Getting Nosy About Nosebleeds: A Primer on Epistaxis

Continuing Education credits for physicians and other healthcare professionals are provided by VCU Healthcare Continuing Education. Check out cribciders.vcuhealth.org for more information. The cribciders' podcast is for entertainment, education, and informational purposes only. The views and statements expressed in this podcast are solely of those of the hosts. Welcome back to the cribciders. I'm Chris the Chumanchu, and I'm joined tonight by my co-host and friend Sam Mazer, say, "Hey buddy. Hey. How are you?" And we have our brand new producer, Nathaniel. Hey, what's up, man? Hello, hello. And our guest tonight is Dr. Jennifer Lavin to discuss epistaxis. But first, Sam, do you want to remind us what the show is all about? I'd love to. So we are the pediatric medicine podcast. We interview leading experts in the fields to bring clinical pearls, practice changing knowledge, and answering lingering questions about core topics in pediatric medicine. We have a fantastic conversation with our guest, Dr. Jennifer Lavin. Dr. Jennifer Lavin is a pediatric otolaryngologist at Ann and Robert H. Luri Children's Hospital of Chicago, and an associate professor of otolaryngology. Head and ex-surgery at the Feinberg School of Medicine. After completing her undergraduate degree in chemistry at Northwestern University, she attended Loyola University, Chicago, stretch school of medicine where she graduated Summa Cum Laude. She then completed her residency training in otolaryngology. Head and ex-surgery at the Northwestern University and fellowship training in pediatric otolaryngology at Children's National Medical Center in Washington, D.C. She began at Luri Children's in 2015, where her subspecialty focus is pediatric cyanoneasal disorders and general pediatric otolaryngology. She also has academic interests in healthcare, quality, and patient safety, and completed a master's of science in healthcare, quality, and safety at Northwestern in 2017. She is here today to teach us best practices to manage nosebleeds in the field, how to respond to very brisk or recurrent nosebleeds, and when to get ENT involved. I'm so ready to get into this, but it may sound a bit nosy, but I'm excited to dig into this topic. I get it. Yeah, this episode is really going to be on the bleeding edge of epistaxis knowledge. Okay. Okay. Dr. Lavin, thank you for coming on this show. Thank you guys for having me. First because we're an informal group. Would it be okay if we call you by your first name? Of course. All right. Is it Jennifer, Jen? Or what would you prefer? You can call me Jen. Jen, excellent. All right. Well, since you're new to our show, I'd like to start with some rapid fire questions. First, we'd like to our listening audience to get to know you a little better. Could you tell us a little bit about yourself, who you are, and maybe something outside of medicine you'd like to do? I am a pediatric otolaryngologist at Lurie Children's Hospital. I subspecialize in general pediatric otolaryngology and sinus. I also do quality and safety for the division. And outside of work, I'm an avid traveler, and I like to run. We've got to hit with the travel question, of course, either where you've been most recently or what would you recommend? Where should we all go? We went to Switzerland last summer. I took my kids and it was phenomenal. It is a great place to take children because there's so many outdoor activities in the mountains in the summer. It's 100 percent recommended. I've heard that actually, that's a good place to take kids, and I didn't really know why, but that makes sense. So, summertime or, I guess, skiing too, right, if you're into that. Okay. All right. Well, maybe. Maybe put it next on the list. All right. Athena, go ahead. All right, Jen. Can you tell us a favorite failure of yours, something that you learned something from? Yeah. So, it's more kind of funny that I learned from me in the future is my kindergarten report card, said Jennifer seems to have trouble using scissors. And I'm a surgeon. And so, this is funny, and my parents actually dug this up and got it to one of my attendings when they did the roast when we graduated. And so, he actually reproduced a copy of this report card at my graduation, and I think what it tells me is, you know, you're always growing and just because things aren't going well early on doesn't mean that you can't grow and change. I love that too. Going to an ENT who is one of the most, I presume, dissect heavy of the surgical sub-specialties as well. Very delicate. Yes. Exactly. You have learned to use scissors in your time. I remediated myself very well. Yes. Exactly. Exactly. But always learning and always keep going. And we can get better at things as what it sounds like. What do you think, Chris? Should we get into it? You're a devoted clinician. Your patients get your best. But if you're finishing charts and admin work during nights and weekends, it's time to meet freed. Freed is more than an AI scribe, it's an AI assistant that writes your notes, automates coding, creates referral letters, patient instructions, answers medical questions, analyzes patient history for smart and visit prep, and pushes everything into your EHR with one click. Freed can be used across all specialties for in-office as well as virtual visits and works in over 90 languages. While it takes only minutes to learn and requires zero IT setup, Freed's white glove US-based success team is available within minutes for every customer, no matter the size of practice. Join 26,000 clinicians who get to focus on patients, not paperwork. Just code Freed50 for $50 off your first month at Freed.ai, that's Freed.ai, F-R-E-E-D.ai. Casey LeBoc is a seven-year-old boy with a history of allergic rhinitis who presents to the clinic for an urgent sick visit in the late fall with acute epistaxis. He has recently recovered from a cold. His father notes that he had set an onset epistaxis at school and was referred to the nurse who had him pinch his nose and hold his head back. His epistaxis quickly resolved, but recurred after about 15 minutes, prompting their presentation to the clinic. External nasal pressure was held on the drive-in. His vital signs are normal for age, and an exam of the nasal fairings shows an area on the left nasal septum with slowly oozing bright red blood and crescent blood over the nairs, despite holding pressure for 15 minutes. Let's start with an anatomy refresher. Where do you think Casey is bleeding from and why does it matter? The majority of nose bleeds occur from