT and PT/INR
Fig. 4. Laboratory abnormalities found during epistaxis work-up.
4. Discussion The majority of pediatric epistaxis is venous and arises from the anterior septum where a network of vessels (Kiesselbach's plexus) lie under a thin mucosal lining that can become dry and excoriated [1]. The etiology of epistaxis is broad and predicting which children are at risk for an underlying neoplasm or bleeding disorder can be a challenge. This study aims to identify characteristics, like age and duration of bleeding, that might be associated with these underlying causes of epistaxis, and to comment on current treatment strategies. The previous report on pediatric epistaxis from our institution assessed 90 patients referred for the evaluation of their epistaxis over a 3-year period (January 1, 2000–January 1, 2003). The study recommended laboratory testing as a routine part of epistaxis work up and found a 22% rate of anemia and 7.8% rate of coagulation disorders. The use routine of FNE to localize the bleeding source was recommended, but routine CT scanning was shown to be of limited diagnostic effectiveness [2]. This study presents an update on pediatric epistaxis management in patients seen from 2004 through 2012. There were 178 children presenting with epistaxis who were not analyzed, as they either lacked a follow-up visit or did not undergo FNE or laboratory work up. This likely reflects a trend toward a reduced diagnostic work up, as most bleeding resolves with conservative measures. Laboratory testing was performed on 131 (74.9%) patients, and 27 (20.6%) patients were found to be anemic. Of these patients, only 2 had a hemoglobin less than 10 mg/dL and 3 had a hematocrit less than 30%. None of the patients required a blood transfusion due to anemia or excessive bleeding. This rate is similar to our previous study where the anemia rate was 22% [2]. Elden et al. [7] found 8.5% (4/47) of their patients to be anemic in their analysis of predictors of bleeding disorders in children with epistaxis. They were evaluating children with severe epistaxis who had failed medical therapy, and who were receiving intraoperative management of epistaxis with cauterization. Although their study found a lesser rate of anemia among patients, they similarly noted that children with anemia and bleeding disorders had a younger mean age (6.4 years) compared to those without (9.5 years), while in our study anemic children had a median age of 5.9 years and those without had a median age of 9.8 years. This difference was statistically significant (p = 0.004), and may reflect the greater
Please cite this article in press as: N. Patel, et al., An update on management of pediatric epistaxis, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.06.009
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impact epistaxis, and the incumbent blood loss, on smaller children. Only 6 (4.6%) of 131 patients with labs had abnormal coagulation studies. Patients with abnormal coagulation studies were statistically older than the patients diagnosed with anemia (10.2 years versus 5.9 years, respectively), although the duration of bleeding did not differ between those with normal labs, anemia, and abnormal coagulation studies. In contrast to Elden's study, we found no significant difference in age between those with normal labs and those with abnormal coagulation studies (p = 0.727), while they showed a trend suggesting younger aged children were at higher risk for an underlying coagulopathy (p = 0.07) [7]. Sandoval et al. [8] found duration, severity, and the presence of other bleeding symptoms to have no predictive value in diagnosing a coagulopathy. They evaluated 178 pediatric patients, with a median age of 7 years, referred to the hematology clinic for evaluation of epistaxis. Laboratory studies included a CBC, PT, PTT, coagulation factor assays, and platelet function studies. Fifty-nine (33%) patients were found to have a coagulopathy. They noted positive family history and an elevated PTT to be predictors of a coagulopathy [8]. Only 1/5 (20.0%) patients in our study with an elevated PTT was found to have a disorder (lupus anticoagulant), and none of these patients had a positive family history. The outstanding feature of the Sandoval study is the nature of their select patient population, i.e. those children referred to a hematology clinic for work up of epistaxis. This likely influenced their data, as the average epistaxis patient is not usually sent to hematology for a work up. Our study showed a 20% rate of a coagulation disorder in those with an elevated PTT, and other studies reporting rates between 10.6% [7] and 33%. Generally the work up of patients with abnormal coagulation studies with additional laboratory analyses and