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Pediatric epistaxis: Epidemiology, management & impact on quality of life
G Model PEDOT 7132 No. of Pages 4
International Journal of Pediatric Otorhinolaryngology xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Pediatric epistaxis: Epidemiology, management & impact on quality of life Karen Davies a, *, Kadambari Batra a , Rania Mehanna a , Ivan Keogh a,b a b
Department of Otolaryngology Head and Neck Surgery, UCHG, Ireland Academic Department of Otolaryngology, NUIG, Ireland
A R T I C L E I N F O
A B S T R A C T
Article history: Received 13 February 2014 Received in revised form 6 May 2014 Accepted 7 May 2014 Available online xxx
Objective: Epistaxis in the pediatric population is a common problem for both primary care physicians (PCPs) and otolaryngologists. Although a frequent reason for referral to ENT clinics, data is lacking regarding causes, effects on quality of life and common treatment modalities. Methods: Prospective, clinical and questionnaire based study, with ethical approval. We identified 50 cases of pediatric epistaxis (<16 years old) over a 6-month period. A thorough clinical history was taken, first aid measures and management outcome was recorded. The impact of recurring epistaxis on parental quality of life was assessed using the Parental Stress Index Short Form (PSISF). Results: Thirty-three males and 17 females (2:1) were included. Mean age at presentation was 8.8 years. Initial management was inadequate, with only 30% of carers applying appropriate first aid measures. Quality of life was significantly affected in 10% of cases with primary parental concerns being fear of excessive blood loss and the stress of soiled bedclothes and night wear. Children were most affected by the negative impact on sporting activity. Otolaryngology consultation found the common causes to be iatrogenic trauma and rhinitis affecting “Littles” area. Of which 78% required silver nitrate cautery, and 22% just required reassurance and advice Conclusions: Recurrent minor nosebleeds in children can be troublesome and alarming for parents and children. We found the PSISF an easy and reliable method of assessing patient and parental stress in dealing with this problem. Raising awareness of simple management strategies among parents and PCPs could significantly reduce associated quality of life issues. Mucosal hydration, cautery and first aid advice are the fundamentals of management. ã 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Epistaxis Pediatric Parental stress index Quality of life Emergency
1. Introduction Epistaxis in the pediatric population is a common problem faced by both primary care physicians (PCPs) and otolaryngologists [1]. Childhood epistaxis is rarely severe and unlikely to require nasal packing or hospital admission. Most are spontaneous, anterior and self-limiting. Gently pressing the nasal ala for 5– 10 min is usually all that is required. Up to 60% of children will have had at least one nosebleed by age ten. Commonly occurring between the ages of 3 and 8 years, the incidence declines in adulthood. However 50% of all adults presenting with epistaxis had epistaxis during childhood. Children younger than 2 years rarely present with epistaxis (1:10,000), trauma (accidental or non accidental) or serious illness (e.g., acute
* Corresponding author. Tel.: +353 851270364. E-mail address: [email protected] (K. Davies).
leukaemia) should be suspected. When a young baby presents with epistaxis, some pediatric health care providers recommend that social workers get involved to investigate the possibility of nonaccidental injury [2]. Incidence is highest in the winter months, being linked to a higher rate of upper respiratory tract infections [3]. The commonest site is the anterior part of the nasal septum, “Little's area” or Kiesselbach's plexus [4]. The majority of cases are idiopathic, but severe, recalcitrant bleeds may have a significant underlying cause such as Hereditary Heamorrhagic Telengiectasia or Juvenile Nasal Angiofibroma in teenage boys. Bleeds can be unpredictable and may have an impact on the quality of life for children and their families. Although epistaxis is a frequent cause for referral to a pediatric otolaryngology clinic in the West of Ireland, very little data is actually available regarding its causes, effects on quality of life, commonly offered treatments and their outcomes. The general awareness about first-aid management of this common condition is lacking amongst children and parents [5].