something called whistlebox plexus. It's a cluster of blood vessels on the anterior septum, and that is, I would say, 90 plus percent of bleeds are originating from that region. That region, I think, has been told to me as the anterior region versus the posterior region. Is that correct? That is correct, yes. Okay. Awesome. And then, so, what do you see on exam to say, hey, this is an anterior bleed from that perspective? In the situations where the bleeding is active, you know, you might actually see an area where the blood is originating from on the anterior septum, not always, because sometimes, especially if it's brisk bleeding, you may not. You might just see blood, but, you know, certainly if it's slow enough, you're going to see that. If it's going to be, you know, so if a patient presents to the emergency department, if they're bleeding on and off, or the bleeding has stopped by the time they get to you, you might see a little crust or a little blood clot overlying that area on the anterior septum, just because you don't see something, however, doesn't say, oh, then it's not an anterior bleed. It's still way more likely to be an anterior bleed than a posterior bleed. Yeah. And that's a geese follow up, then. So why is that the case? Why is this, you know, over 90% of the bleeds are coming from there? Is that just like, you're supposed to bleed for there, easy to bleed from, you know? Why do we see this? So the blood vessels in this plexus are very, very superficial, and the lying that nasal mucosa does become dry in that area, and then also when you talk about young children and things like that, sometimes they're instrumenting their nose with their fingers. And that is an area that can unroof, you know, any sort of bleeding in that area. Any tips on actually doing the exam itself, especially in kids? It means very tough. I mean, they don't, they don't love having their noses looked at, especially I think, you know, in the post-COVID era where there are so many kids having nasal swabs and everything like that. I think that kids do not like you getting near their nose. You do your best to get in there, but I think the reality of the situation is if putting pressure on the nose makes the bleeding stop, that's also a very good indicator. If you can't see anything else. Right. Right. So it sounds like, okay, I do a bad exam that's not the worst thing in the world, it sounds like it could be common. Okay. Thank you. For that validation. All right. I'll bring it back to, we know that there's like anterior and posterior nose bleeds, but why? Why does the distinction matter clinically? It matters clinically because what you need to do to control them is very different. And so anterior nose bleeds are small capillary bleeds, they're from, you know, mucus on the anterior septum. They're very receptive. to holding pressure, whereas posterior nose bleeds frequently can be from a, even sometimes a named vessel or from a mass lesion or something like that, where simply holding pressure right here and pinching the nose shut is not sufficient and often requires either going to the IR suite for embolization, the interventional radiology suite for embolization, or to the operating room for some sort of endoscopic or open ligation. Now, this is not an uncommon mommy call that we will get. You know, so a lot of times I'm not going to be able to see the kid. I'm going to call from a, a frazzle parent who's like, should I take him to the emergency department? What should I do? I have a kid who's got a nose bleed, what can I do? What types of things can we walk a family through to see if we can get control of this nose bleed? You know, I think one of the things that is most fascinating when I have patients come in to see me in clinic is one of the first questions I ask them is what do you do to, because I see them after they've recurrently blood. And I ask them, what do you do to stop the bleed? And most people are not doing an effective method of stopping the bleeds. It's very common for people to pinch up on the nasal bones on the bridge of the nose as opposed to pinching the nostril shut on sort of that fleshy part of the nose. And that, and people think that they're going to stop the bleed there, but that's not actually compressing the blood vessels. Similarly, people will, you know, shove tissues and stuff up their nose. And, you know, that might temporarily stop the problem, but the problem is you take the tissue out and that pulls the blood clot and everything that's securing the tissue with it. And, you know, it's not like a regular packing that you leave in for three days. So you pull it out after 10, 15 minutes. And then, you know, it bleeds again. The other thing, so I think, first of all, I would recommend that you find out from your families, what are they, what have they tried to do to stop the bleeding? Because a lot of times what they're doing needs to be a little bit modified. The second thing is how long are they holding pressure? Because they're, you know, the whole time is relative thing really plays here. So sometimes it feels like forever, but you've held pressure for 30 seconds. And so I will even tell families to pull out their phones and start a stopwatch and don't look. Or, you know, if it's someone with recurrent bleeds, for example, I will tell them to buy one of those little clips from Amazon, you know, it looks like a close pin, but it's got these like flat discs. And it just clips onto the nose. And maybe they'll be more likely to sit versus having to physically hold their nose with their fingers. And so I think, you know, so making sure that they're using good technique, making sure that they hold pressure long enough. And then the last thing, if the child will let them is sometimes, you know, and this is a little bit of expert opinion, but it's something that we commonly use is oxymatazoline, is a good vasoconstrictor. And so the nice thing is you can tell them if they have that on hand to spray it in their nose and pinch. And that might help stop things as well. So what I'm hearing is that you should be pinching. And I'm saying this because it's an audio podcast and so it's want to be very clear to our audience regarding where to pinch. So it's pinching your nostrils closed. So almost like your nose is closed and you can't breathe out of your nose. And that sounds like it's supposed to apply pressure to the the the plexus that's on the nasal septum itself where your blood vessels are. Yeah. Yeah. I mean, I tell patients, I'd be like, pinch is if you're trying to keep a smell out. Ah, great. That's a good way to say it too. And then you were saying obviously do it for longer. Is there a duration that you would say, Hey, do this for this amount of time before you call me type of situation? Is, you know, obviously 30 seconds doesn't sound like quite enough, but is it five minutes? Is it 10 minutes? When do you start getting worried about the amount of time that you're doing? I mean, I tell people initially will hold pressure for for about five minutes because it does feel very long. But usually I start recommending people seek help in the emergency department or something like that. If they've held pressure for 30 minutes, like truly held pressure for 30 minutes, and then the bleeding immediately returns upon releasing. 