hematology consultation is suggested. Besides younger age at diagnosis for those with anemia, there were no outstanding variables, including duration of bleeding and family history, predictive of abnormal laboratory values. Clinical judgment must then be exercised in selecting patients for laboratory work up. For example, a child who continues to bleed despite nasal lubricants might be considered for additional laboratory work up. FNE was performed in 123/175 (70.3%) patients, and 60 (48.8%) had a normal exam. The remaining patients demonstrated at least 1 abnormality. These were almost always benign, with the most common being adenoid hypertrophy. The patient diagnosed with a JNA was a teenage male with daily unilateral left epistaxis for 1 week and nasal airway obstruction. Glad et al. [9] reviewed 45 patients diagnosed with a JNA. All were male patients, with a median age of 15 years, and with presenting symptoms of nasal obstruction (91%) and recurrent epistaxis (63%). They found no correlation between tumor staging and duration of symptoms, and the median duration from symptom onset to diagnosis was 6 months (range 0–49 months). The average age of patients with nasal masses in our study was significantly older compared to those with negative findings on FNE (16.2 versus 10.4 years, p = 0.008). The diagnosis of nasal masses clearly favors teenaged male patients, and nasal endoscopy should continue to be a routine part of the assessment of epistaxis in teenage males. However, in our study, 77 (62.6%) of the patients who underwent FNE were under 12 years of age, which equals anywhere from $40,890 to $72,303 in healthcare charges. Given the low yield of nasal endoscopy findings in younger children in particular, routine use of this portion of the examination does not appear appropriate. Rather careful judgment by the clinician based on the constellation of the patient's symptoms, age, and anterior rhinoscopy findings are recommended. An example might be a child with persistent
5
bleeding, who does not have any obvious bleeding source on anterior rhinoscopy. When assessing current epistaxis treatment strategies, our study agrees with the current literature. Kubba et al. [10] found that chlorhexidine/neomycin antiseptic cream significantly increased the proportion of resolution of recurrent pediatric epistaxis at 8 weeks when compared to no treatment. Calder et al. [11] showed that treatment with silver nitrate cautery in addition to antiseptic cream for epistaxis treatment was significantly more effective than antiseptic cream alone. In their study, however, the study population was limited to children with visible anterior septal vessels. Most children in our study showed resolution of bleeding (88/135 (65.2%)) at the time of the first follow-up with the use of nasal mucosal hydration. The Elden [7] study reported resolution in 191/248 (77%) patients treated with nasal emollient. We found cautery to be effective in select cases, however, those who underwent cautery were significantly older and had a longer duration of symptoms (p = 0.005 and p = 0.009, respectively). This likely reflects the desire to pursue a more aggressive treatment in strategy in those who have been bleeding for longer periods, and are old enough to tolerate the procedure with minimal distress. It appears that the majority of pediatric epistaxis cases can be treated conservatively with nasal mucosal hydration techniques, with nasal cautery as a useful adjuvant treatment in those that fail simple medical management. 5. Conclusion The outpatient evaluation and management of pediatric epistaxis continues to evolve. The choice of laboratory screening with blood counts and bleeding parameters should be based on the clinician's judgment, while taking into account the patient's clinical presentation, symptoms and age. Patients found to have abnormalities should be properly referred for further work up. FNE should be incorporated into a patient's work up when a combination of age, gender, symptoms and physical exam are suggestive of an underlying abnormality. With such a low yield of significant findings, the use of both routine laboratory screening and FNE do not appear to be advantageous from a healthcare cost perspective. References [1] Q. Burtan, Interventions for recurrent idiopathic epistaxis (nosebleeds) in children (review), Cochrane Database Syst. Rev. 9 (2012) 1–23 (No.: CD004461). [2] J. Damrose, J. Maddalozzo, Pediatric epistaxis, Laryngoscope 116 (2006) 387– 393. [3] V. Kiley, J.J. Stuart, C.A. Johnson, Coagulation studies in children with isolated recurrent epistaxis, J. Pediatr. 