http://dx.doi.org/10.1016/j.ijporl.2014.05.013 0165-5876/ ã 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: K. Davies, et al., Pediatric epistaxis: Epidemiology, management & impact on quality of life, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.05.013
G Model PEDOT 7132 No. of Pages 4
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K. Davies et al. / International Journal of Pediatric Otorhinolaryngology xxx (2014) xxx–xxx
2. Objectives With this study we aimed to improve our understanding of the epidemiology of epistaxis in the pediatric age group in the West of Ireland. In collecting a detailed history of this common pediatric problem, we assessed the general awareness of caregivers and evaluated the first-aid management knowledge in the study group. We also sought to use this study as a means to assess the impact on quality of life for both children and their parents when dealing with recurrent epistaxis. 3. Patients and methods Approval for this study was obtained from the Clinical Research and Ethics committee of Galway University Hospital. We then carried out a prospective clinical and questionnaire based study from October 2012 to March 2013. We included all children between the ages of 0–16 years presenting or referred to the Department of Otolaryngology, University College Hospital Galway with recurrent epistaxis. We excluded any child who had a history of otolaryngology referral for epistaxis or prior nasal cautery. A proforma was designed to record all the clinical details and subsequent management with a specific section to assess knowledge levels and awareness of first-aid management of epistaxis. A thorough clinical history and physical examination was performed. Clinical examination included a comprehensive head and neck examination to include anterior rhinoscopy and flexible nasoendoscopy in co-operative patients. The Parental Stress Index Short Form (PSISF) [6] was used to evaluate the effects of epistaxis on the quality of life of the parents and children concerned. PSISF is a validated derivative of the fulllength test and consists of a 36 item self-scoring questionnaire, being applicable for children and parents. It yields a total stress score from three scales: Parental Distress, Parent-Child Dysfunctional Interaction and Difficult Child. It is measured in percentiles and takes less than 10 min to perform. 4. Results Fifty patients were included in our study. Ages ranged from 1 year to 16 years with a mean age of 8.8 years. There were 33 males and 17 females (ratio of 2:1). Common local etiological factors were superficial dilated vessels in Little's area frequently traumatized by nose rubbing, digital trauma, allergic rhinitis, use of topical intranasal steroid sprays, or a preceding history of foreign bodies insertion. Of the fifty cases we encountered, 5 children (10%) reported high total stress scores. These corresponded to the 40% of patients who suffered daily or twice daily episodes of bleeding that tended to last longer than the average bleed time of 5–10 min. The significant impact in this patient group was most apparent as interruptions in classroom and sporting activities Forty-four of the 50 (88%) patients suffered only one episode of epistaxis a week. The duration of each episode was less than 5 min in over 32 (60%) of cases. The timing of each episode was variable in 14 of the 50 (28%), with the average bleed lasting between 5 and 10 min. As such, 27 of the 50 children (54%) reported low total stress scores and no direct effect on their quality of life as a result of relatively minor episodes of epistaxis. The primary caregivers reported moderate scores in 19 cases and very high scores in three cases across all four aspects of the PSISF which yields a total stress score from three scales: Parental Distress, Parent-Child Dysfunctional Interaction and Difficult Child. As it can be difficult for parents to assess the quantity and volume of blood loss during an acute episode of epistaxis, for the purpose of the study we divided the volume of blood loss into a
little, moderate amount, a lot of blood and variable amounts. The severity of the bleeds was subjectively assessed as a lot by parents in 30 (60%) of the cases. The fear of excessive blood loss was a significant factor in causing high parental distress scores. The soiling of nightwear and bedclothes was noted to be of particular concern with high scores in Parent-Child Dysfunctional Interaction and Difficult Child scales. 22 parents and 14 children also reported symptoms of anxiety and fear associated with each episode. Twenty-one patients (42%) presented with bilateral epistaxis and 29 (58%) had a unilateral presentation. There appeared to be a slight predilection for the left nasal cavity as the source of the bleed, with 16 patients reporting mainly left sided epistaxis. However laterality had no impact on stress scores in either patient or primary care giver. Thirty two patients (64%) complained of a perennial problem of epistaxis, the remaining 18 patients felt that bleeds were more prominent during the autumn and winter months. There was a positive family history of epistaxis in 23 patients (46%). This again had no noticeable impact on parental total distress scores. Our proforma also specifically looked for certain aspects in the initial management of these children with epistaxis. This included the application of nasal pressure, position of the child's head during an active episode of epistaxis and the use of nasal tampons of any kind. Twenty-three of the fifty children (46%) had already received some form of primary management before presenting to the otolaryngology department. With sixteen patients having attended the services of a primary care physician (PCP) first and the remaining seven presenting directly to accident and emergency. Interestingly, in 21 cases (42%) no nasal pressure was applied, whereas a further 14 applied pressure incorrectly to the upper half of the nose. The Hippocratic method [7], pinching the soft part of the nose and tilting the head