Nosebleeds in children are a common symptom in children, causing various causes of rupture of nasal mucosal blood vessels and blood flowing out of the front and back nostrils. Most nosebleeds in children are caused by dry air, dry nasal mucosa, picking the nose or blowing the nose vigorously, etc., and there is no serious disease, which can be relieved by simple measures. However, some patients have frequent nosebleeds or heavy nosebleeds, and should seek medical attention as soon as possible to investigate the cause and be wary of local or systemic diseases in the nasal cavity.
epidemiology
infectivity
Some infectious diseases may cause symptoms of nosebleeds, such as influenza.
Good crowd
It is good for infants and young children.
symptom
Typical performance
1. Side farewell
Most epistaxis are unilateral or bilateral.
2. Frequency
It may be intermittent and recurrent bleeding, or it can be continuous bleeding.
3. Bleeding
The amount varies, with blood in the mucus, a few drops or several milliliters, and heavily up to tens or even hundreds of milliliters or more, leading to hemorrhagic shock.
4. Bleeding site
Most often occur in bleeding areas in the lower anterior part of the nasal septum, and sometimes ejective or pulsatile arteriolar bleeding is seen.
5. Crowd characteristics
Almost all epistaxis in adolescents and children occur in bleeding prone areas, and the bleeding site is mostly found in the back of the nasal cavity, and the arterial hemorrhage located near the posterior end of the inferior turbinate and the back of the nasal septum is the more common site of posterior nasal bleeding. The bleeding in this area is generally more fierce and difficult to stop the bleeding, and the bleeding often flows quickly into the pharynx and is vomited out of the mouth.
Concomitant symptoms
1. Suffer from chronic rhinitis, sinusitis, nasal polyps and other local lesions
The child has repeated nosebleeds, accompanied by long-term runny nose, nasal congestion, headache and changes in smell.
2. Recent history of exposure to special drugs and poisons
Children with nosebleeds, nausea, vomiting, rash, dizziness, confusion, etc., should be wary of poisoning or allergies.
3. Suffering from acute infectious diseases
It is often accompanied by fever, chills, muscle aches, fatigue, etc.
4. Suffering from hematological diseases
Repeated nosebleeds, skin bleeding points, gum bleeding, blood in the stool, etc., children may also have anemia, such as paleness, weakness and fatigue.
cause
Summary
Nosebleeds in children are often induced by dry air, dry nasal mucosa, or vigorous nose picking and blowing of the nose. This condition is generally mild and can be relieved on its own. However, if the child often has sudden nosebleeds or a large amount of nosebleeds, he should be wary of systemic lesions such as local nose lesions or blood diseases.
Symptom causes
1. Local causes
(1) Trauma
Nasal bleeding caused by injury to the nose, nasal septum, sinuses, anterior fossa and middle fossa floor caused by trauma and surgery, if the anterior ethmoid artery, internal carotid artery rupture or its pseudoaneurysm rupture, it can lead to severe epistaxis and even life-threatening. Severe coughing, sneezing, nose blowing, nose picking, nasal intubation, and sudden changes in naso-sinus air pressure (such as flying at high altitudes) can also cause epistaxis.
(2) Inflammation
(1) Non-specific inflammation of the nasal sinuses: such as acute rhinitis, acute rhinosinusitis, dry rhinitis, atrophic rhinitis, etc.
(2) Specific infections of nasal sinuses: such as nasal induration, tuberculosis, leprosy, diphtheria, syphilis, HIV, rhinomycosis, etc., can cause nosebleeds due to mucosal lesions.
(3) Nasal septum disease
These include deviated septum, septal ulcer, and nasal septum perforation, which often have epistaxis.
(1) Deviated septum: mostly occurs near the crest or talar process or on the convex surface of the deviation, where the mucosa is thinner and the tension is larger.
(2) Nasal septum ulcer: such as mucosal erosion, scab, ulceration.
(3) Nasal septum perforation: the perforation margin is dry or crusted.
(4) Tumors
Pediatric epistaxis caused by tumors generally do not have much bleeding in the early stages, but can occur repeatedly. Late destruction of large blood vessels can cause fatal hemorrhage. Vascular tumor bleeding is generally more severe.
(1) Benign and malignant tumors of the nasal cavity and sinuses: benign tumors such as hemangiomas, papillomas, fibrohemangiomas, etc., malignant tumors such as squamous cell carcinoma, adenocarcinoma, sarcoma, lymphoma, etc.