100 (1982) 579–581. [4] M. Beran, L. Stigendal, B. Petruson, Haemostatic disorders in habitual nosebleeders, J. Laryngol. Otol. 101 (1987) 1020–1028. [5] E. Katsanis, K.H. Luke, E. Hsu, M. Li, D. Lillicrap, Prevalence and significance of mild bleeding disorders in children with recurrent epistaxis, J. Pediatr. 113 (1988) 73–76. [6] P. Moorthy, B. Reddy, H. Qaiyum, S. Madhira, S. Kolloju, Management of juvenile nasopharyngeal angiofibroma: a five year retrospective study, Indian J. Otolaryngol. Head Neck Surg. 62 (October, 4) (2010) 390–394. [7] V. Elden, M. Reinders, C. Witmer, Predictors of bleeding disorders in children with epistaxis: value of preoperative tests and clinical screening, Int. J. Pediatr. Otolaryngol. 76 (2012) 767–771. [8] C. Sandoval, S. Dong, P. Visintainer, Clinical and laboratory features of 178 children with recurrent epistaxis, J. Pediatr. Hematol. Oncol. 65 (2002) 47–49. [9] H. Glad, B. Vainer, C. Buchwald, B.L. Petersen, S.A. Theilgaaard, P. Bonvin, et al., Juvenile nasopharyngeal angiofibromas in Denmark 1981–2003: diagnosis, incidence, and treatment, Acta Otolaryngol. (Stockh) 127 (2007) 292–299. [10] H. Kubba, C. MacAndie, M. Botma, J. Robison, M. O'Donnell, G. Robertson, et al., A prospective, single blind, randomized controlled trial of antiseptic cream for recurrent epistaxis in childhood, Clin. Otolaryngol. 26 (2001) 46–465. [11] N. Calder, S. Kang, L. Fraser, T. Kunanandam, J. Montgomery, H. Kubba, A double-blind randomized controlled trial of management of recurrent nosebleeds in children, Otolaryngol. Head Neck Surg. 140 (2009) 670–674.
Please cite this article in press as: N. Patel, et al., An update on management of pediatric epistaxis, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.06.009
International Journal of Pediatric Otorhinolaryngology xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
An update on management of pediatric epistaxis Neel Patel a,b , John Maddalozzo a,c, Kathleen R. Billings a,c, * a Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Otolaryngology – Head and Neck Surgery, 225 East Chicago Ave, Box #25, Chicago, IL 60611, USA b University of Illinois Hospital and Health Sciences System, Department of Otolaryngology – Head and Neck Surgery, 1855 West Taylor St, Suite 2.42, Chicago, IL 60612, USA c Northwestern University Feinberg School of Medicine, Chicago, IL, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 15 April 2014 Received in revised form 1 June 2014 Accepted 5 June 2014 Available online xxx
Objective: To evaluate the work-up and treatment of pediatric epistaxis in an outpatient clinical setting, with a focus on the diagnostic utility and associated costs of nasal endoscopy and adjunctive laboratory data. Study design: Retrospective, case series. Methods: Children under 18 years of age seen in an outpatient clinical setting at a tertiary care hospital between 2004 and 2012 for the primary diagnosis of epistaxis were identified. Patient characteristics were analyzed from a statistical and cost perspective. Results: A total of 175 patients with epistaxis were included. One hundred twenty-two (69.7%) were male, with a mean overall age of 9.1 years (range 5 months to 17.9 years). The duration of bleeding ranged from 0.25 to 84 months (mean 11.5 months). Nasal endoscopy was performed in 123 (70.2%) patients. Three (2.4%) had nasal polyps, and 1 (0.8%) a juvenile nasopharyngeal angiofibroma. The average age of patients with nasal masses was significantly older (16.2 years versus 10.4 years, p = 0.008). Of 131 patients with available blood work, laboratory values demonstrated anemia in 27 (20.6%) patients, elevated partial thromboplastin time in 5 (3.8%), and an abnormal platelet function analysis in 1 (0.8%) patient. Those with anemia were statistically younger (p = 0.001), than those with either normal labs or abnormal coagulation studies. Epistaxis resolved in 88/135 (65.2%) who had follow-up visits. Conclusion: The majority of pediatric epistaxis cases resolved with nasal mucosa hydration. Nasal endoscopy can be reserved for teenaged patients with epistaxis, and routine laboratory screening may be useful in select cases based on the clinical judgment. ã 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Epistaxis Pediatric epistaxis Epistaxis management
1. Introduction Epistaxis (nosebleed) is a common pediatric problem, although it is rare before 2 years of age. It is reported to affect 30% of children aged 0–5 years, and over 50% of children 5 years and older [1] and is a common reason for parents to seek medical attention for their children. Most nosebleeds arise from the anterior septum in a richly vascular region called the Kiesselbach's plexus. When this area is exposed to drying or minor trauma, bleeding can arise. Most children can be managed with nasal ointments and saline solution with some requiring additional intervention such as cautery.