slightly forward was only applied by 15 (30%) of primary carers. Forty-two cases (84%) reported a tilt of the head as an adjunctive method to control the bleeding, but only 19 used the correct forward head tilt. In 12 (24%) cases some form of a selfmade nasal tampon was used to try and stop the bleeding, usually in the form of a plug of tissue or cotton wool. As previously mentioned, 16 (32%) patients had sought the advice of their PCP. This was found to be in the form of oral antibiotics, application of topical emollient creams and nasal sprays or a direct referral to an otolaryngology clinic. Most of the time, parents did not present during an acute episode to the PCP or emergency department. Emergency department management seemed to provide little input. The advice given was frequently incorrect such as incorrect point of pressure application, head position or the lack of prescribed topical mucosal hydration. Here again, in 90% of cases management generally culminated in an otolaryngology referral. All patients presenting to otolaryngology outpatients were given and demonstrated the correct method of first aid management in epistaxis. In 39 (78%) cases, anterior rhinoscopy showed definite evidence of superficial dilated vessels at Little's area: silver nitrate cautery was therefore performed after nasal preparation with local anaesthetic. All except one patient, who underwent cautery had the additional prescription of topical Naseptin1. Reassurance and first aid advice played a prominent part in otolaryngology management, and was found to be the only treatment in 11 (22%) cases. 5. Discussion Pediatric epistaxis is a condition well known to all otolaryngology departments. It may generate distress and anxiety amongst both patients and parents [8]. Treatment of significant
Please cite this article in press as: K. Davies, et al., Pediatric epistaxis: Epidemiology, management & impact on quality of life, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.05.013
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or recurrent epistaxis might include vasoconstrictor drops, cautery with silver nitrate and topical creams. Nasal packing is rarely indicated in children. In children with refractory epistaxis, underlying local or systemic factors (e.g., nasal tumor or bleeding disorder) should always be considered. The mean age of patients in this study was 8.8 years, ranging between 1 and 16 years. This proved to be slightly higher than the mean age of presentation in the Damrose and Maddalazzo [9] study where the average age was 7.3 years and the Brown and Berkowitz [8] study where it was 7.8 years. This condition has a universal predilection for males with a ratio of 2:1 in our study and a similar predominance of male patients reported in other studies [8–10]. Although pediatric epistaxis has been frequently reviewed, information about the associated impact on patient and parental quality of life is lacking. The parental stress index short form aimed to assess the impact these episodes of epistaxis had on everyday life of our local patient group. The PSI-SF is a standardized tool that yields scores for parental stress across four areas. It has 36 items and provides both raw and percentile scores. Each item is graded on a five-point Likert scale, from 1 (strongly disagree) to 5 (strongly agree) [11]. This information was not previously noted in the reviewed literature. The Parental Distress domain measures the distress that parents feel about their parenting role in light of other personal stresses, and has a cut-off score of 36; the Parent-Child Dysfunctional Interaction domain focuses on the perception of the child as not responsive to parental expectations, and has a cut-off score of 27; and the Difficult Child subscale represents behaviors that children often engage in that may make parenting easier or more difficult, and has a cut-off score of 36 and finally the Total Stress subscale scores ranges from 36 to 180, with higher scores indicating greater levels of parental stress. Thus, a raw score of 90 or higher than the 85th percentile are interpreted as “clinically significant” for high levels of family stress. Fourteen (28%) children and 22 (44%) parents reported high total stress scores associated with each episode. The reported effects were mainly in relation to limitation of daily and sporting activities and a general sense of fear of impending bleeds. Most cases occur due to vascular fragility aggravated by digital manipulation or local inflammation of Little's area on the anterior nasal septum [12]. Other causes include allergic rhinitis, infections, trauma and bleeding disorders. Overall, parental awareness about the causes and first aid management of this condition was quite poor. 64% of the parents in our study did not know about possible etiology and two-thirds had used incorrect pressure technique in trying to control bleeding. This led to high parental distress and overall total stress scores. Where parents felt helpless in not being able to control bleeding in their children. Recurrent bleeds were common, occurring in 88% of the patients in our study group. With episodes occurring three or more times a week in as many as 40% of the children. The children who were affected by daily bleeds reported higher total stress scores secondary to the disruptive effect on school and classroom activities. The study by Damrose reported 34% cases with daily episodes and 45% patients with at least weekly bleeds, which reiterates recurrent epistaxis to be a significant problem. The duration of each episode in our study was variable, most commonly lasting less than 10 min. Although usually commoner in the winter months, seasonal variation was not found to be significant in this study with 64% reporting perennial symptoms. Seasonal variation had little to no effect on overall stress scores. The Damrose [9] and Brown [8] studies revealed similar results, where patients presented with equal frequency throughout the seasons. In up to 42% cases, the bleeding was found to be bilateral.
