Predictors of bleeding disorders in children with epistaxis: value of preoperative tests and clinical screening.

Objective: To identify prevalence of previously undiagnosed bleeding disorders in children with severe epistaxis who failed medical therapy requiring intraoperative nasal cautery.
Study Design: Retrospective chart review 10/15/2006-12/31/2010.
Setting: Single provider outpatient otolaryngology clinic.
Inclusion Criteria: children (<19 years) with epistaxis referred to otolaryngology, no known bleeding disorder, failed medical therapy and received surgical nasal cautery.
Data Collected: duration/severity of epistaxis, bleeding history, family history of bleeding. A screening CBC, PT and PTT were performed on all patients.
Results: Of 248 subjects referred for epistaxis, 47(19%) met inclusion criteria (mean age 9.2±0.5 years; 61.7% male). 31.9% (15/47) had abnormal coagulation studies but on repeat testing only 2 patients had persistent coagulation abnormalities. 15 patients were referred to hematology, 5 were diagnosed with a bleeding disorder (3 - type 1 von Willebrand's disease, 1 - platelet aggregation disorder, 1 - mild factor VII deficiency). Out of the entire cohort 10.6% (5/47) had a bleeding diathesis. Clinical predictive factors for having a bleeding diathesis were explored and included previous emergency room visits for epistaxis (p=0.04). A trend was found in those presenting with epistaxis at a younger age (p=0.07).
Conclusion: Children with recurrent epistaxis despite medical therapy are at higher risk of having a bleeding disorder. In this highly selected group of patients 10.6% (5/47) were found to have a bleeding disorder. Screening coagulation studies (PT, PTT) only revealed 20% (1/5) of patients with a bleeding disorder. Only a subsequent comprehensive hematology evaluation revealed the diagnosis in the majority of patients.
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