Differential Diagnosis

A. Anterior Epistaxis. The most common source of bleeding in children is at the confluence of anterior ethmoidal, sphenopalatine, and nasopalatine arteries and veins in the anterior septum (Kiesselbach plexus or Little area). Bleeding may be unilateral or switch from one side to the other. Dry ambient environment contributes to bleeding, as does nose picking. Bleeding may recur on frequent basis.

B. Posterior Epistaxis. Unusual in children. Bleeding can be brisk and appear to be bilateral. Blood often pours down back of nose and into oropharynx.

C. Neoplasms. JNA in adolescent boys is associated with prior self-limited bleeding before a more brisk event occurs. May cause nasal obstruction, initially unilateral. Nasopharyngeal carcinoma (NPC) is seen in teenage African-American boys in the United States. Nasal obstruction and ipsilateral serous otitis media or firm cervical lymph nodes are noted on exam.

D. Coagulopathies. Bleeding history serves as guide to possibility of coagulopathy. Obtain laboratory tests as indicated.

E. Foreign Body. Small children may present with a long-standing history of unilateral purulent or foul nasal discharge. Diagnosis is by examination; treatment is removal.

F. Trauma. History of overt injury is usually easily obtained. Fractures will have physical signs of displaced nasal bones or septum. Picking or rubbing nose may be a response to allergic itching.

G. Systemic Illness. History and physical exam should provide clues to presence of systemic disease causing nosebleed.

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