Epistaxis in children — branching viva

Opening — the four-year-old with a profuse nosebleed

Examiner: A four-year-old is brought to the emergency department with brisk nasal bleeding for twenty minutes. His father has him tilted backward in a chair, pressing a towel against the bony bridge of the nose, and the child has just vomited a small amount of swallowed blood. Talk me through your immediate thoughts and actions. [4]

Candidate should cover: recognition of the two first-aid errors — tilting backward, which sends blood to the stomach causing vomiting and aspiration risk, and pinching the bony bridge, which does not compress the Little's area vessels; the correct technique of sitting upright, leaning forward and applying firm continuous pressure to the soft, cartilaginous lower part of the nose for at least 10 to 15 minutes while breathing through the mouth; and immediate assessment of airway, breathing and circulation with intravenous access. [8]

Branch 1 — escalation to cautery and packing

Examiner: The bleeding continues after correct first aid and topical oxymetazoline, and you can see a bleeding vessel on the anterior septum. Walk me through your definitive steps and the rule that governs cautery. [5]

Candidate should cover: silver-nitrate cautery of the identified bleeding point under topical local anaesthesia; the one-side-of-the-septum rule — cauterise one surface only because bilateral chemical devascularisation risks septal perforation; and nasal packing with an absorbable or non-absorbable tampon if cautery fails or no point is visible, with ENT referral for the posterior or refractory bleed. [6]

Branch 2 — the seven-year-old with bruising and a family history

Examiner: Now a different child: a seven-year-old with recurrent nosebleeds, easy bruising and a mother with heavy periods and an uncle who bled after a dental extraction. What changes in your approach? [2]

Candidate should cover: an underlying bleeding disorder, with von Willebrand disease the commonest inherited cause; the first-line panel of full blood count and film, coagulation screen and iron studies; the extended work-up of von Willebrand factor antigen, ristocetin cofactor and factor VIII with haematology referral; and the rationale to defer cautery until after investigation because it may both miss the diagnosis and cause prolonged post-procedural bleeding. [2]

Branch 3 — the adolescent boy and the tumour

Examiner: Finally, a thirteen-year-old boy with recurrent unilateral epistaxis and progressive nasal obstruction over three months. What must you consider, and how do you manage it? [12]

Candidate should cover: juvenile nasopharyngeal angiofibroma, a highly vascular tumour of the adolescent boy; the need for contrast CT and MRI of the nasopharynx rather than a clinic biopsy, because biopsy can provoke catastrophic bleeding; and ENT referral for pre-operative embolisation and surgical resection. The durable first-aid teaching and the recurrent-disease measures — antiseptic cream and cautery of a visible vessel — remain the backbone for the common benign majority. [11] [12]