Endoscopic view of a superior labial artery deformity that caused severe epistaxis in a child. (Rhinoscopic Clinic).

A 6-year-old girl was brought to our office with a 2.5 year history of intermittent, severe, left-sided epistaxis. These episodes had occurred approximately once per week, and they were controlled with digital compression. During the preceding 6 months, the frequency of her episodes had increased to three times per week. The patient and hermother denied any history of trauma, nasal foreign body, or digital manipulation. The patient had no known history of bleeding disorders; the family history was unavailable because the patient had been adopted.

The initial physical examination revealed that the patient was otherwise healthy. Her epistaxis was active and originated along the anterioinferior septum. Her oral cavity and pharynx were clear of any bleeding. Silver nitrate cauterization was performed in the office, and the bleeding stopped. However, 1 month later, the bleeding returned as brisk and as frequent as before.

At this point, the patient was brought to the operating room for endoscopic evaluation and bleeding control under general endotracheal anesthesia. On endoscopic visualization, it quickly became apparent that the source of the bleeding was a prominent superior labial artery on the left (figure). The vessel coursed from an inferolateral position to a superomedial location along the left nasal vestibule and septum; it bifurcated on the septum into visible anterior and posterior branches. Suction electro-cautery was performed on both septal branches and the main superior labial artery nasal branch. Further endoscopic evaluation of both nares detected no other abnormalities. The patient tolerated the procedure very well, and 7 months postoperatively she had experienced no subsequent nosebleeds.

Approximately 30% of children up to 5 years of age, 56% of those aged 6 to 10 years, and 64% of those aged 11 to 15 years have experienced at least one episode of epistaxis. (1) Recurrent epistaxis in children is common and is often considered to be a red flag for a bleeding disorder. A recent study demonstrated that 33% of children with recurrent epistaxis who had been referred for a hematologic work-up had a coagulopathy. (2) Therefore, an extensive evaluation of recurrent epistaxis in children is warranted.

Possible etiologies can be classified as local and systemic. Local factors include trauma (e.g., digital manipulation or fracture), nasal spray use, an inflammatory reaction, an anatomic deformity, foreign-body impaction, an intranasal tumor, chemical inhalation, nasal-prong oxygen delivery, continuous positive airway pressure, and surgery. Systemic factors include a vascular disorder, a blood dyscrasia, a hematologic malignancy, allergy, malnutrition, alcohol use, hypertension, a drug reaction, and infection. (3)

In our patient, the obvious anatomic deformity was responsible for the recurrent epistaxis. The superior labial artery, a branch of the facial artery, gives off nasal arterial branches medially to the septum and laterally to the alae. The septal branches contribute to Kiesselbach's area (a.k.a. Little's area). A prominent or aberrant superior labial artery would be at particular risk for bleeding in the setting of other local or systemic factors, especially digital manipulation. However, not all diagnoses are so readily apparent, so a thorough history and a more involved nasal examination may be indicated.

Treatment of children with epistaxis can be a challenge. Most nosebleeds are self-limiting, and only a small percentage are seen by otolaryngologists. (4) For severe or recurrent epistaxis, conservative office-based measures can be attempted, provided that the child is cooperative. However, if bleeding persists, a visit to the operating room may be necessary for both diagnosis and management.

References

(1.) Petruson B. Epistaxis in childhood. Rhinology 1979;17:83-90.

(2.) Sandoval C, Dong S, Visintainer P, et al. Clinical and laboratory features of 178 children with recurrent epistaxis. J Pediatr Hematol Oncol 2002;24:47-9.

(3.) Santos PM, Lepore LM. Epistaxis. In: Bailey B, ed. Head and Neck Surgery--Otolaryngology. Philadelphia: Lippincott Williams and Wilkins, 2001.

(4.) Guarisco JL, Graham HD III. Epistaxis in children: Causes, diagnosis and treatment. Ear Nose Throat J 1989;68:522-38.

From the Section of Otolaryngology, the Yale-New Haven Hospital and the Yale University School of Medicine, New Haven, Conn. (Dr. Yanagisawa and Dr. Coelho), and the Section of Otolaryngology, Hospital of St. Raphael, New Haven (Dr. Yanagisawa).