* Corresponding author at: Ann and Robert H. Lurie Children's Hospital, Division of Otolaryngology – Head and Neck Surgery, 225 East Chicago Ave, Box #25, Chicago, IL 60611, USA. Tel.: +1 312 227 6230; fax: +1 312 227 9414. E-mail addresses: [email protected] (N. Patel), [email protected] (J. Maddalozzo), [email protected] (K.R. Billings).
No consensus exists on the standard work-up and treatment for pediatric epistaxis. A previous review of pediatric epistaxis by one of the co-authors provided a general approach including a history and physical exam, including anterior rhinoscopy, complete blood count, coagulation profile and computed tomography (CT) of the sinuses. The study showed that CT imaging is not indicated in the initial work up of pediatric epistaxis [2]. Laboratory testing for anemia and coagulation disorders and flexible nasal endoscopy (FNE) continues to be part of the practice paradigm for some otolaryngologists when assessing patients with epistaxis. Recurrent epistaxis may be the first sign of coagulopathy and may lead to anemia [3–5]. Epistaxis raises an additional concern of a nasal cavity or nasopharyngeal mass, such as a juvenile nasopharyngeal angiofibroma (JNA) in an adolescent male [6]. Identifying those patient characteristics suggestive of an increased risk for these hematologic concerns and/or nasal masses becomes important to the otolaryngologist when assessing the average patient with epistaxis. The goal of this study was to assess our current trends in
http://dx.doi.org/10.1016/j.ijporl.2014.06.009 0165-5876/ ã 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: N. Patel, et al., An update on management of pediatric epistaxis, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.06.009
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working up pediatric epistaxis, emphasizing patient characteristics associated with abnormal laboratory and FNE data. 2. Material and methods Approval was obtained from the Institutional Review Board at Ann and Robert H. Lurie Children's Hospital of Chicago. This is a retrospective case series of consecutive patients below 18 years of age seen for the primary diagnosis of epistaxis by the two senior authors in an outpatient clinical setting between January 2004 and December 2012. The patients were identified using a database filter with “epistaxis” (ICD-9 code 784.7) as the primary diagnosis or reason for visit. Three hundred fifty-nine patients with this diagnosis were identified. Exclusion criteria included patients seen initially in the emergency department [3], initially as inpatients [2], with a known coagulopathy [7], and significant medical histories [6]. There were 178 patients seen for a single visit who did not undergo nasal endoscopy or laboratory testing, and who were not included for further analysis. The remaining 175 patients, who had follow-up, nasal endoscopy, or laboratory work up were included in the study. The frequency and duration of epistaxis, medical history, family history, associated symptoms, physical exam findings, nasal endoscopy findings, laboratory values, treatment instituted, and treatment outcomes were recorded. The general work up included a thorough history, physical examination, FNE and laboratory screening including a complete blood count, prothrombin time (PT), and activated partial thromboplastin time (PTT) with reference to the international normalized ratio (INR). Some patients also underwent a platelet function analysis (PFA). Anemia was defined as a hemoglobin 38.4 s, and an abnormal PFA as >200 s. Patient characteristics associated with abnormal laboratory results and abnormal FNE were analyzed statistically. A cost analysis of the expenditure associated with laboratory and endoscopic assessments was performed. All the categorical data was expressed in frequencies and percentages. Chi-square analysis was used to look at comparisons between categorical data and the frequency of FNE and laboratory testing. Continuous data was described using mean and standard deviation for normally distributed data, and median and interquartile range for non-normally distributed data. If continuous variables were normally distributed a t-test was used to compare patients who had or did not have FNE, and an analysis of variance was used to compare the laboratory data (normal