3
Review of the literature on this subject did not suggest a strong family history of epistaxis with only 10% of cases with a positive family history as reported by Barkowitz [8] and 29% in the study by Damrose [9]. We encountered a positive family history of 46% in our study. However it was apparent from the PSISF results that laterality, seasonal variation and family history had no effect on overall total stress scores. Frequency, duration or the presence of a family history of epistaxis was also not predictive of an underlying coagulopathy. Parents generally sought the advise of their PCPs or local emergency department first. Tassone et al. conducted a study to assess knowledge and management techniques of PCPs in the UK [13], this revealed that of 428 PCPs only 40% gave correct advice regarding the position of the head and point of application of pressure and only 20% were comfortable to perform cautery. Appropriate advice and management was more common in PCPs who had previous otolaryngology experience. Our study found PCPs in the West of Ireland tended towards conservative management in the form of prescription of sprays, creams or antibiotics. Referral to otolaryngology services was the end point of their management without any attempt at cautery or nasal packing. Eze et al. performed an audit to assess the management technique of accident and emergency staff, including doctors, nurses and paramedics. The correct response rate for first aid technique in senior medical and nursing staff was only 43%. Furthermore, this audit found 80% of patients discharged home with recurrent epistaxis received no advice regarding the possible trigger factors for further bleeds, possible prevention and proper first aid measures [14]. Our study corroborated this finding that either inaccurate or insufficient advice was given to those who attended the emergency department. Otolaryngology management tends to focus on appropriate advice regarding the first-aid management, cauterizing bleeding points, the use of topical creams such as Naseptin1 and hydration of the nasal mucosa with saline nasal sprays or drops [15,16]. The results of our study reiterate this fact, where cautery and emollients were used in 78% of cases. Reassurance and education was the only treatment required in 11 (22%) of referred cases. A recent novel study by Bjelakovic et al. has proposed the use of propanolol in children with recurrent primary epistaxis [17]. 6. Conclusion Pediatric epistaxis is a condition commonly encountered in otolaryngology. There remains a lack of awareness regarding causes and management amongst primary carers, primary care physicians and emergency department staff. Recurrent epistaxis can be troublesome and alarming for parents and children. With 42% of primary care givers and patients reporting a significant impact on quality of life using the Parental Stress Index Short Form (PSISF), we found the PSISF to be an assessor, patient and parent friendly tool in evaluating quality of life issues surrounding the issue of pediatric epistaxis. Raising awareness of simple management strategies among parents and PCPs could significantly reduce the stress and quality of life impact associated with this common condition. Regardless of medical specialty, first aid measures, mucosal hydration and chemical cautery form the fundamentals of managing this common condition. References [1] B. Petruson, Epistaxis in childhood, Rhinology 17 (1979) 83–90. [2] N. McIntosh, J.Y. Mok, A. Margerison, Epidemiology of oronasal heamorrhage in the first 2 years of life: implications for child protection, Pediatrics 120 (2007) 1074–1078.
Please cite this article in press as: K. Davies, et al., Pediatric epistaxis: Epidemiology, management & impact on quality of life, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.05.013
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[3] M.M. Paparella, D.A. Shumrick, Epistaxis, Otolaryngology, vol. 3, 2nd ed., W.H. Saunders, 1980, pp. 1994–2008. [4] B.C. Okafor, Epistaxis: a clinical study of 540 cases, Ear Nose Throat J. 63 (1984) 153–159. [5] G.W. McGarry, C. Moulton, The first aid management of epistaxis by accident and emergency department staff, Arch. Emerg. Med. 10 (1993) 298–300. [6] B.H. Loyd, R.R. Abidin, Revision of the Parent Stress Index, J. Pediatr. Psychiatry 10 (2) (1985) 169–177. [7] O.H. Shaheen. Epistaxis. In: Mackay I.S, Bull T.R. (Eds.), Scott Brown’s Otolaryngology, 5th ed, vol. 4. Butterworths, London, pp.272-282. [8] N.J. Brown, R.G. Barkowitz, Epistaxis in healthy children requiring hospital admission, Int. J. Pediatr. Otolaryngol. 68 (2004) 1181–1184. [9] J.F. Damrose, J. Maddalazzo, Pediatric epistaxis, Laryngoscope 116 (2006) 387– 393. [10] S. Loughran, E. Spinou, W.A. Clement, R. Cathcart, H. Kubba, N.K. Geddes, A prospective, single blind, randomized controlled trial of petroleum jelly/ vaseline for recurrent pediatric epistaxis, Clin. Otolaryngol. 29 (2004) 266– 269.
[11] R.R. Abdin, Parenting Stress Index-Short Form Manual, Western Psychological Services, Los Angeles, CA, 1990. [12] J.L. Guarisco, H.D. Graham III, Epistaxis in children: causes, diagnosis and treatment, Ear Nose Throat J. 68 (1989) 522–532. [13] P. Tassone, C. Georgalas, E. Appleby, B. Kotecha, Management of patients with epistaxis by general practitioners: impact of otolaryngology experience on their practice, Eur. Arch. Otorhinolaryngol. 263 (2006) 1109–1114. [14] N. Eze, S. Lo, A. Toma, Advice given to patients with epistaxis by A&E doctors, Emerg. Med. J. 22 (2005) 724–725. [15] Z.G.G. Makura, G.C. Porter, M.S. McCormack, Pediatric epistaxis: the Alder Hey experience, J. Otolaryngol. Otol. 116 (2002) 903–906. [16] J. Ruddy, D.W. Proops, K. Pearman, et al., Management of epistaxis in children, Int. J. Pediatr. Otorhinolaryngol. 21 (1991) 139–142. [17] B. Bjelakovic, M. Bojanovic, S. Lukic, L. Saranac, V. Vukomanovic, S. Prijic, et al., The therapeutic efficacy of propranolol in children with recurrent primary epistaxis, Drug Des. Devel. Ther. 7 (2013) 127–129 (Epub 2013 March 1).