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It's like having a research partner who never gets tired. Whether it's working through a tricky and patient diagnosis, reviewing the latest management guidelines, or putting together a teaching topic for my residents, Claude helps me think deeper instead of just skimming the surface. So, CryptSetters listeners, ready to tackle bigger problems? Get started with Claude today at Claude.ai/cripsetters. That's Claude.ai/cripsetters and check out ClaudePro which puts access to all the features mentioned in today's episode. Claude.ai/cripsetters. Are there any other things that we're supposed to know about like hold your head forward? Hold your head back. Jump up three times. I don't know. Are there any things that we're supposed to do besides packing and maybe a little oxymetasoline? I think the head position thing doesn't really have an impact on whether or not the bleed will stop per se, but if the pressure is not controlling the bleeding, you're holding your head back, then the blood's all going to just be going down your throat and then people are going to be coughing and sputtering. So, I think the lean forward thing is more just for an airway protection. We're about to get to like, okay, now we're at the doctor's office, so we have a lot more tools than when your parents on the phone. But before that, it sounds like you said 30 minutes not stopping go present to care. Is there any other thing that we should do to think about severity of epist access and when to when to present? I think the severity, you know, anterior bleeds can be alarmingly brisk and so there's not a threshold unless it were extinguinating hemorrhage, you know, which I mean would be highly unlikely. There's not a threshold for which I'm like, oh, if you're bleeding that much because a lot of people are very frightened by clots and so that they, you know, pass a blood clot and then are just like, oh, this is so bad. I have to go to the emergency room now, but that sets your body trying to stop the bleed. And so there's really not an amount aside from like I said, life-thirning hemorrhage. All right, awesome. So let's say we go to the emergency room. This is bleeding for longer than 30 minutes or they just don't really get the instructions the way you kind of presented it, which is, which is might be more common than it actually requiring that level of care. Would you mind, say, I'm the emergency doctor seeing, seeing Casey, would you mind kind of starting in the order of operations here, what you would start to try and, you know, what's considered success, what's considered failure, and would just walk through the options all the way to open surgery with ENT? Yeah, and some of this also depends on the patient. So this, if this isn't otherwise completely healthy child with no coagulopathy at all, then, you know, I would start still again withholding pressure because still the most likely scenario is that pressure was ineffectively held or incompletely held. And so we would start with that. With children also, we tend to really like it, lorry to try to avoid removable packing if possible. That's something that's very common in the adult patient population because an adult can then tolerate going back in a few days and having it removed, whereas a child may not. And so if it does come to needing to escalate to some sort of packing material, so I don't usually use, for example, silver nitrate in the acute setting. Some people do. And so it's not the wrong answer to try silver nitrate. But to your point earlier, sometimes it's hard to see that exact source. And silver nitrate is really nice when you just apply it to the very source because if you're just, you know, blanket applying it to the whole mucosa, then it, I mean, you're burning the whole mucosa. And so that's not ideal in my mind. And that's why I tend to try to avoid it. And so we tend to resort to then absorbable packings if, you know, your afferent, or excuse me, if you're oxymatazoline and your, your pressure and things like that isn't working. And so then I do not know the generic names for this. So I do apologize. But we use surgesel, which is an absorbable packing. Sometimes that we will place in the nose. It's like a mesh kind of packing and it doesn't physically take up space. And then there is a another type of packing called nasa pore that's kind of like a spongy packing that goes in the nose and it looks like a little kind of almost packing peanut if you will and both of those are dissolvable and you can place them in the nose and then they will they will dissolve on their own. Can you kind of explain actually I'm now again talking to a surgeon and I don't know this. How do those items actually work? So you're saying they're not there to apply pressure right they're not they don't take up a large amount of space so they're there because there's something in the materials that do something? Is that my understanding that correct or my understanding point? Yeah they have hemacetic properties so surgery cell is even used in the operating room and it actually induces clotting. Another thing that is used and sometimes even actually is used over the counter because you can get it is the you know the bleed stops or it's the the military grade you know the quick clot and again I don't know any sort of generic names of that but it was it was used originally in combat and they actually do manufacture something for nosebleeds that can be placed in the nose as well. And like totally I've seen TXA sprays be used in the nose wondering about your experience there if that's something we should be reaching for and and maybe when. So there's not a whole lot of literature specifically on TXA and nosebleeds but there is literature on TXA and hemoptysis and there is emerging literature on TXA use and post-tons select me hemorrhage and