versus anemia and/or coagulation abnormalities). If the data was not normally distributed, Mann–Whitney was used to compare those who had or did not have FNE, and Kruskal–Wallis was used to compare the laboratory data. A p value of 4 follow up visits. Initial follow up appointments were 2–4 weeks after the first visit. The longest follow up time was 5 years and 10 months. There were 122 (69.7%) males and 53 (30.3%) females with a mean age of 9.1 years (range 0.42–17.9 years, standard deviation 4.4 years), and median age of 8.2 years. The median age of male patients was 7.0 years, and females 10.9 years, which was statistically significant (p = 0.002). Nasal trauma, 8 blunt and 9 digital, was reported in 17
(9.7%) patients, with no statistical difference in age (p = 0.58) or duration of bleeding (p = 0.92) (Table 1). The most common associated symptom (Fig. 1) was nasal obstruction in 82 (46.9%) patients. Bleeding duration was reported in 121 (69.1%) patients, with a mean of 12.0 months (range 0.25–84 months), and a median of 6.0 months (standard deviation 15.2 months). The duration of bleeding when divided by gender was not statistically significant (p = 0.752) (Table 1). Eighty-five (70.2%) patients reported a duration less than or equal to 12 months duration, 22 (18.1%) for 12–24 months, and 14 (11.5%) patients reported nosebleeds for greater than 24 months. Otitis media, allergic rhinitis, sinusitis, and asthma were the most common medical conditions reported (Fig. 2). There was a reported family history of bleeding tendencies or coagulopathy in 9 (5.1%) patients. Twelve (12.6%) patients had family members with recurrent epistaxis. A maternal history of hereditary hemorrhagic telangiectasia (Osler–Weber–Rendu) was reported in 1 (0.6%). The difference in median age with or without a family history of epistaxis was not significant (p = 0.77), although the duration of bleeding was significantly longer for those with a family history compared to those without (12 versus 5 months, p = 0.015) (Table 1). None of the children with a family history of bleeding disorders were found to have a coagulopathy, although 3 were anemic. A total of 135 (77.1%) patients had at least one follow-up visit (Table 2). Of these, 88 (65.2%) patients reported resolution of epistaxis at the first follow-up visit. All the patients were started on varying methods of nasal mucosal hydration (emollient, saline spray, and/or humidity). Recommended emollients included nasal Table 1 Pediatric epistaxis variables analyzed by age and duration of bleeding. Variable
Median diagnosis age (years)
Male Female p-value
7.02 10.85 0.002*
6.00 5.00 0.752
Negative family history Positive family history p-value
8.15 9.16 0.773
5.00 12.00 0.015*
No trauma Trauma p-value
8.2 6.62 0.576
6.00 6.00 0.920
No mass on endoscopy 10.38 Nasal mass on 16.21 endoscopy 0.008* p-value
Epistaxis duration (months)
4.00 9.00 0.976
No cautery Cautery p-value
7.41 10.65 0.005*
3.00 12.00 0.009*
Normal labs Anemia Coagulopathy p-value
9.79 5.86 10.22 0.004*
5.50 6.00 6.00 0.734
Normal labs Anemia p-value
9.79 5.86 0.001*
Normal labs Coagulopathy p-value
9.79 10.22 0.727
Anemia Coagulopathy p-value
5.86 10.22 0.040*
*
Significant value.
Please cite this article in press as: N. Patel, et al., An update on management of pediatric epistaxis, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.06.009
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Dry nose Fever Weakness Dizziness Easy bruising Headache Cough Facial Pain URI Snoring Nasal Obstruction None
0
10
20
30
40
50
60
70
80
90
# of Patients Fig. 1. Common symptoms associated with pediatric epistaxis.
100 90
# of Patients
80 70 60 50 40 30 20 10 0
History Fig. 2. Medical history of pediatric epistaxis patients.
saline gel, petroleum jelly or antibiotic ointment. In the emollient group, 54/81 (66.7%) patients reported resolved bleeding, while 17/34 (50.0%) of the non-emollient group had resolved. Fourteen (10.4%) patients were treated with silver nitrate (AgNO3) cautery to the nasal septum, and 12 (85.7%) reported resolution at first follow-up. Patients who received cautery were significantly older and had significantly longer duration of symptoms compared to those who did not (10.7 versus 7.4 years, p = 0.005 and 9 versus 3 months, p = 0.009, respectively) (Table 1).