(2) Benign and malignant tumors of the nasopharynx: such as fibrohemangioma and nasopharyngeal cancer of the nasopharynx can cause epistaxis.
(5) Others
Such as nasal foreign bodies, nasal insects, etc., which can cause repeated nosebleeds.
2. Systemic causes
(1) Blood diseases
The nasal cavity is mainly hemorrhage, more common on both sides, often accompanied by bleeding from other parts of the body.
(1) Abnormal platelet quality or quantity: such as aplastic anemia, thrombocytopenic purpura, leukemia, etc.
(2) Abnormal coagulation mechanism: such as hemophilia, long-term use of salicylic acid drugs, extensive use of anticoagulant drugs, thrombolytic and fibrinolytic drugs, dysproteinemia, etc.
(2) Acute febrile infectious diseases
For example, influenza, measles, malaria, scarlet fever, typhoid fever, hemorrhagic fever and infectious hepatitis, etc., are mostly due to high fever, nasal mucosa congestion and dryness, resulting in bleeding, and the bleeding site is mostly in bleeding areas.
(3) Severe nutritional disorders and vitamin deficiency
When vitamin C, vitamin P, vitamin K and calcium are deficient, it causes changes in vascular fragility and affects the coagulation process, and is prone to nosebleeds.
(4) Chemical and drug poisoning
Phosphorus, mercury, arsenic, benzene, etc. poisoning can disrupt the function of the hematopoietic system and cause nosebleeds.
(5) Hereditary hemorrhagic telangiectasia
There is a family history, and bilateral nasal septal submucosa, tongue, lip, palm telangiectasia is common, and bilateral epistaxis are severe and recurrent.
(6) Chronic diseases of liver and kidney and rheumatic fever
Liver damage, coagulation disorders, and small vessel damage can also be accompanied by epistaxis.
Common diseases
Acute rhinitis, acute sinusitis, dry rhinitis, atrophic rhinitis, deviated septum, nasopharyngeal fibrohemangioma, nasopharyngeal cancer, poisoning, leukemia, etc.
Medical treatment
Home treatment
1. If your nose is bleeding, immediately gently pinch your nose with your thumb and index finger.
2. If you are injured, you should sit down, take a washbasin, and tilt your head forward, just above the basin, to prevent blood from flowing backward.
3. Press the nostrils for at least ten minutes, during which time do not raise your head.
4. Slowly release the pressing finger.
5. Continue to tilt your head forward and gently wipe the area around your mouth and nose with a piece of clean gauze or towel soaked in cold water.
6. If the nose is still bleeding, repeat the above steps.
7. If the bleeding still cannot be stopped, send it to the hospital immediately. During this period, the injured person must pinch their nose at all times.
Emergency (120) indications
1. Nosebleeds after a serious accident, such as after a car accident.
2. Heavy bleeding and nosebleeds are difficult to stop by pressing.
3. Nosebleeds affect normal breathing.
4. Other life-threatening diseases.
All of the above must be dealt with by calling the emergency number or emergency department in time.
Outpatient indications
1. Children have repeated nosebleeds.
2. Accompanied by new masses in the nasal cavity, accompanied by gradually worsening nasal congestion, abnormal sense of smell, and pus and odor.
3. Accompanied by repeated skin ecchymosis, gum bleeding, and wounds that are not easy to stop bleeding.
4. Other severe, persistent or progressive symptoms and signs appear.
Nasal mucosal bleeding, accompanied by the above conditions, must be consulted in time.
Visit the department
1. Nosebleeds or other critical situations should be treated in an emergency.
2. Considering that the child has nasal disease, relevant examinations and treatments can be carried out in the otolaryngology.
3. Children with stable condition can go to the pediatrician.
Preparation for medical treatment
1. Those who are in stable condition make an appointment to register in advance and bring their ID card/household registration book, medical insurance card, medical card, etc.
2. You may need to do a nasal examination to keep your face and nose clean and hygienic.
3. If you have recent medical experience, please bring relevant medical records, examination reports, laboratory test sheets, etc.
4. If you have taken some medications to relieve symptoms recently, you can carry a medicine box.
5. Arrange for parents to accompany them for medical treatment.
6. You can prepare a list of questions you want to consult in advance.
What questions doctors may ask patients
1. When do the symptoms of nosebleeds in children start? Is there a lot of bleeding?
2. Does your child have nasal congestion, nasal pain, runny nose and other symptoms? Is there blood in the snot and sputum?
