Immediate Questions

A. How old is patient? Nosebleeds are unusual in very young children. In adolescent boys, juvenile nasopharyngeal angiofibroma (JNA) is a rare, benign, highly vascular neoplasm of the nasopharynx that can cause significant bleeding.

B. Was there trauma to the nose? Allergic rhinitis can cause itching and subsequent rubbing of the nose, traumatizing mucosa. Prior trauma from a direct blow on the nose may cause septal injury and bleeding. A dry environment causes crusting, and young children may be prone to picking the nose, irritating septal mucosa. Unilateral foul or purulent nasal discharge suggests a foreign body. In hospitalized patients, indwelling nasal tubes or suction trauma may injure mucosa and promote bleeding.

C. What medication(s) has patient taken? Use of NSAIDs promotes bleeding, particularly in children with undiagnosed coagulopathy. Antihistamines may thicken secretions and cause drying and cracking of mucosa. Nasal sprays, particularly those not in an aqueous vehicle or that rely on propellants, can traumatize mucosa. Patient should be instructed on proper way to spray nasal medications, directing stream away from septum. Herbal or alternative medications (eg, ginseng) may be associated with bleeding.

Is there a history of recent surgeries? Procedures requiring nasal intubation can injure mucosa. Adenoidectomy, sinus surgery, and repair of nasal fracture, among other procedures, all carry a small risk of postoperative bleeding, as does use of a nasal tube with a pH probe or nasogastric (NG) tube after an abdominal procedure.

History of bleeding problems? Many children have never been surgically challenged; therefore, seek information suggesting coagulopathy (eg, unusual or prolonged bleeding with circumcision, umbilical cord separation, or dental extractions; unusual bruising with play or immunizations; history of unusual or large bruises in muscles or joints; unusually heavy menstrual flow in adolescent girls; history of blood transfusion; family history of bleeding problems).

Any systemic illnesses? Renal and hepatic diseases are associated with bleeding problems. Does child have a hematologic malignancy?

What therapy has been offered to prevent or stop nosebleeds? Measures to moisten mucosa and humidify the nasal cavity are most effective in preventing bleeding. With active bleeding, using ice, pinching nasal bones, or having child lie down are not effective. Lying down may cause blood to enter the posterior pharynx, causing child to choke and gag. Is bleeding unilateral? Is there blood in the mouth? Most bleeding occurs from anterior septal vessels and may be unilateral or switch from side to side. Consider posterior epistaxis if blood is seen entering the posterior oropharynx when child has not been lying down.

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