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Evaluation of epistaxis in children

Anna H Messner, MD
Section Editors
Jonathan I Singer, MD
Glenn C Isaacson, MD, FAAP
Deputy Editor
James F Wiley, II, MD, MPH


Epistaxis is common in children. Childhood nosebleeds are rarely severe and seldom require hospital admission [1]. Nonetheless, frequent minor nosebleeds can be both bothersome and alarming for parents and children.

The evaluation of epistaxis in children will be reviewed here. The epidemiology, etiology, and management of epistaxis in children are discussed separately. (See "Epidemiology and etiology of epistaxis in children" and "Management of epistaxis in children".)


Although nosebleeds in children are rarely life threatening, the initial evaluation should focus upon the respiratory and hemodynamic stability of the patient rather than the bleeding. Normal appearance, vital signs, and respiratory function are evidence that the examiner can safely attend to the presenting complaint. On the other hand, abnormalities in these indices may signal an emergency. Airway intervention and fluid resuscitation are sometimes necessary in massive epistaxis. (See 'Emergency treatment' below.)

The goal of the evaluation is to determine the site and etiology of bleeding. Nosebleeds in children have a variety of etiologies, ranging from self-limited mucosal irritation to life-threatening neoplasms (table 1). Distinguishing between local and systemic causes of bleeding is critical to the institution of timely and appropriate therapy [2]. (See "Epidemiology and etiology of epistaxis in children" and "Management of epistaxis in children".)


Rapid assessment of general appearance, vital signs, airway stability, and mental status are necessary to identify children with respiratory or hemodynamic instability who require airway intervention and/or fluid resuscitation [3,4]. Airway intervention is needed for patients who are spitting or regurgitating blood [5]. (See "Emergency endotracheal intubation in children" and "Hypovolemic shock in children: Initial evaluation and management", section on 'Fluid resuscitation' and "Management of epistaxis in children".)

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Literature review current through: Nov 2017. | This topic last updated: Sep 07, 2016.
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  1. Brown NJ, Berkowitz RG. Epistaxis in healthy children requiring hospital admission. Int J Pediatr Otorhinolaryngol 2004; 68:1181.
  2. Edelstein DR, Khabie N. Epistaxis. In: Primary Pediatric Care, 4th ed, Hoekelman RA (Ed), Mosby, St. Louis 2001. p.1058.
  3. Delgado EM, Nadel FM. Epistaxis. In: Fleisher and Ludwig's Textbook of Pediatric Emergency Medicine, 7th edition, Shaw KN, Bachur RG (Eds), Wolters Kluwer, Philadelphia 2016. p.149.
  4. Alvi A, Joyner-Triplett N. Acute epistaxis. How to spot the source and stop the flow. Postgrad Med 1996; 99:83.
  5. Bernius M, Perlin D. Pediatric ear, nose, and throat emergencies. Pediatr Clin North Am 2006; 53:195.
  6. McIntosh N, Mok JY, Margerison A. Epidemiology of oronasal hemorrhage in the first 2 years of life: implications for child protection. Pediatrics 2007; 120:1074.
  7. Hey E. Sudden oronasal bleeding in a young child. Acta Paediatr 2008; 97:1327.
  8. 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.
  9. Rees P, Kemp A, Carter B, Maguire S. A Systematic Review of the Probability of Asphyxia in Children Aged <2 Years with Unexplained Epistaxis. J Pediatr 2016; 168:178.
  10. Sandoval C, Dong S, Visintainer P, et al. Clinical and laboratory features of 178 children with recurrent epistaxis. J Pediatr Hematol Oncol 2002; 24:47.
  11. Medeiros D, Buchanan GR. Major hemorrhage in children with idiopathic thrombocytopenic purpura: immediate response to therapy and long-term outcome. J Pediatr 1998; 133:334.
  12. Katsanis E, Luke KH, Hsu E, et al. Prevalence and significance of mild bleeding disorders in children with recurrent epistaxis. J Pediatr 1988; 113:73.
  13. Coleman CC Jr. Diagnosis and treatment of congenital arteriovenous fistulas of the head and neck. Am J Surg 1973; 126:557.
  14. Pathak PN. Epistaxis--due to ruptured aneurysm of the internal carotid artery. J Laryngol Otol 1972; 86:395.
  15. Köroglu M, Arat A, Cekirge S, et al. Giant cervical internal carotid artery pseudoaneurysm in a child: endovascular treatment. Neuroradiology 2002; 44:864.
  16. Chong LY, Head K, Hopkins C, et al. Intranasal steroids versus placebo or no intervention for chronic rhinosinusitis. Cochrane Database Syst Rev 2016; 4:CD011996.
  17. Guarisco JL, Graham HD 3rd. Epistaxis in children: causes, diagnosis, and treatment. Ear Nose Throat J 1989; 68:522, 528.
  18. Krempl GA, Noorily AD. Use of oxymetazoline in the management of epistaxis. Ann Otol Rhinol Laryngol 1995; 104:704.
  19. Hurtado TR, Zeger WG. Hemotympanums secondary to spontaneous epistaxis in a 7-year-old. J Emerg Med 2004; 26:61.