3. Does your child have skin ecchymosis, bleeding spots, or bleeding gums?
4. Has your child had nosebleeds before? What causes it?
5. Have you had any recent trauma, colds, or rhinitis?
6. Do relatives have rhinitis, nasal tumors, or blood diseases?
7. Have you used any special drugs recently?
What questions can patients ask their doctor?
1. What is the most likely cause of my child’s nosebleeds?
2. Are there other possible reasons for my child’s condition?
3. What tests does my child need? Do I need to be hospitalized?
4. What treatment does my child need now?
5. Are there any risks associated with these treatments?
6. Does my child have other diseases, will this affect the treatment?
7. Can it be cured? Will it recur?
8. How should I take care of myself after returning home?
9. Does the disease need to be reviewed? How often?
examine
Expected inspection
The doctor will first perform a nasal examination of the child to preliminarily judge the nasal condition. A systematic physical examination may then be performed to determine the presence of systemic lesions. Subsequently, the child may be asked to do blood routine, coagulation mechanism tests, etc. If necessary, the child will be asked to undergo CT scan, nasal and sinus endoscopy.
physical examination
The doctor will first observe the child’s nose shape and skin condition, touch the child’s nasal area to determine whether there are abnormal lumps and tenderness, and check the nasal cavity. The doctor will also assess whether the child’s sense of smell is normal.
Laboratory tests
1. Blood routine
According to the hemoglobin level, the amount of bleeding can be judged, whether there is anemia. Determine whether platelets are abnormal.
2. Blood coagulation four items
It can reflect the body’s blood coagulation and is used to assist in the detection of hemorrhagic blood disorders.
3. Etiological examination
It can reflect the infection of the body and is used to rule out acute infectious diseases.
4. Blood biochemical examination
It can understand whether there are abnormalities in liver function and kidney function.
5. Secretion detection and culture
Nasal secretions are examined for characteristics, odors, and microscopic observation for the presence of pathogenic bacteria, blood cells, or cancer cells.
Imaging tests
1. Digital subtraction angiography (DSA) and CT angiography (CTA)
It helps to find the responsible vessels for intractable bleeding in the back of the nasal cavity and is of diagnostic significance for epistaxis caused by traumatic pseudoaneurysm.
2、MRI
It can be used to investigate intracranial vascular malformations in children with hereditary hemorrhagic telangiectasia and help clarify the diagnosis.
Pathological examination
For children with tumors, histopathological examination can be performed, and the doctor will take a small part of the tissue from the lesion to make a slice and place it under a microscope to observe the benign and malignant tumor.
Other tests
1. Anterior rhinoscopy
Anterior microscopy can detect bleeding in the front of the nasal cavity, such as whether there is a dilated venous plexus in the bleeding area below the front of the septum, whether the mucosa is eroded, and whether the nasal septum is perforated.
2. Nasal endoscopy
Nasal endoscopy has unique advantages in finding bleeding sites in the back of the nasal cavity. Before endoscopy, adequate anesthesia and contraction of the nasal cavity are required, and the anterior and lower parts of the septum, the back of the lower nasal passage, the lower part of the posterior septum, the margin of the posterior nostrils, and the olfactory fissure can be examined one by one according to the parts prone to nosebleeds.
diagnosis
Diagnostic principles
Doctors mainly judge the condition based on the child’s medical history, bleeding time, frequency, bleeding rate, changes in the child’s vital signs, whether there is obvious anemia, and clinical manifestations of anemia, combined with auxiliary examinations. For children with persistent bleeding and heavy bleeding, doctors will stop the bleeding first. For children whose nosebleeds have been suspended or have stopped bleeding, the doctor will first ask the parents about the child’s medical history, such as whether there is a recent history of colds, trauma, and whether there is a history of recurrent nosebleeds in the past.
differential diagnosis
1. Hemoptysis
People with hemoptysis often have a history of lung disease, which is pink foamy and blood mainly comes from the lungs and trachea. Sometimes nosebleeds flow into the mouth and come out of the mouth, pay attention to identification.