Table 2 An analysis of treatment strategies and their outcomes for patients presenting with epistaxis. Treatment
Resolved epistaxis (n = 88)
Unresolved epistaxis (n = 47)
Emollient (n = 81) Non-emollient (n = 34) Silver nitrate (n = 14)
54 (66.7%) 17 (50.0%) 12 (85.7%)
27 (33.3%) 17 (50.0%) 2 (14.3%)
3.2. Diagnostic findings FNE was performed in 123 (70.3%) patients. The majority of abnormalities identified were benign (Fig. 3). Four (3.3%) patients were found to have nasal masses, including 3 with nasal polyps. Only 1 (0.8%) patient demonstrated a worrisome mass, which was eventually diagnosed as a JNA. The average age of patients with nasal masses (polyps or JNA) was significantly older when compared to those with no masses (16.2 versus 10.4 years, p = 0.008), but there was no statistical difference in duration of epistaxis (p = 0.98) (Table 1). The patient diagnosed with the JNA underwent embolization and resection of the mass, and the patients with polyps were treated medically. Laboratory results were available for 131 (74.9%) patients (Fig. 4). Laboratory evaluations consisted of a CBC, PT/INR, and PTT. A PFA was available for 17 patients and abnormal in 1. Newly identified laboratory abnormalities were found in 33 (25.2%) patients, with anemia in 27 (20.6%) patients. Five (3.8%) patients were identified as having an isolated elevated PTT. On further hematologic work up, 1 was found to have a positive lupus
Please cite this article in press as: N. Patel, et al., An update on management of pediatric epistaxis, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.06.009
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60
34
# of Patients
24
5
4
3
2
1
1
1
1
Fig. 3. Flexible nasal endoscopy findings of patients presenting with epistaxis.
anticoagulant. A single (0.8%) elevated PFA was identified in a patient with a history of DiGeorge syndrome, although the result was only mildly elevated at 209 s. There was no statistically significant difference (p = 0.73) in duration of bleeding between the 3 groups: normal, anemic, coagulopathic, although there was a difference when looking at age (Table 1). Median age of anemic patients was significantly younger (5.9 years) when compared to those with normal labs (9.8 years), and to those with abnormal coagulation studies (10.2 years), with a p-value of 0.001 and 0.04, respectively. There was no significant age difference in those with normal labs and abnormal coagulation studies (p = 0.73). 3.3. Associated costs The cost of laboratory testing at our institution includes $144 for a CBC, $94 for a PT/INR, $118 for a PTT, and $259 for a PFA. If no laboratory testing had been performed, a saving of $51,039 would have resulted. Charges for nasal endoscopy at our institution have a variety of costs depending on the nature of the examination: nasal endoscopy (CPT 31231) $939, nasopharyngoscopy (CPT 92511) $769, and flexible fiberoptic laryngoscopy (CPT 31575) $570. This means charges for FNE ranged from $70,100 to $115,497 for 123 patients examined by these methods.
Elevated PT/INR 1%
Elevated aPTT 4%
Elevated PFA 1%
Anemia 20% Normal 74%
# of Patients = 131 Normal = 97 Anemic = 27 Elevated PTT = 5 Elevatd PT/INR = 1* Elevated PFA = 1
*One patient had both an elevated PTT and PT/INR
Fig. 4. Laboratory abnormalities found during epistaxis work-up.
4. Discussion The majority of pediatric epistaxis is venous and arises from the anterior septum where a network of vessels (Kiesselbach's plexus) lie under a thin mucosal lining that can become dry and excoriated [1]. The etiology of epistaxis is broad and predicting which children are at risk for an underlying neoplasm or bleeding disorder can be a challenge. This study aims to identify characteristics, like age and duration of bleeding, that might be associated with these underlying causes of epistaxis, and to comment on current treatment strategies. The previous report on pediatric epistaxis from our institution assessed 90 patients referred for the evaluation of their epistaxis over a 3-year period (January 1, 2000–January 1, 2003). The study recommended laboratory testing as a routine part of epistaxis work up and found a 22% rate of anemia and 7.8% rate of coagulation disorders. The use routine of FNE to localize the bleeding source was recommended, but routine CT scanning was shown to be of limited diagnostic effectiveness [2]. This study presents an update on pediatric epistaxis management in patients seen from 2004 through 2012. There were 178 children presenting with epistaxis who were not analyzed, as they either lacked a follow-up visit or did not undergo FNE or laboratory work up. This likely reflects a trend toward a reduced diagnostic work up, as most bleeding resolves with conservative measures. Laboratory testing was performed on 131 (74.9%) patients, and 27 (20.6%) patients were found to be anemic. Of these patients, only 2 had a hemoglobin less than 10 mg/dL and 3 had a hematocrit less than 30%. None of the patients required a blood transfusion due to anemia or excessive bleeding. This rate is similar to our previous study where the anemia rate was 22% [2]. Elden et al. [7] found 8.5% (4/47) of their patients to be anemic in their analysis of predictors of bleeding disorders in children with epistaxis. They were evaluating children with severe epistaxis who had failed medical therapy, and who were receiving intraoperative management of epistaxis with cauterization. Although their study found a lesser rate of anemia among patients, they similarly noted that children with anemia and bleeding disorders had a younger mean age (6.4 years) compared to those without (9.5 years), while in our study anemic children had a median age of 5.9 years and those without had a median age of 9.8 years. This difference was statistically significant (p = 0.004), and may reflect the greater
Please cite this article in press as: N. Patel, et al., An update on management of pediatric epistaxis, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.06.009
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impact epistaxis, and the incumbent blood loss, on smaller children. Only 6 (4.6%) of 131 patients with labs had abnormal coagulation studies. Patients with abnormal coagulation studies were statistically older than the patients diagnosed with anemia (10.2 years versus 5.9 years, respectively), although the duration of bleeding did not differ between those with normal labs, anemia, and abnormal coagulation studies. In contrast to Elden's study, we found no significant difference in age between those with normal labs and those with abnormal coagulation studies (p = 0.727), while they showed a trend suggesting younger aged children were at higher risk for an underlying coagulopathy (p = 0.07) [7]. Sandoval et al. [8] found duration, severity, and the presence of other bleeding symptoms to have no predictive value in diagnosing a coagulopathy. They evaluated 178 pediatric patients, with a median age of 7 years, referred to the hematology clinic for evaluation of epistaxis. Laboratory studies included a CBC, PT, PTT, coagulation factor assays, and platelet function studies. Fifty-nine (33%) patients were found to have a coagulopathy. They noted positive family history and an elevated PTT to be predictors of a coagulopathy [8]. Only 1/5 (20.0%) patients in our study with an elevated PTT was found to have a disorder (lupus anticoagulant), and none of these patients had a positive family history. The outstanding feature of the Sandoval study is the nature of their select patient population, i.e. those children referred to a hematology clinic for work up of epistaxis. This likely influenced their data, as the average epistaxis patient is not usually sent to hematology for a work up. Our study showed a 20% rate of a coagulation disorder in those with an elevated PTT, and other studies reporting rates between 10.6% [7] and 33%. Generally the work up of patients with abnormal coagulation studies with additional laboratory analyses and hematology consultation is suggested. Besides younger age at diagnosis for those with anemia, there were no outstanding variables, including duration of bleeding and family history, predictive of abnormal laboratory values. Clinical judgment must then be exercised in selecting patients for laboratory work up. For example, a child who continues to bleed despite nasal lubricants might be considered for additional laboratory work up. FNE was performed in 123/175 (70.3%) patients, and 60 (48.8%) had a normal exam. The remaining patients demonstrated at least 1 abnormality. These were almost always benign, with the most common being adenoid hypertrophy. The patient diagnosed with a JNA was a teenage male with daily unilateral left epistaxis for 1 week and nasal airway obstruction. Glad et al. [9] reviewed 45 patients diagnosed with a JNA. All were male patients, with a median age of 15 years, and with presenting symptoms of nasal obstruction (91%) and recurrent epistaxis (63%). They found no correlation between tumor staging and duration of symptoms, and the median duration from symptom onset to diagnosis was 6 months (range 0–49 months). The average age of patients with nasal masses in our study was significantly older compared to those with negative findings on FNE (16.2 versus 10.4 years, p = 0.008). The diagnosis of nasal masses clearly favors teenaged male patients, and nasal endoscopy should continue to be a routine part of the assessment of epistaxis in teenage males. However, in our study, 77 (62.6%) of the patients who underwent FNE were under 12 years of age, which equals anywhere from $40,890 to $72,303 in healthcare charges. Given the low yield of nasal endoscopy findings in younger children in particular, routine use of this portion of the examination does not appear appropriate. Rather careful judgment by the clinician based on the constellation of the patient's symptoms, age, and anterior rhinoscopy findings are recommended. An example might be a child with persistent