Please cite this article in press as: K. Davies, et al., Pediatric epistaxis: Epidemiology, management & impact on quality of life, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.05.013
International Journal of Pediatric Otorhinolaryngology xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Pediatric epistaxis: Epidemiology, management & impact on quality of life Karen Davies a, *, Kadambari Batra a , Rania Mehanna a , Ivan Keogh a,b a b
Department of Otolaryngology Head and Neck Surgery, UCHG, Ireland Academic Department of Otolaryngology, NUIG, Ireland
A R T I C L E I N F O
A B S T R A C T
Article history: Received 13 February 2014 Received in revised form 6 May 2014 Accepted 7 May 2014 Available online xxx
Objective: Epistaxis in the pediatric population is a common problem for both primary care physicians (PCPs) and otolaryngologists. Although a frequent reason for referral to ENT clinics, data is lacking regarding causes, effects on quality of life and common treatment modalities. Methods: Prospective, clinical and questionnaire based study, with ethical approval. We identified 50 cases of pediatric epistaxis (<16 years old) over a 6-month period. A thorough clinical history was taken, first aid measures and management outcome was recorded. The impact of recurring epistaxis on parental quality of life was assessed using the Parental Stress Index Short Form (PSISF). Results: Thirty-three males and 17 females (2:1) were included. Mean age at presentation was 8.8 years. Initial management was inadequate, with only 30% of carers applying appropriate first aid measures. Quality of life was significantly affected in 10% of cases with primary parental concerns being fear of excessive blood loss and the stress of soiled bedclothes and night wear. Children were most affected by the negative impact on sporting activity. Otolaryngology consultation found the common causes to be iatrogenic trauma and rhinitis affecting “Littles” area. Of which 78% required silver nitrate cautery, and 22% just required reassurance and advice Conclusions: Recurrent minor nosebleeds in children can be troublesome and alarming for parents and children. We found the PSISF an easy and reliable method of assessing patient and parental stress in dealing with this problem. Raising awareness of simple management strategies among parents and PCPs could significantly reduce associated quality of life issues. Mucosal hydration, cautery and first aid advice are the fundamentals of management. ã 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Epistaxis Pediatric Parental stress index Quality of life Emergency
1. Introduction Epistaxis in the pediatric population is a common problem faced by both primary care physicians (PCPs) and otolaryngologists [1]. Childhood epistaxis is rarely severe and unlikely to require nasal packing or hospital admission. Most are spontaneous, anterior and self-limiting. Gently pressing the nasal ala for 5– 10 min is usually all that is required. Up to 60% of children will have had at least one nosebleed by age ten. Commonly occurring between the ages of 3 and 8 years, the incidence declines in adulthood. However 50% of all adults presenting with epistaxis had epistaxis during childhood. Children younger than 2 years rarely present with epistaxis (1:10,000), trauma (accidental or non accidental) or serious illness (e.g., acute
* Corresponding author. Tel.: +353 851270364. E-mail address: [email protected] (K. Davies).
leukaemia) should be suspected. When a young baby presents with epistaxis, some pediatric health care providers recommend that social workers get involved to investigate the possibility of nonaccidental injury [2]. Incidence is highest in the winter months, being linked to a higher rate of upper respiratory tract infections [3]. The commonest site is the anterior part of the nasal septum, “Little's area” or Kiesselbach's plexus [4]. The majority of cases are idiopathic, but severe, recalcitrant bleeds may have a significant underlying cause such as Hereditary Heamorrhagic Telengiectasia or Juvenile Nasal Angiofibroma in teenage boys. Bleeds can be unpredictable and may have an impact on the quality of life for children and their families. Although epistaxis is a frequent cause for referral to a pediatric otolaryngology clinic in the West of Ireland, very little data is actually available regarding its causes, effects on quality of life, commonly offered treatments and their outcomes. The general awareness about first-aid management of this common condition is lacking amongst children and parents [5].
