Epistaxis

Etymology taken from the Greek, epistaxis is the outflow of blood from the nose

What causes it in children ?

In the vast majority of cases, it is a child who bleeds frequently from the nose (on one or both sides) and who returns regularly to the consultation. The examination reveals small vessels on the vascular spot (the front wall of the nasal septum), forming a real tree-like structure. These vessels are fragile and bleed at the slightest local mishap (untimely scratching, chronic purulent or clear nasal discharge, especially in case of allergic attack). Other cyclical factors are well known to ENT specialists. These include the season :

• In summer, heat creates a normal vasodilatation of the vessels, aggravating their fragility and favoring bleeding ;

• In winter, the phenomenon is the same. Excessive heating and the lack of humidification of the rooms (starting with the bedroom) create a local dryness that is detrimental and favors bleeding

Why children ?

It is commonly accepted that the vessels of the vascular spot are more fragile at this age. Certainly because young people are growing for years and the organs that follow this development are more fragile during the growth phase. These epistaxis stop spontaneously in adulthood.

In adults, what are the causes ?

The diagnosis is different: let’s exclude epistaxis in patients with anticoagulant treatment, where epistaxis can be a sign of poor treatment balance. The diagnosis remains simple, but goes far beyond the ENT framework. The same is true of the patient with a hematological disorder, whether the epistaxis is indicative of the diagnosis or in a patient treated with chemotherapy, which can affect the platelet line. These include :

• Epistaxis in a patient with crusty rhinitis, causing aggressive cleansing that damages the mucosa and promotes iterative bleeding. Treatment is based on local lubrication and antibiotic ointment.

• A septum perforation at the level of the vascular spots, whatever its cause, triggers the same effects and will benefit from the same treatments.

• Rendu-Osler disease, although rare, is formidable. It is a familial disease transmitted by the autosomal dominant mode (i.e. by the non-sexual chromosomes and only one allele out of two is sufficient to transmit the disease). It is a potentially serious disease, recognizable by the presence of telangiectasias (dilation of small vessels resulting in purplish spots, sometimes visible on the lips, tongue, fingers and very frequent in the nose), which have the characteristic of bleeding very easily. The severity of the disease is due to the frequency of bleeding, which can affect many organs.
Their treatment ranges from transfusion (repeated bleeding causing anemia) to drug treatments, but also embolization by solid microparticles released into the circulation and blocking the feeding arterial trunk causing the bleeding.

• A severe blood pressure surge can trigger epistaxis. This should be considered a valve and the patient should be reassured that epistaxis is preferable to intracranial bleeding.

• An infected sinusitis can cause epistaxis, but also a nasal tumor, whether benign or malignant (rare). The examination makes the diagnosis. Medical and/or surgical treatment solves the problem of bleeding. Here are listed the main causes of epistaxis in children and adults, keeping in mind two essential points :

• It is most often children,
• The prognosis (except for Rendu-Osler, which is particularly recurrent and affects many organs) is always not serious.

Treatment of epistaxis : what not to do

Before necessarily going to the ENT when epistaxis recurs, simple means are sufficient, in the vast majority of cases, to solve the problem immediately. Provided, of course, that you practice the right gestures. However, the treatment methods that are reported to us and scrupulously applied by zealous patients are sometimes mind-boggling.

In case of a nosebleed, apply a cold wet cloth on the back of the neck (or on the forehead, or even ice in the mouth) and lie down.

If the bleeding does not stop, it will immediately disappear at the sight of the worried patient, since the blood, like any fluid, will take the shortest and most sloping route, flowing into the back of the patient’s throat, who is immediately reassured, but should not be. Attila died in this way on his wedding night !
This method, contrary to common sense, does not solve anything and can even complicate the evolution. Indeed, the blood clot that accumulates in the back of the nose or the back of the throat can move, once the patient is asleep, taking, once again, the shortest way offered to it: the trachea and the lungs ! Fortunately, nosebleeds have never killed anyone, at least if we exclude the rupture of the carotid artery in a deep sinus. But this is a very different context and remains an exception within an exception

In case of a nosebleed, the root of the nose (at the very top of the nose) must be pinched.

The root of the nose (at the level of the clean bones of the nose) does not get depressed. It will therefore be very difficult to stop anything. This method will not regenerate anything either.

What to do

Let’s remind you, in a simple way, what you should do before going to the specialist.

• Tilt your head forward to let the blood out,
• Blow your nose (this will not increase the flow, on the contrary, because the clots maintain the bleeding),
• And pinch the tip of your nose between your thumb and forefinger for ten minutes, watch in hand To do this, you need two fingers and not one (because you are not compressing anything). You can use a bit of Coalgan^©but this requires that you have it at your disposal, while your fingers are always on the trip !

Subsequently, the treatment at the ENT office will consist of a cauterization of the vascular spot(s) with caustic acid. This method does not last forever, but usually leaves the child alone for six months. Finally, cauterization of the vascular spot is painless and children who are used to it have no anxiety about coming back to the office for a minimally invasive procedure.

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