so I think that just knowing those links it certainly is reasonable we manage our post-tons select me hemorrhage because of the literature that's emerging with TXA that's nebulized so instead of sprays and sometimes that's really easy with a younger child because if you're thinking about trying to you know wrestle then when they're crying and trying to get a spray in their nose versus just getting a mask on and getting them breathing a nebulizer it is often a little bit easier to do that. So you often recommended nebulized TXA over dunking a piece of gauze and TXA and trying to stick it up there is that correct. I mean I think it's whatever you think that the child will tolerate the most. And you know speaking of tolerating how do you you know we just talked about how sprays are tough oxymetazoline is a spray. Any recommendations on how to do that correctly you know we got a lot of recommendations for intranasal flutica zone that actually want to kind of cross body and go to the outside. I imagine you would want to do the opposite here but I'm curious how this is done. The direction of the spray is pretty broad and so I think especially when you're dealing with a child who's very squirmy just aiming it in is is enough. I mean if you can angle it towards a septum that would be wonderful but I don't think you need to do that in order to set it off. Is it once spray pernostral is that technically your dose that you can only use up to six times? Yeah I would start with ones especially in a smaller child. In some patients might just be pretty easy to fix quickly say we do oxymetazoline and you know hold the nose. We're supposed to only give six doses or you know twice daily for three days. I assume that resets at some point where we can dose that again for twice daily three days. Do you happen to know that interval you know because if we need three days off you know as long as they have a once a week and can treat it at home you know we can probably feel pretty good. But I realized I never I never really asked that question before. Yeah I don't know if there's a hard and fast answer to that one. I think that in general I say no more than three days in a row and then if it's been a week it's probably fine if they're doing it you know once a week or something like that but certainly any sort of more frequency and there's not like a prescriptive do not do it more than x number of days out of you know but other than that three day period that they tell you on the labels. I did actually you know we kind of talked about oxymetazoline we talked about TXA we talked about packing talked about silver nitrate the packing I know you talked more about using something like surgesel that has hemostatic properties around it than the large volume packing that sometimes use an adult I would like to talk about that just for our audience to learn that and I'd like to learn it myself. So what would be I guess we can even say what would be the indications are in a kid it sounds like it's last line of defense so when would you use it and then like how do you get into a kid when you know how long is it staying when does it go out what antibiotics do you need with it like all this type of stuff how should we know how to use that if it's maybe even it's all we have in our clinic regardless of whether it should be last resort or not. So you know the the most common you know there's two sizes of mirror cells one is about four mill or four centimeters and one is about six centimeters and it's a it's a rigid device that you place in the nose and you just go straight back and then it the nasal secretions actually start to cause it to expand or you can drop a little bit of saline or something like that to get it to expand and then it expands and actually physically takes up space and causes physical pressure and sometimes you just need to pack the side that's bleeding there are times where you do have to pack both sides just because sometimes putting pressure on the contralateral septum especially if something is a little bit more of a brisk bleed helps because then you get pressure on both sides and so those go in and again stay for three to five days. The other type of nasal packing is something called as people call it a rapid rhino or rhino rocket and it is something that goes in and actually has a little balloon attached to it so in addition to the material that is got the you know there's a little gauze like you then also have a little balloon that you can inflate and you can put varying amounts of air. So it sounds like both of those are three to five days and so if you're in the emergency room you'd have to go back somewhere if you're inpatient admitted you can be there for three to five days and this is what we've heard that you're supposed to provide some sort of antibiotic prophylaxis in the setting of you know toxic shock from strap or something along those lines is that still the literature is that still the recommendation. I think the reason that people do it is there is no literature because people it's a study that people are afraid to conduct it. Okay. And so I think that people are always just going to give it because they don't want they don't want to risk it. Okay and that's just just group-a-strap coverage. Is that correct? So for us it's usually sefilexin but it could be anything along those lines if you are on another antibiotic for whatever reason. Okay. And then I guess the last component of that is if you're in the pediatric ED and you're like all right this is our last line defense we should do it. Do we sedate the kid to do it? Do we give them a little intranasalement as followed by a little intranasal packing? How is this usually done logistically? I mean logistically we tend to not sedate for this but concern I would have with sedating is if you've got a child that's bleeding and their ability to control their airway in an active bleed might become more compromised and so it's such a quick thing to be able to put packing in if you get the child immobilized enough that I would probably just place it. Do we need to think about other things besides slowing down bleeding? Like are there other things that we need to think about whether it's do we need to get labs at this time at what point do we need to start other medications or is this just as long as we get the the bleeding out of control that's that's our first thing we need to get done. Yeah I would say in a child if you can get the bleeding under control in a reasonable amount of time and it doesn't sound like they blood too much I don't think you need to automatically get