5
bleeding, who does not have any obvious bleeding source on anterior rhinoscopy. When assessing current epistaxis treatment strategies, our study agrees with the current literature. Kubba et al. [10] found that chlorhexidine/neomycin antiseptic cream significantly increased the proportion of resolution of recurrent pediatric epistaxis at 8 weeks when compared to no treatment. Calder et al. [11] showed that treatment with silver nitrate cautery in addition to antiseptic cream for epistaxis treatment was significantly more effective than antiseptic cream alone. In their study, however, the study population was limited to children with visible anterior septal vessels. Most children in our study showed resolution of bleeding (88/135 (65.2%)) at the time of the first follow-up with the use of nasal mucosal hydration. The Elden [7] study reported resolution in 191/248 (77%) patients treated with nasal emollient. We found cautery to be effective in select cases, however, those who underwent cautery were significantly older and had a longer duration of symptoms (p = 0.005 and p = 0.009, respectively). This likely reflects the desire to pursue a more aggressive treatment in strategy in those who have been bleeding for longer periods, and are old enough to tolerate the procedure with minimal distress. It appears that the majority of pediatric epistaxis cases can be treated conservatively with nasal mucosal hydration techniques, with nasal cautery as a useful adjuvant treatment in those that fail simple medical management. 5. Conclusion The outpatient evaluation and management of pediatric epistaxis continues to evolve. The choice of laboratory screening with blood counts and bleeding parameters should be based on the clinician's judgment, while taking into account the patient's clinical presentation, symptoms and age. Patients found to have abnormalities should be properly referred for further work up. FNE should be incorporated into a patient's work up when a combination of age, gender, symptoms and physical exam are suggestive of an underlying abnormality. With such a low yield of significant findings, the use of both routine laboratory screening and FNE do not appear to be advantageous from a healthcare cost perspective. References [1] Q. Burtan, Interventions for recurrent idiopathic epistaxis (nosebleeds) in children (review), Cochrane Database Syst. Rev. 9 (2012) 1–23 (No.: CD004461). [2] J. Damrose, J. Maddalozzo, Pediatric epistaxis, Laryngoscope 116 (2006) 387– 393. [3] V. Kiley, J.J. Stuart, C.A. Johnson, Coagulation studies in children with isolated recurrent epistaxis, J. Pediatr. 100 (1982) 579–581. [4] M. Beran, L. Stigendal, B. Petruson, Haemostatic disorders in habitual nosebleeders, J. Laryngol. Otol. 101 (1987) 1020–1028. [5] E. Katsanis, K.H. Luke, E. Hsu, M. Li, D. Lillicrap, Prevalence and significance of mild bleeding disorders in children with recurrent epistaxis, J. Pediatr. 113 (1988) 73–76. [6] P. Moorthy, B. Reddy, H. Qaiyum, S. Madhira, S. Kolloju, Management of juvenile nasopharyngeal angiofibroma: a five year retrospective study, Indian J. Otolaryngol. Head Neck Surg. 62 (October, 4) (2010) 390–394. [7] V. Elden, M. Reinders, C. Witmer, Predictors of bleeding disorders in children with epistaxis: value of preoperative tests and clinical screening, Int. J. Pediatr. Otolaryngol. 76 (2012) 767–771. [8] C. Sandoval, S. Dong, P. Visintainer, Clinical and laboratory features of 178 children with recurrent epistaxis, J. Pediatr. Hematol. Oncol. 65 (2002) 47–49. [9] H. Glad, B. Vainer, C. Buchwald, B.L. Petersen, S.A. Theilgaaard, P. Bonvin, et al., Juvenile nasopharyngeal angiofibromas in Denmark 1981–2003: diagnosis, incidence, and treatment, Acta Otolaryngol. (Stockh) 127 (2007) 292–299. [10] H. Kubba, C. MacAndie, M. Botma, J. Robison, M. O'Donnell, G. Robertson, et al., A prospective, single blind, randomized controlled trial of antiseptic cream for recurrent epistaxis in childhood, Clin. Otolaryngol. 26 (2001) 46–465. [11] N. Calder, S. Kang, L. Fraser, T. Kunanandam, J. Montgomery, H. Kubba, A double-blind randomized controlled trial of management of recurrent nosebleeds in children, Otolaryngol. Head Neck Surg. 140 (2009) 670–674.
Please cite this article in press as: N. Patel, et al., An update on management of pediatric epistaxis, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.06.009