2. Vomiting blood
People who vomit blood often have a history of digestive system diseases, often brown or black in blood, and the blood mainly comes from the gastroesophagus. Sometimes severe nosebleeds will cause a large amount of blood to be swallowed and vomited out again, which needs to be identified.
treat
Anticipated treatment
The situation of nosebleeds is more complicated, most children do not have serious diseases, and occasional nosebleeds do not require medical attention, and simple measures can be implemented at home to stop the bleeding. Some patients with recurrent nosebleeds or heavy bleeding need to seek medical attention to clarify the cause and treat it.
Treatment
For children whose condition is stable and bleeding has stopped, the doctor will observe the patient’s symptoms, carefully inquire about the medical history, and give appropriate treatment after clarifying the cause in combination with various examinations. For some children with continuous heavy bleeding, the doctor will examine the nasal cavity and nasopharynx in detail, and according to the bleeding situation and bleeding site, local hemostatic drugs, cauterization, freezing, tamponade, electrocoagulation, surgery and other methods will be used to stop local bleeding. In the case of severe bleeding, the child and his companion are often nervous, and if necessary, chlorpromazine or lumina sodium can be injected to calm it down and reduce bleeding. Cold compresses on the neck, neck, head, and chest also reflexively reduce bleeding.
drug therapy
1. Vitamins
It can supplement nutrients such as vitamins C, K, P, etc.
2. Hemostatic agent
When the hemostasis cannot be stopped by compression, drugs can be considered to stop the bleeding, and the commonly used drugs are thrombin, antifibrinolytic aromatic acid, 6-aminocaproic acid, phenol sulfoethylamide, Yunnan Baiyao capsules, etc.
3. Local injection of sclerosing agent
For those with recurrent bleeding, local sclerosing agents can be injected to form scar tissue in the area, occluding blood vessels and stopping bleeding.
4. Sedative drugs
In the case of severe bleeding, the child is often accompanied by nervous tension, and if necessary, sedative drugs can be injected to calm it down and reduce bleeding. Commonly used drugs are chlorpromazine, lumina sodium, etc.
Related drugs
Thrombin, antifibrinolytic aromatic acid, 6-aminocaproic acid, phenol sulfoethylamide, Yunnan Baiyao capsules, chlorpromazine, lumina sodium, vitamin C, vitamin K, vitamin P
Surgical treatment
1. Submucosal dissection or scratching of the nasal septum
For repeated bleeding in front of and below the nasal septum, this surgery may be considered.
2. Nasal septal skin grafting
This procedure can be performed in patients with hereditary hemorrhagic telangiectasia.
3. Correction of deviated septum
If the nasal septum is deviated, this technique can be used to correct it.
Other treatments
1. Acupressure to stop bleeding
The child can pinch both nasal wings with his fingers or press the bleeding side of the nasal septum to the nasal septum for about 10~15 minutes, and cold compresses can be applied to the forehead and back of the neck at the same time. This method is suitable for children with low bleeding and bleeding sites in bleeding areas.
2. Cauterization to stop bleeding
After contraction and surface anesthesia of the nasal mucosa, the bleeding blood vessels are closed with physical therapy. This method is suitable for patients with repeated small bleeding and clear bleeding points, and the cauterization effect under nasal endoscopy is better.
3. Stopping bleeding by tamponade method
It is the most effective and commonly used method of nasal hemostasis. It is suitable for those with severe bleeding, large bleeding surface or unknown bleeding site. This method uses tamponade to directly compress the nasal bleeding site to block the ruptured blood vessel and achieve the purpose of hemostasis. Including anterior nostril nasal tamponade and posterior nostril nasal tamponade.
4. Nasal endoscopic hemostasis
With the help of nasal endoscopes, it is easy to identify the active bleeding points in various parts of the nasal cavity, especially the posterior nasal cavity. At the same time, hemostasis treatment was completed by means of nasal local tamponade, laser, microwave, high-frequency electrocoagulation and other means under direct observation, with little damage, less pain for the child, accurate and rapid hemostasis, and good effect.
5. Vascular ligation to stop bleeding
For those who cannot stop bleeding after repeated anterior and posterior nostril tamponade and medical treatment, vascular ligation can be considered for those who have severe bleeding from trauma or surgical damage to large blood vessels. The contraindication is epistaxis caused by coagulation mechanism disorders.