labs. I would say if you it's a case of recurrent bleeding or there are other stigmata of something that might be wrong you know say the kid has other bruising or you know there's other concerns for maybe an underlying disorder that might be associated with the nosebleeds then I think then you can get that but if it's just a single nosebleed that didn't go away after 30 minutes I don't think you need to do a full workout. All right so we've done all the things in the ED we've like put the oxymetasoline in we've like maybe thought about TXA and silver nitrate we're thinking about putting in large volume device to include the the nairs at what point do we stop and we say oh ENT should come and see this kid when when do you like to get involved in these cases? I mean I think some of it is the culture of the institution that drives a lot of that I would say culturally our institution involves us fairly early on and so if we're starting to put packing material if any kind in we're at the bedside but you know different institutions might handle that differently. I think that's reasonable just say hey if you're starting to push stuff in there packing the various type again we're not good at surgesel to call ENT. Do you do anything different? Do the nasopharyngeal scope for example does that make a difference in anything you do do we need to call you for diagnostic purposes if not treatment purposes? I would say most of the time a flexible scope at the bedside in an active bleed is not helpful because it's very hard to see anything really the only thing that would Help me see is it made if things were so bad that I were taking a patient back to the operating room and then had rigid scopes and also suction in one hand and a rigid scope in the other and I can actually see. But with a flexible scope, it would become just a field of blood very quickly. And I just, I think we're actually going to ask some of these questions in a second. So I just want to ask this final piece to kind of close out this part of the case and then we can talk a little bit about those secondary causes. Surgical procedures we kind of talked about, it sounds like the threshold is where we've been for everything, which is if we can't stop the bleeding, we go to the next thing and the next thing after what we discussed is surgical procedures. That sound about accurate. Yeah, yeah, if nothing else stops it, then I would go to the operating room. Awesome. And then the last question, and I think this applies to all of our cases so far. Who are you admitting for OBS saying, worry that this is going to rebleed? And who are you discharging after it stopped bleeding? And if there is a OBS window time that you'd recommend, say, four hours, six hours, I don't know, something along those lines. Certainly any patient who has a, you know, some sort of bleeding disorder, be it, you know, something that they were born with or something that was acquired through like chemotherapy or something like that. Those patients are going to need to probably come in and be observed for a little bit. If it's a patient that is otherwise healthy, they do not really need to be observed. Awesome. So it sounds like we're discharging most of our patient's home, which is fantastic. Hopefully, after we do a good job, after listening to you in this episode, all right. Let's say Casey gets three to four nose bleeds per year. What defines recurrent epistaxis for the primary care pediatrician? I would say, I mean, I would put three to four nose bleeds a year in the normal range for a child. I start to worry about it being more recurrent if it is getting in the way of their daily life. And so I would say occurring weekly, maybe twice a month or more frequently. It's the children that I end up seeing clinic are the ones who are just like the school is calling me, I'm having to pick them up all the time or they're playing sports and then they're constantly getting nose bleeds. That's the kind of patient that tends to get sent to me. And I imagine another group that might want to see you as anyone who is developing anemia, for example, and we think the only active issue is nose bleeds. But I think that's up to primary care to say, hey, what symptoms are you experiencing and do you see power? Do you see tachycardia? Do you see someone, you know, a little bit more fatigued and then we work them up in our own world for anemia and then say, okay, where's the bleeding come from and we decided it was the nose and then referred to ENT. Is that a group of patients you sometimes see? Absolutely. Okay. Awesome. And so I'll just kind of jump into the next portion there. And so it seems like this is impacting kids' quality of life. You know, before seeing you, what can we do? Maybe preventative measures, that type of thing in the primary care world before referring to ENT. So since the majority of nose bleeds happen, again, on the anterior septum and a lot of it is due to nasal mucosa being dry. And so that's why you are going to see a little bit of seasonality, especially to recurrent epist access, where there is worsening in the winter months where the air is very dry or in areas where, you know, just the air is dry in general. And so anything that you can do to maintain the moisture of the nasal mucosa is going to be helpful. And so, you know, the easiest lowest hanging fruit is like a nasal saline. If a child will tolerate a nasal saline spray, if a child will not tolerate a nasal saline spray, there are nasal saline gels on the market that can be placed in the in the nostrils. And that can be just placed at morning and night. I say, you know, when you brush your teeth, just put the gel on both sides of the nose. Those things are sort of your best bet. I would say that a lot of otolaryngologists will use off-label mupericin ointment. Sorry, that's more on it once they hit us. So that's something that we can prescribe too. So it's, you know, things that we can't do, there are things that you would do in your first visit. Maybe I should have changed the question that way. But things that you would do in your first visit at ENT that we can try in our first visit here before having to send you under on their way. Should we not tell them to show Vaseline up their nose or anything? You could do Vaseline. I tend to like, I mean, any sort of emollient is totally fine. And so Vaseline aquafore, I tend to really like the saline gels. One of the brands that is the most common is air. It's spelled A-Y-R. And the reason that I like the saline gels is because it is isotonic or they're about and it's using saline as