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.

Management of isolated sphenoid sinus disease in children: a surgical perspective.

OBJECTIVE: To determine the spectrum of diseases and optimal timing of surgical drainage for the opacified sphenoid sinus in children. METHODS: Ten year retrospective chart review of children with isolated sphenoid sinus disease. RESULTS: Fourteen patients (mean age 11 ± 2.8 years, range 6.5-15.1 years) were diagnosed with isolated sphenoid sinus disease. Five patients had acute, severe bacterial sphenoiditis, four had sphenoid mucoceles, three had suspected tumors involving the sphenoid bone, clivus or sella, and two were identified incidentally when imaging studies were obtained for unrelated reasons. Headache was the most common symptom. Cranial nerve or other intracranial complications were present in all of those referred because of infection, but in none of the other patients. Computed tomography (CT) revealed the presence of disease in all cases. Compared with CT, magnetic tomography (MRI) was more helpful in identifying the extent of disease spread in two patients with acute bacterial sphenoiditis and in three patients with suspected tumors. All improved with surgical drainage or biopsy of the suspected tumor. In two cases, children were treated conservatively with antibiotics and the primary symptoms resolved. CONCLUSIONS: Isolated sphenoid sinus disease is rare in children. Those with clinically significant disease presented with progressive, severe headaches and minimal sinus symptoms. MRI studies were important to identify the source of headache and evolving complications in several of these patients.