http://dx.doi.org/10.1016/j.ijporl.2014.05.013 0165-5876/ ã 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: K. Davies, et al., Pediatric epistaxis: Epidemiology, management & impact on quality of life, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.05.013
G Model PEDOT 7132 No. of Pages 4
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K. Davies et al. / International Journal of Pediatric Otorhinolaryngology xxx (2014) xxx–xxx
2. Objectives With this study we aimed to improve our understanding of the epidemiology of epistaxis in the pediatric age group in the West of Ireland. In collecting a detailed history of this common pediatric problem, we assessed the general awareness of caregivers and evaluated the first-aid management knowledge in the study group. We also sought to use this study as a means to assess the impact on quality of life for both children and their parents when dealing with recurrent epistaxis. 3. Patients and methods Approval for this study was obtained from the Clinical Research and Ethics committee of Galway University Hospital. We then carried out a prospective clinical and questionnaire based study from October 2012 to March 2013. We included all children between the ages of 0–16 years presenting or referred to the Department of Otolaryngology, University College Hospital Galway with recurrent epistaxis. We excluded any child who had a history of otolaryngology referral for epistaxis or prior nasal cautery. A proforma was designed to record all the clinical details and subsequent management with a specific section to assess knowledge levels and awareness of first-aid management of epistaxis. A thorough clinical history and physical examination was performed. Clinical examination included a comprehensive head and neck examination to include anterior rhinoscopy and flexible nasoendoscopy in co-operative patients. The Parental Stress Index Short Form (PSISF) [6] was used to evaluate the effects of epistaxis on the quality of life of the parents and children concerned. PSISF is a validated derivative of the fulllength test and consists of a 36 item self-scoring questionnaire, being applicable for children and parents. It yields a total stress score from three scales: Parental Distress, Parent-Child Dysfunctional Interaction and Difficult Child. It is measured in percentiles and takes less than 10 min to perform. 4. Results Fifty patients were included in our study. Ages ranged from 1 year to 16 years with a mean age of 8.8 years. There were 33 males and 17 females (ratio of 2:1). Common local etiological factors were superficial dilated vessels in Little's area frequently traumatized by nose rubbing, digital trauma, allergic rhinitis, use of topical intranasal steroid sprays, or a preceding history of foreign bodies insertion. Of the fifty cases we encountered, 5 children (10%) reported high total stress scores. These corresponded to the 40% of patients who suffered daily or twice daily episodes of bleeding that tended to last longer than the average bleed time of 5–10 min. The significant impact in this patient group was most apparent as interruptions in classroom and sporting activities Forty-four of the 50 (88%) patients suffered only one episode of epistaxis a week. The duration of each episode was less than 5 min in over 32 (60%) of cases. The timing of each episode was variable in 14 of the 50 (28%), with the average bleed lasting between 5 and 10 min. As such, 27 of the 50 children (54%) reported low total stress scores and no direct effect on their quality of life as a result of relatively minor episodes of epistaxis. The primary caregivers reported moderate scores in 19 cases and very high scores in three cases across all four aspects of the PSISF which yields a total stress score from three scales: Parental Distress, Parent-Child Dysfunctional Interaction and Difficult Child. As it can be difficult for parents to assess the quantity and volume of blood loss during an acute episode of epistaxis, for the purpose of the study we divided the volume of blood loss into a
little, moderate amount, a lot of blood and variable amounts. The severity of the bleeds was subjectively assessed as a lot by parents in 30 (60%) of the cases. The fear of excessive blood loss was a significant factor in causing high parental distress scores. The soiling of nightwear and bedclothes was noted to be of particular concern with high scores in Parent-Child Dysfunctional Interaction and Difficult Child scales. 22 parents and 14 children also reported symptoms of anxiety and fear associated with each episode. Twenty-one patients (42%) presented with bilateral epistaxis and 29 (58%) had a unilateral presentation. There appeared to be a slight predilection for the left nasal cavity as the source of the bleed, with 16 patients reporting mainly left sided epistaxis. However laterality had no impact on stress scores in either patient or primary care giver. Thirty two patients (64%) complained of a perennial problem of epistaxis, the remaining 18 patients felt that bleeds were more prominent during the autumn and winter months. There was a positive family history of epistaxis in 23 patients (46%). This again had no noticeable impact on parental total distress scores. Our proforma also specifically looked for certain aspects in the initial management of these children with epistaxis. This included the application of nasal pressure, position of the child's head during an active episode of epistaxis and the use of nasal tampons of any kind. Twenty-three of the fifty children (46%) had already received some form of primary management before presenting to the otolaryngology department. With sixteen patients having attended the services of a primary care physician (PCP) first and the remaining seven presenting directly to accident and emergency. Interestingly, in 21 cases (42%) no nasal pressure was applied, whereas a further 14 applied pressure incorrectly to the upper half of the nose. The Hippocratic method [7], pinching the soft part of the nose and tilting the head