opposed to petroleum. And so I think that it tends to moisturize the lining of the mucus a little bit better. That's a perfect segue to my next question, which is, what testing can we be doing for these patients with recurrent epist access before we send them to your office? How do we set them up for success? I think, you know, I mean, obviously considering your basic labs, making sure that they're not anemic, some pediatricians do like to check, you know, basic clotting labs. And so under, you know, you're getting your PT, PT, maybe some sort of platelet function assay, something like that to get the majority of the low hanging fruit with it when it comes to bleeding disorders. I think aside from that, it honestly speaking, if none of those labs were obtained by the time that someone comes to me, I don't consider it problematic, but you know, some people come with them and some people don't. One question is, do you have any quick tricks on some of our, some of our pediatric patients who have chronic disease and maybe on like chronic nasal cannula, you know, I know we can try humidifying, but are there any other tips, like tips of the trait, tricks that you may have come across that may be useful in some of those patients? It's so hard when you have a child who's on nasal cannula. Yeah, if you can use any sort of humidification through the cannula, that's your best bet. If it's, if it's someone who can use instead some sort of mask or face tend. So in an inpatient setting, for example, we'll say try to switch to maybe a humidified mask or humidified face tend if the child will tolerate it. It's too, too prevent the nosebleeds or prevent the drying, but it is definitely a challenge in that population. Hey, Cripp said it's listeners, whether this is your first episode or you've been with us since day one, you know our goal has always been to share real wisdom of our practicing medicine. So let's talk about something to actually change my day today as a hospitalist. That's fake scrubs. I can't walk into a clinic or hospital without seeing people in fake scrubs, and I get it. I wear them too. They're incredibly soft, form fitting, and durable, and it's not just dust. If you've been watching a certain popular ER drama TV, yep, they're in Figs 2. These scrubs get it. That's what drew me in and what keeps me coming back. And because we work with kids and kids come with messes, I love that figs are into microbial. When stuff gets on your scrubs and it will, you just wash them and they come out wrinkled free. I've washed mine well over 50 times and they still look brand new. All that and so much more is why we've teamed up with Figs. Now crib centers listeners can get 15% off. Just go to wearfigs.com and use code FigsRX. That's w-e-a-r-f-i-g-s.com and use code FigsRX for 15% off. One question I have is do we have any known, so I mean I've had patients who are on like nasal steroids like a flotica zone or a nasal anticholiner, so like a nasal atro event for a variety of other reasons, which we're obviously trying to dry their noses out for one reason or other, do you have any thoughts on how to approach those situations and trying to balance the symptoms that we're trying to treat versus the side effects that are sort of happening with epistaxis? It's definitely a challenge and I think someone mentioned this a little bit earlier but one of the techniques that I counsel patients on if they're using flotica zone, for example, is to spray at crossbody and so to use their right hand to deliver the spray to the left side of their body, to their left-nare and vice versa. That angles it towards the turbulent, which is really what you want to have the dose of steroid against because that's what you're trying to shrink. That's the structure in the nose that is going to be the most vulnerable to swelling and things like that and so that's what you're trying with the flotica zone to treat. When you're spraying it away from the nasal septum, you're not having any sort of loss of therapeutic effects per se, but maybe you might decrease the amount of dose that is hitting that lining and drying it out and maybe thinning the mucosa, etc. I also say that sometimes you can chase, if you will, the flotica zone with like the saline gel or with some sort of vaseline or something like that so you're just staying on top of the dryness or just really being very aggressive about your nasal regimen as far as using the same method. saline in general. And so technically speaking, it sounds like intranasal flutica's own would increase the risk of bleeding, especially if it's pointed towards the area that bleeds. Is that correct? And I presume just because. Yeah, that that's something that is that is accepted in no to learning. Yeah. Besides the improper use of these sprays, are there any other like risk factors that you think about modifying for our patients with recurrent episexis? I mean, earlier I mentioned, you know, children for lack of a better term, they pick their nose a lot. And certainly anything that can unroof any sort of crust or anything that is on the blood vessel will increase your risk. And so I I counsel them on that, you know, but I also have young children and know that that's easier said than done. So is that a behavior you've been able to successfully change for some of your patients? And are there any? Absolutely. Yeah. No, or in my own children. So. One question I have as we're talking about things that may contribute to increasing risk factors for episexis. Do you know of any types of social terms of health that might affect our patients? Is there other relationships between like air quality, climate, the patients may be in terms of like pollution or anything else that may may put burden on increased episexis? That's a fantastic question. And it's one that I'm not 100% sure the answer to, you know, certainly anything where the air is more dry. And so if it's an area where there's dry air and there's not, you know, proper dehumidifier or proper humidifiers and things like that in an apartment or something like that, that would increase it. But as far as whether, you know, air pollution or air quality would enter into it, I'm not sure. You know, I think this is pretty a good summary of the interior bleeder that recurrent bleeder. I was thinking we would jump onto the next case. Nothing. What do you think? Yeah. Sounds good. All right. Case number two, B is a previously healthy 11 year old female presents with sudden onset nausea, coffee ground, emphasis and one episode of bright red hemoptysis. Your initial exam shows an acutely