1 Introduction
Epistaxis is a common complaint seen in the pediatric otolaryngology outpatient setting. In most cases, bleeding originates from Kiesselbach's plexus, a robust vascular network located in the anteroinferior portion of the nasal septum [
1]. While most cases are self‐limiting, a subset of children experience frequent, recurrent anterior epistaxis (RAE) [
2,
3]. Bleeding can be further exacerbated by associated underlying bleeding disorders or coagulopathy [
1].
Treatment of epistaxis requires a stepwise approach ranging from simple, non‐invasive measures to more advanced surgical care [
1,
2]. Epistaxis prevention begins with avoiding local trauma (from nasal picking or local manipulation), humidification, and topical moisturization, including nasal saline, emollients, or petroleum jelly [
1,
2]. Initial management of minor bleeding includes external direct nasal pressure, oxymetazoline‐soaked pledgets, topical prothrombotic agents, nasal packing, and chemical cauterization with silver nitrate [
1,
2].
Surgical intervention is reserved for those patients who fail these conservative measures. Though existing literature is limited, reports have identified modified septoplasty and techniques like septal release as effective measures to treat recurrent recalcitrant pediatric epistaxis [
4]. Sub‐mucoperichondrial dissection results in fibrosis and scarring of causative vasculature on the mucosal flaps, providing both short‐ and long‐term improvement [
5,
6]. In one instance, modified septoplasty with synthetic dural grafting was used for the treatment of a patient with hereditary hemorrhagic telangiectasia with refractory epistaxis [
7]. However, the use of the septal release technique in managing pediatric patients with associated bleeding disorders or coagulopathy remains limited in the literature. One case report describes its efficacy in a patient with Glanzmann thrombasthenia [
8].
Our study aims to compare the outcomes of septal release for management of recurrent, refractory epistaxis in children with and without an underlying bleeding disorder. We seek to describe our surgical technique, demonstrate its efficacy, and identify favorable factors for patient selection.
2 Materials and Methods
2.1 Study Design and Participants
We conducted a retrospective cohort analysis of pediatric patients (n = 19) who underwent septal release for recurrent epistaxis between 2014 and 2024 at University Hospitals Rainbow Babies and Children's (USA). Septal release was defined as any septoplasty procedure in which no cartilaginous or bony work was performed (i.e., cartilage removal, osteotomy). Patients were divided into two groups based on the presence or absence of diagnosed bleeding disorders, including von Willebrand disease, thalassemia, platelet dysfunction, dysfibrinogenemia, and hemophilia.
2.2 Surgical Technique
The mechanism by which septal release aids in hemostasis has not been well described. It is thought that in raising submucoperichondrial flaps, the native septal blood supply is disrupted, and the tissue undergoes local fibrosis and scarring, which is thought to de‐vascularize the tissues. All procedures were performed under general anesthesia. In our septal release technique, a Kilian incision is made providing access to the area of Kiesselbach's plexus. The mucoperichondrial flap limits were defined anteriorly by the Kilian incision at the mucocutaneous junction, superiorly by the junction of the septal cartilage and the ethmoid bone, inferiorly by the maxillary crest, and posteriorly approximately 2–3 cm from the incision to ensure complete devascularization of the anterior plexus.
The technique was performed bilaterally to disrupt the native septal blood supply on both sides. In this pediatric cohort, no cartilaginous or bony work was performed to preserve growth and development of nasal cartilage through puberty. The nasoseptal flaps are then placed back over the cartilage to allow for healing, contracture, and scarring. We utilize HemoPore bioresorbable nasal packing (Stryker Corporation, Kalamazoo, MI) in lieu of splints which also has the benefit of additional hemostatic properties and to avoid the trauma of splint removal.
2.3 Data Collection
Information was collected on patient demographics, the presence of bleeding disorders, the number of healthcare visits for epistaxis before surgery, and the types and frequencies of pre‐operative treatments. These treatments included applications of bacitracin, saline spray/gel, oxymetazoline nasal spray, and chemical cauterization. We investigated the incidence of post‐operative epistaxis amongst the two groups to evaluate the effectiveness of septal release in managing recurrent epistaxis. Follow‐up period ranged from 1 year to 3 years after septal release.