slightly forward was only applied by 15 (30%) of primary carers. Forty-two cases (84%) reported a tilt of the head as an adjunctive method to control the bleeding, but only 19 used the correct forward head tilt. In 12 (24%) cases some form of a selfmade nasal tampon was used to try and stop the bleeding, usually in the form of a plug of tissue or cotton wool. As previously mentioned, 16 (32%) patients had sought the advice of their PCP. This was found to be in the form of oral antibiotics, application of topical emollient creams and nasal sprays or a direct referral to an otolaryngology clinic. Most of the time, parents did not present during an acute episode to the PCP or emergency department. Emergency department management seemed to provide little input. The advice given was frequently incorrect such as incorrect point of pressure application, head position or the lack of prescribed topical mucosal hydration. Here again, in 90% of cases management generally culminated in an otolaryngology referral. All patients presenting to otolaryngology outpatients were given and demonstrated the correct method of first aid management in epistaxis. In 39 (78%) cases, anterior rhinoscopy showed definite evidence of superficial dilated vessels at Little's area: silver nitrate cautery was therefore performed after nasal preparation with local anaesthetic. All except one patient, who underwent cautery had the additional prescription of topical Naseptin1. Reassurance and first aid advice played a prominent part in otolaryngology management, and was found to be the only treatment in 11 (22%) cases. 5. Discussion Pediatric epistaxis is a condition well known to all otolaryngology departments. It may generate distress and anxiety amongst both patients and parents [8]. Treatment of significant
Please cite this article in press as: K. Davies, et al., Pediatric epistaxis: Epidemiology, management & impact on quality of life, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.05.013
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or recurrent epistaxis might include vasoconstrictor drops, cautery with silver nitrate and topical creams. Nasal packing is rarely indicated in children. In children with refractory epistaxis, underlying local or systemic factors (e.g., nasal tumor or bleeding disorder) should always be considered. The mean age of patients in this study was 8.8 years, ranging between 1 and 16 years. This proved to be slightly higher than the mean age of presentation in the Damrose and Maddalazzo [9] study where the average age was 7.3 years and the Brown and Berkowitz [8] study where it was 7.8 years. This condition has a universal predilection for males with a ratio of 2:1 in our study and a similar predominance of male patients reported in other studies [8–10]. Although pediatric epistaxis has been frequently reviewed, information about the associated impact on patient and parental quality of life is lacking. The parental stress index short form aimed to assess the impact these episodes of epistaxis had on everyday life of our local patient group. The PSI-SF is a standardized tool that yields scores for parental stress across four areas. It has 36 items and provides both raw and percentile scores. Each item is graded on a five-point Likert scale, from 1 (strongly disagree) to 5 (strongly agree) [11]. This information was not previously noted in the reviewed literature. The Parental Distress domain measures the distress that parents feel about their parenting role in light of other personal stresses, and has a cut-off score of 36; the Parent-Child Dysfunctional Interaction domain focuses on the perception of the child as not responsive to parental expectations, and has a cut-off score of 27; and the Difficult Child subscale represents behaviors that children often engage in that may make parenting easier or more difficult, and has a cut-off score of 36 and finally the Total Stress subscale scores ranges from 36 to 180, with higher scores indicating greater levels of parental stress. Thus, a raw score of 90 or higher than the 85th percentile are interpreted as “clinically significant” for high levels of family stress. Fourteen (28%) children and 22 (44%) parents reported high total stress scores associated with each episode. The reported effects were mainly in relation to limitation of daily and sporting activities and a general sense of fear of impending bleeds. Most cases occur due to vascular fragility aggravated by digital manipulation or local inflammation of Little's area on the anterior nasal septum [12]. Other causes include allergic rhinitis, infections, trauma and bleeding disorders. Overall, parental awareness about the causes and first aid management of this condition was quite poor. 64% of the parents in our study did not know about possible etiology and two-thirds had used incorrect pressure technique in trying to control bleeding. This led to high parental distress and overall total stress scores. Where parents felt helpless in not being able to control bleeding in their children. Recurrent bleeds were common, occurring in 88% of the patients in our study group. With episodes occurring three or more times a week in as many as 40% of the children. The children who were affected by daily bleeds reported higher total stress scores secondary to the disruptive effect on school and classroom activities. The study by Damrose reported 34% cases with daily episodes and 45% patients with at least weekly bleeds, which reiterates recurrent epistaxis to be a significant problem. The duration of each episode in our study was variable, most commonly lasting less than 10 min. Although usually commoner in the winter months, seasonal variation was not found to be significant in this study with 64% reporting perennial symptoms. Seasonal variation had little to no effect on overall stress scores. The Damrose [9] and Brown [8] studies revealed similar results, where patients presented with equal frequency throughout the seasons. In up to 42% cases, the bleeding was found to be bilateral.
