A. Physical Exam Key Points. Diagnosis of epistaxis is usually readily made based on history or physical exam.

1. General appearance. Pallor, toxicity, and signs of shock or malignancy may be present, but pediatric epistaxis is rarely severe enough to cause hemodynamic instability or chronic anemia. Most children appear healthy and active; patients with malignancy or severe systemic disease are exceptions.

2. Vital signs. Tachycardia and hypotension are not expected without unusual brisk hemorrhage.

3. EENT. Unilateral serous otitis media with a firm ipsilateral cervical lymph node suggests NPC. Hypoesthesia over V2 or abnormalities of extraocular muscles suggests invasion of inferior orbital fissure, seen with advanced JNA. Blood pouring into the posterior oropharynx is suggestive of posterior bleeding. Excoriation of the nares on one side with foul odor suggests a foreign body. Evaluate for signs of atopy (eg, allergic shiners, Denny crease, mouth breathing).

4. Anterior rhinoscopy. Keys to locating an active source of anterior bleeding or intranasal foreign body are adequate light, appropriate instruments, cooperative patient, and skilled assistance. Assess color and texture of mucosa. Clear secretions, boggy turbinates, and bluish mucosa are seen in patients with allergic rhinitis.

5. Nasopharyngoscopy. Used to define presence of a nasopharyngeal mass and carried out, in the absence of active bleeding, after topical decongestion and analgesia of nasal mucosa.

B. Laboratory Data. Routine laboratory studies, including PT and PTT, are not needed in healthy children with negative personal and family bleeding histories and diagnosis suggestive of common anterior epistaxis.

1. CBC with platelet count and differential. Warranted with history of significant blood loss, suspicion of bleeding disorder in patient or family, or with long-standing, recurrent bleeding.

2. Von Willebrand evaluation. Useful when medical or family history suggests coagulopathy.

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