2.4 Statistical Analysis
Descriptive statistics were utilized to summarize the data, focusing on means for continuous variables such as age, number of visits for epistaxis, number of treatment applications, and post‐operative epistaxis episodes. For the statistical analysis, Microsoft Excel (Microsoft Corp, Redmond, WA) was used to compare descriptive data between patients with and without bleeding disorders. We used descriptive statistics to examine and compare pre‐ and post‐operative bleed rates within each group. Given that treatment and visit counts were discrete and non‐normally distributed with small sample sizes, the Mann–Whitney U test was used for comparisons between groups. A Fisher's exact test was used to compare the rates of post‐operative (post‐op) epistaxis up to 1 year after surgery between the two groups. A Wilcoxon signed‐rank test was used to compare the pre versus post septal release episodes of epistaxis during the period one year before versus one year after septal release within each group.
2.5 Ethical Considerations
This study was approved by the University Hospitals Cleveland Medical Center Institutional Review Board (IRB) (USA) as STUDY20210734 on 06/29/2021.
3 Results
Our study included a cohort of 19 pediatric patients who underwent septal release for recurrent epistaxis. Descriptive statistics are shown in Table 1. Of these patients, 5 had bleeding disorders, and 14 did not. All the patients with bleeding disorders were male, and the average age was 11.5 years. In contrast, the group without bleeding disorders had an average age of 16.1 years and included 7 females and 7 males.
Pre‐operatively, patients with and without bleeding disorders had a similar number of epistaxis episodes in the year before surgery, averaging 1.79 ± 1.12 visits, compared to 1.20 ± 0.45 visits for those without bleeding disorders.
In total, patients with bleeding disorders were prescribed a higher number of total conservative treatments (7.6 treatments) compared to those without (2.2 treatments). Multiple treatments prescribed in a single visit explain the difference between number of visits and number of treatments. When comparing each treatment type independently, there were no notable differences in the number of medication prescriptions between patients with and without bleeding disorders except for the use of saline (Table 2).
Post‐operatively, the average annual number of subsequent epistaxis episodes following septal release was 0.57 ± 0.76 episodes per year in the no bleeding disorder group, compared to 0.80 ± 1.10 episodes per year among those with bleeding disorders (Table 3). Among patients without bleeding disorders, the number of epistaxis episodes significantly decreased in the year following septal release compared with the year before the procedure, as determined by the exact Wilcoxon signed‐rank test (W = 6.0, p = 0.016). In contrast, no significant change was observed among patients with bleeding disorders (W = 5.0, p = 0.75).
The cohort included 19 patients (5 with bleeding disorders, 14 without). Specific disorders identified were von Willebrand disease (n = 2), platelet dysfunction (n = 1), thalassemia (n = 1), and dysfibrinogenemia (n = 1).
Post‐operative complications were minor and transient, including nasal congestion and mild dryness. No major complications (septal perforation, cerebrospinal fluid leak, or septal hematoma) occurred in either group [
9].
4 Discussion
Management of refractory epistaxis poses a significant challenge, particularly in the pediatric population. While primarily intended to correct septal deviation and nasal obstruction, septal release is an emerging surgical option to address refractory epistaxis in the setting of failed conservative measures. To date, only small case reports and case series have described the use of septal release as a treatment for refractory epistaxis. We describe our institutional experience utilizing septal release for the treatment of epistaxis in children with and without bleeding disorders. We demonstrate the efficacy, safety, and patient selection for the use of septal release in this context.
4.1 Patient Selection
Optimal patient selection is critical to the success of septal release for refractory epistaxis. All patients in our cohort had failed conservative treatment, including multiple types of treatment modalities and multiple trials of each treatment. For children, in particular, the risks of acute blood loss secondary to epistaxis must be weighed against the risk of anesthesia and surgery. All patients had favorable pre‐operative risk assessments with minimal medical comorbidities. All patients were over the age of 4 years old, which allowed for both increased ease of surgical technique and improved adherence to post‐operative management, including nasal moisturization and avoidance of digital trauma. We found that, in general, patients with bleeding disorders underwent septal release at an earlier age than those without, which we suspect may be due to increased severity of bleeds in the setting of underlying coagulopathy.