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Review of the literature on this subject did not suggest a strong family history of epistaxis with only 10% of cases with a positive family history as reported by Barkowitz [8] and 29% in the study by Damrose [9]. We encountered a positive family history of 46% in our study. However it was apparent from the PSISF results that laterality, seasonal variation and family history had no effect on overall total stress scores. Frequency, duration or the presence of a family history of epistaxis was also not predictive of an underlying coagulopathy. Parents generally sought the advise of their PCPs or local emergency department first. Tassone et al. conducted a study to assess knowledge and management techniques of PCPs in the UK [13], this revealed that of 428 PCPs only 40% gave correct advice regarding the position of the head and point of application of pressure and only 20% were comfortable to perform cautery. Appropriate advice and management was more common in PCPs who had previous otolaryngology experience. Our study found PCPs in the West of Ireland tended towards conservative management in the form of prescription of sprays, creams or antibiotics. Referral to otolaryngology services was the end point of their management without any attempt at cautery or nasal packing. Eze et al. performed an audit to assess the management technique of accident and emergency staff, including doctors, nurses and paramedics. The correct response rate for first aid technique in senior medical and nursing staff was only 43%. Furthermore, this audit found 80% of patients discharged home with recurrent epistaxis received no advice regarding the possible trigger factors for further bleeds, possible prevention and proper first aid measures [14]. Our study corroborated this finding that either inaccurate or insufficient advice was given to those who attended the emergency department. Otolaryngology management tends to focus on appropriate advice regarding the first-aid management, cauterizing bleeding points, the use of topical creams such as Naseptin1 and hydration of the nasal mucosa with saline nasal sprays or drops [15,16]. The results of our study reiterate this fact, where cautery and emollients were used in 78% of cases. Reassurance and education was the only treatment required in 11 (22%) of referred cases. A recent novel study by Bjelakovic et al. has proposed the use of propanolol in children with recurrent primary epistaxis [17]. 6. Conclusion Pediatric epistaxis is a condition commonly encountered in otolaryngology. There remains a lack of awareness regarding causes and management amongst primary carers, primary care physicians and emergency department staff. Recurrent epistaxis can be troublesome and alarming for parents and children. With 42% of primary care givers and patients reporting a significant impact on quality of life using the Parental Stress Index Short Form (PSISF), we found the PSISF to be an assessor, patient and parent friendly tool in evaluating quality of life issues surrounding the issue of pediatric epistaxis. Raising awareness of simple management strategies among parents and PCPs could significantly reduce the stress and quality of life impact associated with this common condition. Regardless of medical specialty, first aid measures, mucosal hydration and chemical cautery form the fundamentals of managing this common condition. References [1] B. Petruson, Epistaxis in childhood, Rhinology 17 (1979) 83–90. [2] N. McIntosh, J.Y. Mok, A. Margerison, Epidemiology of oronasal heamorrhage in the first 2 years of life: implications for child protection, Pediatrics 120 (2007) 1074–1078.
Please cite this article in press as: K. Davies, et al., Pediatric epistaxis: Epidemiology, management & impact on quality of life, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.05.013
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[3] M.M. Paparella, D.A. Shumrick, Epistaxis, Otolaryngology, vol. 3, 2nd ed., W.H. Saunders, 1980, pp. 1994–2008. [4] B.C. Okafor, Epistaxis: a clinical study of 540 cases, Ear Nose Throat J. 63 (1984) 153–159. [5] G.W. McGarry, C. Moulton, The first aid management of epistaxis by accident and emergency department staff, Arch. Emerg. Med. 10 (1993) 298–300. [6] B.H. Loyd, R.R. Abidin, Revision of the Parent Stress Index, J. Pediatr. Psychiatry 10 (2) (1985) 169–177. [7] O.H. Shaheen. Epistaxis. In: Mackay I.S, Bull T.R. (Eds.), Scott Brown’s Otolaryngology, 5th ed, vol. 4. Butterworths, London, pp.272-282. [8] N.J. Brown, R.G. Barkowitz, Epistaxis in healthy children requiring hospital admission, Int. J. Pediatr. Otolaryngol. 68 (2004) 1181–1184. [9] J.F. Damrose, J. Maddalazzo, Pediatric epistaxis, Laryngoscope 116 (2006) 387– 393. [10] S. Loughran, E. Spinou, W.A. Clement, R. Cathcart, H. Kubba, N.K. Geddes, A prospective, single blind, randomized controlled trial of petroleum jelly/ vaseline for recurrent pediatric epistaxis, Clin. Otolaryngol. 29 (2004) 266– 269.
[11] R.R. Abdin, Parenting Stress Index-Short Form Manual, Western Psychological Services, Los Angeles, CA, 1990. [12] J.L. Guarisco, H.D. Graham III, Epistaxis in children: causes, diagnosis and treatment, Ear Nose Throat J. 68 (1989) 522–532. [13] P. Tassone, C. Georgalas, E. Appleby, B. Kotecha, Management of patients with epistaxis by general practitioners: impact of otolaryngology experience on their practice, Eur. Arch. Otorhinolaryngol. 263 (2006) 1109–1114. [14] N. Eze, S. Lo, A. Toma, Advice given to patients with epistaxis by A&E doctors, Emerg. Med. J. 22 (2005) 724–725. [15] Z.G.G. Makura, G.C. Porter, M.S. McCormack, Pediatric epistaxis: the Alder Hey experience, J. Otolaryngol. Otol. 116 (2002) 903–906. [16] J. Ruddy, D.W. Proops, K. Pearman, et al., Management of epistaxis in children, Int. J. Pediatr. Otorhinolaryngol. 21 (1991) 139–142. [17] B. Bjelakovic, M. Bojanovic, S. Lukic, L. Saranac, V. Vukomanovic, S. Prijic, et al., The therapeutic efficacy of propranolol in children with recurrent primary epistaxis, Drug Des. Devel. Ther. 7 (2013) 127–129 (Epub 2013 March 1).
Please cite this article in press as: K. Davies, et al., Pediatric epistaxis: Epidemiology, management & impact on quality of life, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.05.013