distressed child with blood at the nairs and the mouth. Fidels are significant for a heart rate of 120 beats per minute, a respiratory rate of 18, and a blood pressure of 110 over 70. The exam of the nasopharynx shows blood in the nairs bilaterally and dripping down the posterior pharynx. Our first question is, do you think there's enough evidence here to suggest that this bleed is posterior epistaxis? And how do we distinguish this between a pulmonary bleed or a GI bleed? It's a fantastic question. I think the blood draining down into the posterior pharynx could be a sign of a posterior bleed, but there are tons of anterior bleeds where you see blood in the posterior pharynx. And so it's certainly not pathendomonic as far as whether or not this is, you know, related to a GI bleed and how to distinguish between epistaxis, a GI bleed and hemoptysis. It's also can be very challenging, especially in a child who is maybe upset and crying. And so you don't know where things are coming from. Sometimes it's like if a child is leaning forward and it's clearly draining out anteriorly, that can help, you know, narrow things down. If it's only coming out when they, you know, cough or, you know, or if they very obviously throw up, that's one thing. But sometimes there is a very gray line. And it is not unheard of for us pulmonology and GI to be called on a patient that's bleeding and together are trying to find a source. You know, we kind of glanced over this initially in the first case. And then this one's, it's becoming a little bit more complicated than I thought. Can you kind of walk us through with a classical presentation is of a posterior nose bleed or posterior epistaxis? And then we can try to see if we can fit our illness script in some way. Yeah. So I mean, a classic posterior nose bleed is maybe one where they're spitting out blood a little bit more than it's coming out. It might be more brisk. It might be more bilateral. It's often impressive in quantity. The other thing that can sometimes lead you to expect a posterior bleed is if you are, for example, pinching and leaning forward and it's still draining down the back of the throat and that's not doing anything. Or if you have a patient that has other kind of history that is concerning for posterior bleed, like progressive nasal obstruction or something like that. And you know, we like to think of the word posterior being in the back. It's still epistaxis, right? So it still should be coming out of your nose. And if it's not coming out of your nose at all, we might be able to move ourselves more to the, um, to the GI pulmonary. Does that, is that wrong? Or is that, because I don't want to make assumptions here? I would say it might decrease the chances in epistaxis, but it doesn't completely rule it out. But you can also, if you're, if you have a cooperative patient, and again, this is one of the biggest challenges and peds. But if you have a cooperative patient and you're looking in their posterior or a pharynx, if you're seeing blood draining down, it could still be epistaxis versus if it's just coming up when they cough or vomit or spit. And then is there any, is it maybe useful also to try to treat it? And as you were mentioning, like, it's holding yourself forward. And if it doesn't get better, that kind of tells us something, maybe it could help differentiate between pulmonary GI as well. So how would you like go first line to treat a posterior epistaxis or posterior nose bleed? I mean, similar to, you know, I mean, if I've, if I've held pressure and it's not helping, and I'm starting to think it's a posterior bleed, I might at that point then resort more towards the packing, like the non-absorbable packing to see if I can control it. Either the ones with the balloon or just the mirror cells. There is something that otolaryngology does is called a posterior pack, which is it's an anterior pack with some sort of, you know, either balloon or mirror cell packing, plus often like a fully catheter that is placed in the nose and then inflated and pulled forward and clamped. That's something that that would be, that's a specialist level move. That's something that that we would recommend. We would encourage being called for. It sounds like there are specific, like, packing that you're avoiding. So like the surgical cell or like, and I now forget what you called it, but like the little packing peanut that you put in those I'm assuming are not deep enough to get to the posterior space. I think it's not, it's some of it's that it's not deep enough, but the other thing is if it's truly a posterior bleed, so it's not coming from the kisselbuck plus plexus, I would be more worried about it being bleeding from a lesion or bleeding most commonly from, you know, in an older patient, you can have, you know, a arterial bleed. So the internal maxillary artery can sometimes bleed or this phenopalatine artery can bleed. And so often we will do an interventional radiology embalization or endoscopic phenopalatine artery ligations, things like that. And that brings up, like, what's the ideology behind a posterior bleed? You know, we say, hey, a little bit of dryness, maybe some trauma to the anterior side. What's most commonly the ideology that might also help us with trying to differentiate between GI poem, et cetera, as we're like, oh, well, that that's a good story for a posterior bleed versus, you know, I would say in adults and children is very different. But I would say in children, the only scenario that I personally in my 10 years of being at lary have seen a posterior bleed in has been in the setting of a juvenile nasopharyngeal angiophibroma. And so that's be, you know, a large mass lesion in the back of the, the nose growing into the nasopharynx and also into the nasal cavity. The other things that we see, I mean, I suppose that is theoretically possible. If you have a child who has history of radiation, maybe for a brain tumor or, you know, maybe they have a history of like a rabdo myosarcoma of like their nasopharynx or something like that. Something like radiation to that area could compromise the structural integrity of some of the blood vessels. And so I would be worried about a arterial posterior bleed and a patient like that. So it sounds like that there's something that literally has to be invading the blood vessel, whether it be, or there's some question about arterial blood vessel integrity in the back of your nose to be concerned, which seems to be rare and a few and far between. Yeah, a few and far between. Awesome. And so does that actually change what you would