4.2 Outcomes
Within our cohort, septal release offers favorable bleeding outcomes for patients with and without bleeding disorders. Across both groups, patients had decreased post‐operative epistaxis episodes compared to the number of pre‐operatively. Patients in both groups overall had a similar number of pre‐operative visits for epistaxis (mean ± standard deviation = 1.79 ± 1.12) compared to patients without bleeding disorders (1.20 ± 0.45) during the year prior to septal release. Additionally, on average, these patients were trialed on conservative therapies more often than those without bleeding disorders. This may, in part, be attributed to the difficulty of controlling epistaxis in patients with bleeding disorders [
8]. While topical treatments like chemical cautery are often effective for patients without bleeding disorders, cautery frequently fails and can even make bleeding worse in patients with underlying blood dyscrasias due to aberrant platelet activation and coagulation cascades. This may also explain the increased use of saline amongst patients with bleeding disorders as an attempt to avoid cauterization whenever possible. Our findings demonstrated that septal release resulted in significantly decreased bleed rates post‐operatively for patients without bleeding disorders. Among patients with bleeding disorders there was no notable non‐significant decrease from pre‐ to post‐operative bleed rates. This may be explained in part by the different etiology and pathophysiology of epistaxis in patients with bleeding disorders. Septal release predominantly addresses epistaxis through fibrosis of septal vasculature located at Kiesselbach's plexus and thus can help pediatric patients with epistaxis most commonly due to nasal dryness and/or digital trauma to the anterior septum. In patients with bleeding disorders, we suspect that septal release alone may not be sufficient to control bleeding as these patients may have increased tendency to bleed from other vascular sites within the nose secondary to systemic coagulopathy rather than external factors such as dryness or trauma.
4.3 Safety Profile
Septal release is both an effective and safe intervention for refractory epistaxis. Common minor complications include nasal congestion, pain, and dryness, which are often transient and resolve with conservative treatment. More severe complications include septal perforation, cerebrospinal fluid leak, and septal hematoma [
9]. Amongst both cohorts, patients experienced few minor post‐operative complications, and none of our patients experienced severe complications.
4.4 Limitations and Future Directions
Our study has several limitations. Firstly, our sample size is small, mainly because refractory epistaxis is relatively uncommon, and septal release is a novel treatment modality currently infrequently utilized in this context. Consequentially, our cohorts were not fully balanced with respect to age and sex and there was lack of a control group. The differences in average age and sex between the two groups may have played a role in differing surgical efficacy; however, the current literature is lacking and future studies should be aimed to investigate this further. With only 5 patients with bleeding disorders included, the generalizability of our findings is also limited. We suspect that amongst pediatric patients with bleeding disorders, only a small percentage require otolaryngologic intervention for epistaxis and thus our cohort may fail to capture more generalized practice patterns for management of epistaxis within this population. Septal release has previously been described only in case reports and case series. With increasing utilization of this technique, future studies should be directed to capture a larger sample size to elucidate further differences in efficacy between patients with and without bleeding disorders. Secondly, the optimal timing for septal release for refractory cases remains to be determined. In our cohort, the time to surgical intervention from the first epistaxis visit largely depended on the frequency and severity of epistaxis episodes, which varied widely amongst our cohort. The study was also limited by short follow up time, and future studies evaluating long‐term follow up are warranted. Additionally, in our study we did not account for use of blood, plasma products, or immunoglobulins amongst children with bleeding disorders and thus may have missed additional treatment attempts before or after surgical intervention. There remains no consensus on the maximum duration of conservative measures before considering surgical intervention, and further research should be aimed at standardizing treatment guidelines [
2]. Lastly, given the retrospective nature of the study, we were only able to account for in office visits for the diagnosis code “epistaxis” and thus there were likely other bleeding episodes which were not accounted for if the patient did not seek medical care at the time of the bleed. We assume a scheduled office visit for epistaxis management to serve as a surrogate for frequency and/or severity of bleeds to the point that patients sought expert care.
Septal release disrupts the superficial vascularity of the anterior septum. While neovascularization may theoretically occur following fibrosis, we contend that the surgical induction of sub‐mucoperichondrial fibrosis creates a dense physical barrier and contracture of the tissue. This process reduces the overall density and friability of the vessels in Kiesselbach's plexus. Even if microscopic new vessels form, the replacement of delicate mucosa with more resilient fibrotic tissue makes the area significantly less susceptible to the environmental triggers (dryness, digital trauma) that typically initiate RAE.
Regarding the use of HemoPore packing, while it is a known hemostatic agent, its role in this study was to facilitate internal “splinting” without the need for traditional splints. In non‐operative patients, packing provides only temporary relief; the sustained reduction in bleeding observed in our cohort (up to 3 years) suggests the surgical fibrosis, rather than the temporary packing, is the primary therapeutic driver.
5 Conclusion
Septal release is an effective and safe treatment for refractory pediatric epistaxis, providing the most significant benefit to those without underlying coagulopathies. Based on our small sample size, we suggest that septal release is a safe and effective treatment for refractory epistaxis and should be considered for children who have failed conservative measures. However, it may be more effective for those without bleeding disorders. Further research is warranted to elucidate its role in the epistaxis management algorithm, optimize patient selection criteria, refine surgical technique, and assess long‐term outcomes across larger cohorts.
2026 The Author(s). Eye & ENT Research published by John Wiley & Sons Australia, Ltd on behalf of Higher Education Press.
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