Dr Irfan Zafar P.G.R. /E.N.T.

Supervisor Prof Dr Israr Ahmed

PAEDIATRIC

EPISTAXIS

Abstract
In 100 successive cases of epistaxis in children

,71 were idiopathic followed by accidental trauma and forigen body(12/100). Infection in the nose , nasopharynx (adenoids)was seen in 7/100. tumor in nose and paranasal sinuses, nasopharynx in 5/100 and bleeding disorders were also seen in 5/100 respectively. Males and females were affected in ratio 2:1. Except in cases of tumor ,forign body , medical treatment was adequate to control bleeding.

introduction
Epistaxis or bleeding from nose is a

frequently seen symptom in children presenting to E.N.T. department .Interior of nose is a very vascular area supplied by both external and internal carotid system. There is a rich confluence of vessels in the littles area, which is dependent antero-inferior part of nasal septum and is frequent site of bleeding
2.

Introductioncontd
Epistaxis in children can vary from blood

stained nasal discharge to serious bleeding.Bleeding can be unilateral or bilateral. Epistaxis can be accompanied by a variety of other symptoms and signs like nasal obstruction , nasal discharge, which may be foul smelling. Present study was conducted to identify causes of epistaxis in children and to suggest appropriate treatment for each group.

Patients and methods

Patient with epistaxis were received either in emergency or in the outdoor, E.N.T. department

or were refered from other departments like Paediatrics. Patients presenting with an acute episode of epistaxis were given initial medical treatment by pinching of nose , anterior nasal packing and sometimes blood transfusion as required. .All patients presenting in between the episodes of epistaxis were acessed by history , general physical examination , E.N.T. and systemic examination

Patients and methods

. In addition complete blood and urine

examination , bleeding and clotting profile were obtained including platelet count.Liver function tests were obtained in relevent cases. Radiology of nose , paranasal sinuses and nasopharynx and plain chest x ray was obtained in all cases.. C.T. scan of nose ,para nasal sinuses and nasopharynx was done in cases where a tumor was suspected.

Results
Table 1 ----age incidence
Birth 1-2 years 2-3 years 3-4 years 4-5 years 5-6 years 6-7 years 7-8 years 8-9 years 9-10 years 10-11 years 11-12 years Nil Nil 2 3 5 5 7 11 15 17 17 18

results
Table 2 -----sex incidence

Male Female Total

66 34 100

66% 34%

Results
Table 3 ----causes of bleeding
With normal coagulation Causes Idiopathic Foreign body nose and trauma number 71/100 12/100

U.R.T. infection
Tumors With abnormal coagulation Acute leukemia Von willebrand Disease Haemphilia

7/100
5/100 1 1 3

Modes of treatment
Medical treatment Nasal pinch-ing and local applic -ation of Emol-ient Anteri or nasal packi ng Poste rior nasal packi ng Caute ry of bleedi ng point Remo val of foreig n body

Surgical treatment Ligati Aden on of oidect vessel omy s Septa l surge ry Remo val of tumor s Angio fibro maGi -ant cell granu loma Radia tion of tumor

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DISCUSSION
Despite the fact that causes of epistaxis in pediatrics population are at cosiderable variance

from those seen in adults,previous studies have tended to the group causes of epistaxis in children and adult together.This study was conducted to focus on the causes of epistaxis seen in paediatric population and to discuss treatment. As in adults,the group in which no cause could be identified(Idiopathic)comprised of largest (71/100).

DISCUSSION
It has been postulated that frequent picking of

nose leads to ulceration and crusting of the fragile nasal mucosa. These crusts on separation either by finger or by forceful sneezing lead to bleeding and this is the most common cause of spontaneous bleeding from the nose seen in children. This problem tends to exacerbate in hot and dry climate because of itching in nose . Pinching of nose and local cold application is enough to stop bleeding in majority of these cases of spontaneous nasal bleed .

Discussion ---contd
Rarely anterior packing or electric /chemical cautery

is required to control bleeding, this is to be followed by local application of emolient like petroleum jelly for 2-3 weeks. Nasal picking of course is to be avoided . Trauma and forign body constitute the next common group (12/100). Any young child having history of foul smelling blood stained nasal discharge should be suspected of having a nasal foreign body until proved other wise. These cases continue to be neglected and are given frequent courses of antibiotic which proove unfruitful unless the forign body is removed.

Discussion---contd
Nasal infections and adenoids can give rise to

bilateral nasal bleeding specially , on forceful blowing of nose while cleaning . These cases quickly clear up with medical treatment and rarely hospital admission required.

References
1. Shaheen.O.M.,In Mackay S.T.and bull T.R.(Ed) Scott Browns Otolaryngology, 5th Edition Vol4

.London, Butter Worth,1987: 272-282. 2.Monux A.,Toms M., KaiserCand Gavilane: Conservative Management of Epistaxis. The Journal of Laryngology and Otology 1992;104:868-870 3.Narula A.A.,Vallis M. P. Bradley P.J.:Surgical management of nose bleed.J.Laryngol.Otol 1987:101:359-362

Refrences
4.Singh b. : Combines Int. Maxillary and ant.

Ethmnoidal arterial occlusion: the treatment of choice in intractable Epistaxis :J.laryngol.Otol.1992:106;507-710 5.Zaidi.S.H.Jafri I.H. Juvenil nasopharyngeal angiofibroma: Pak .J. otolaryngology, 1987;4:77-84.