6. Vascular embolization method to stop bleeding
Bleeding vessels are determined under digital subtraction to embolize the target artery. This method is suitable for refractory epistaxis, through effective repeated anterior and posterior nasal tamponades, especially the use of nasal endoscopy combined with laser, electrocoagulation and microwave and internal medicine treatment that cannot stop bleeding, trauma or surgical injury to large blood vessels with violent bleeding and pseudoaneurysm rupture diagnosis and treatment of rupture. This procedure cannot be used to control epistaxis caused by the anterior or posterior ethmoid artery. Those who are allergic to contrast media; Severe liver and kidney insufficiency; intramaxillary artery, ophthalmic artery and vertebral artery with anastomotic branches; This method is contraindicated for epistaxis caused by coagulation mechanism disorders.
预后
一般预后
总体来说，流鼻血患儿经过积极的治疗，其预后大多是比较好的。但严重的外伤如颅底骨折伤及颈内动脉，鼻腔、鼻窦、鼻咽部恶性肿瘤晚期及白血病引起的大出血，预后往往较差。
危害性
反复少量出血可引发贫血，部分病情严重患儿可致失血性休克导致死亡。
自愈性
多数少量出血可自止或自行压迫后停止。
治愈性
小儿流鼻血经过原发病的治疗以及对症治疗出血可以停止，部分病情严重的患儿可能出血不止。
治愈率
多数患儿流鼻血的症状可以缓解。
根治性
部分小儿流鼻血随着病因的去除，流鼻血的情况可以恢复正常，一些患儿的流鼻血情况会反复出现。
复发性
部分患儿会反复出现流鼻血的情况。
日常
护理原则
要找出出血的原因，采取有效的预防措施，伴有鼻部疾患的，可行手术，房间干燥可改善房间的温湿度。
心理护理
针对患儿的紧张情绪，要稳定患儿情绪，用和蔼可亲的态度去安慰患儿消除紧张、恐惧感。避免患儿忧虑、过分紧张。协助患儿进行洗脸、洗脚，口腔护理，消除孤独感。
生活管理
1、生活环境
温湿度要适宜，避免干燥引起出血，鼻腔可滴入薄荷石蜡油等，保持鼻黏膜湿润。填纱条及拆纱条时动作都要轻柔，防止因粗鲁动作损伤黏膜造成新的出血。
2、口腔护理
进行漱口，防止出血后口腔中的异味及细菌繁殖等。
病情监测
1、局部观察
患儿经过治疗后，要继续观察有无局部出血。
2、全身情况观察
要注意观察全身情况变化，如出血较多的会出现血压下降，脉细，面色苍白，出冷汗，烦躁不安，口渴等，要警惕休克。注意患儿的休息，局部填塞后患儿头痛，影响休息，可遵医嘱给于服镇静、催眠药，保证患儿睡眠。
饮食
饮食调理
鼻腔填塞的患儿，吃饭吞咽有一定困难，要鼓励患儿多食入一些高蛋白、高维生素、补血的食物，避免食入上火的食物。保持大便通畅，防止因便秘引起压力增高导致再出血。
Dietary advice
1. The diet should be comprehensive, and some grains such as millet can be added to the staple food to increase nutrition.
2. You can eat more foods rich in vitamin K, such as spinach, purple cabbage, cabbage, and lettuce.
3. Pay attention to the intake of high-quality protein, and pay attention to supplementing iron-rich foods such as pork liver and red meat.
4. Eat more vegetables and fruits, keep the stool smooth, and avoid nosebleeds caused by excessive force.
Dietary taboos
1. Don’t eat spicy and irritating foods.
2. Drinking less coffee and tea may affect iron absorption.
3. Pay attention to overly cold and overheated food before eating.
prophylaxis
Preventive measures
1. Maintain the temperature and humidity of the room appropriately, and use a humidifier to increase the indoor humidity when the air is dry.
2. Avoid blowing your nose vigorously, picking your nose with sharp objects, and try not to pick your nose.
3. Keep the nasal cavity moist, you can use saline nasal drops or nasal sprays.
4. Avoid frequent use of cold medicines and anti-allergy drugs, excessive use may cause nasal dryness and bleeding.
5. When using special drugs, you need to strictly follow the doctor’s instructions and pay attention to monitoring toxic side effects.
6. Family members should tell children not to put any objects in the nasal cavity. If your child likes to pick his nose, pay attention to trimming his nails.
7. Actively treat underlying diseases, such as deviated septum, hypertension, liver and kidney diseases, etc.
8. Drink enough water every day, keep your throat and airway moist, and wear a mask when you go out.
9. Children should stay away from second-hand smoke.