do for a workup standpoint? So in this case, would you get labs? Would you get imaging? Is there something that we should do from a from a workup standpoint? If this is going to be arterial? So again, the first thing I would try to do is stop the bleeding. And then once the, you know, and if the bleeding is unable to be stopped at the bedside, that patient might go to the interventional reality. sweet or that patient might go probably more commonly in the pediatric world, go to the operating room, just for an endoscopy, and just to try to see where this bleeding is coming from. If the bleeding is able to be stopped, and so the demographic of a patient, for example, with a juvenile, nasopharyngeal, angiovibroma is going to be your adolescent male. And so if you've got unrelenting bleeding, especially if it's recurrent in an adolescent male, it might be a good idea to consider imaging in that case, in which case like a CT scan of the sinuses would be able to pick that up. That certainly leads into one of my next questions is, you know, what are some major red flags that really should be doing further diagnostic workup, talking to ENT about scoping and looking at other things? I think there are sort of stigmata of, I mean, well, you know, there's your systemic, you know, choialopathies and things like that. And so I would say, you know, your, the most common thing we see is as a kid that is, you know, having an anterior bleed that is just dry nasal mucosa, and then less likely, maybe a kid who that's their presenting symptom of either an underlying choialopathy, underlying found willing brands disease, or even in rare cases, like a presentation of a leukemia like syndrome or things like that. The other things that we would like sometimes see is another patient with a hereditary hemorrhagic telangectasia. The other things that could be stigmata of that is a lot of times patients with HHT will have other telangectages on their oral mucosa. And so I've seen that once. And in that patient, you, I saw a little telangectages all over their soft palate as well. And so certainly looking for any sort of other stigmata of some other underlying cause of bleeding is helpful. But the one thing I wanted to talk about for just secondary causes, you listed a bunch of them already, and I'm not going to get too specific, but there is one that I just want to follow up on. That's the juvenile nasopharyngeal angiophibromate. Sounds scary like it could technically cause posterior nose bleeding. I actually honestly have no idea what that is, which is my just explaining what that is, kind of a basic level for us as pediatricians. Yeah, so it is a benign tumor, but it can be, it's very slow growing, but it can be locally very invasive. And it is located in the posterior nasal cavity into the nasopharynx. And so it slowly grows and it pushes on the, it goes into sometime the area behind the maxillary sinus into the nasopharynx and into the nose and can cause progressive nasal obstruction in a child. It's something that is only seen in adolescent males. It is something that you don't see out of this demographic. And so if you have an adolescent male coming in, that is something it's very, very rare, but could be on the differential. It's not going to be on the differential of a young female, for example. All right, and just to follow that up, am I going to be seeing these tumors when I look inside of my patient's noses? No, and so the juvenile nasopharyngeal angiophibroma is something that is located in the posterior nasal cavity. And so you can see it with a nasal endoscopy or if your suspicion is high enough in the primary care setting. Honestly, if there's any suspicion for that, I would just refer to otolaryngology, but it can be diagnosed with a CT scan. Fantastic. I want to thank you again for spending so much time with us tonight talking about nose bleeds because I think this is the most I've ever learned about nose bleeds my entire medical career. So it's fantastic. I really appreciate learning about this, learning what juvenile nasopharyngeal angiophibroma is our as we begin to wrap up, I was wondering if you could any take home points you would like to provide to our listeners. A couple of things that once our listeners finish this episode, these are things you really want them to walk away with. I think making sure that patients understand good technique for stopping acute nose bleeds, having an understanding of what is the first line of defense for a recurrent nose bleed being your nasal saline in the saline gels, etc. I think those are, and then also understanding that in the rare cases, you know, your zebra diagnosis, but always think of the back of your head adolescent boy with progressive nasal obstruction or bleeding that will not stop by holding pressure or things like that. Make you think of other causes. Jen, thank you again for spending all evening with us tonight. I learned so much about epistaxis. Before we go, is there anything you'd like to plug, anything fun, personal thing, anything that you think our listeners should check out before they leave? As far as, you know, things to plug, I don't have anything clinical to plug, but if you're looking for, if you are an avid traveler like me and are looking for information about travel, I do have a sub-stack called "Rounds to Runways" and it talks about being a busy physician and managing to be able to travel in my free time and travel with family. Excellent. Well, we'll definitely have to put those in the show notes and we'll check it out as well. So thank you again for coming on the show. We appreciate it and hopefully we can have you back on again sometime. It's for the kids! Get our show notes on our website at www.TheCribSiders.com. We're committed to providing you with high-value practice changing knowledge and to do that, we need your feedback. So please subscribe, rate, and review the show on our podcast or contact us at [email protected]. Special thanks to our producer for this episode, Dr. Nathaniel, Shurikoreja, and our wonderful social media team, which is mostly Denise Cruz on Exploosky and Instagram. I've been Sam Hazer. I've been Nathaniel Sirikoreja. And this has been Chris the Chew Man Chew. Thank you and good night. Hey, Nathaniel. Yeah. Who's there? Kisselbok. Kisselbok, who? Kisselbok, in my day, we didn't know about the plexus. I don't know. Knock knock. Who's there? Nari's. Nari's who? Nari's a dull moment in pediatric ENT. Nice. I don't have any other good ones there. They also are so. All right. Bye, guys. I like the Kisselbok. Kisselbok. Kisselbok, who?