nose bleeding

Epistaxis (Nosebleeds)

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Epistaxis (Nosebleeds)

Epistaxis (eh·puh·stak·suhs) comes from the Greek word “epistazein” which means “bleed from the nose” and is a combination of the two words: “epi” meaning “upon, in addition” and “stazein” meaning “to drip”. Epistaxis (also called a nosebleed) refers to a minor bleeding from the blood vessels of the nose.

Epistaxis is an extremely common problem in the primary care setting. Predisposing factors include nasal trauma (nose picking, foreign bodies, forceful nose blowing), rhinitis, nasal mucosal drying from low humidity or supplemental nasal oxygen, deviation of the nasal septum, atherosclerotic disease, hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome), inhaled nasal cocaine or other drug use, and alcohol use.

Poorly controlled hypertension has traditionally been associated with epistaxis, although confounding factors during bleeding events make establishing a causal relationship impossible.

Anticoagulation or antiplatelet medications may be associated with a higher incidence of epistaxis, more frequent recurrence of epistaxis, and greater difficulty controlling bleeding, but they do not cause epistaxis. Bleeding is most common in the anterior septum where a confluence of veins creates a superficial venous plexus (Kiesselbach plexus).

Are nosebleeds serious?

Although seeing blood coming out of your noise can be alarming, most nosebleeds are not serious and can be managed at home. Some, however, should be checked by your doctor. For instance, if you have frequent nosebleeds, see your doctor. This could be an early sign of other medical problems that needs to be investigated. A few nosebleeds start in the back of the nose. These nosebleeds usually involve large blood vessels, result in heavy bleeding and can be dangerous. You will need medical attention for this type of bleed, especially if the bleeding occurs after an injury and the bleeding hasn’t stopped after 20 minutes of applying direct pressure to your nose.

Anterior epistaxis

Anterior epistaxis refers to a nosebleed that originates from the anterior (frontal) part of the nose. Most of the time, cases of anterior epistaxis originate from the Kiesselbach plexus, which is a vascular network found on the nasal septum, as these arteries can be easily traumatized. Anterior epistaxis is the most common type of nosebleed, and usually involves one nostril.

Posterior epistaxis

Posterior epistaxis refers to bleeding from the posterior or superior nasal cavity. Most often, it originates from the Woodruff plexus, which is a vascular network found in the lateral wall of the nasal cavity. Posterior epistaxis usually involves both nostrils. For these types of nosebleeds, the blood may also flow backwards and uncomfortably get swallowed or coughed up (hemoptysis).

Often, diagnosis of posterior epistaxis occurs after failing to manage an anterior epistaxis, or noticing bleeding into the posterior pharynx or throat. It is often harder for healthcare professionals to visualize the source of a posterior bleeding in a physical examination; thus, a nasal endoscopy is often performed by a clinician to help identify the origin of the bleed.

Clinical Findings

It is important in all patients with epistaxis to consider underlying causes of the bleeding. Laboratory assessment of bleeding parameters may be indicated, especially in recurrent cases. Once the acute episode has passed, careful examination of the nose and paranasal sinuses to rule out neoplasia and hereditary hemorrhagic telangiectasia is wise.

Patients presenting with epistaxis often have higher blood pressures than control patients, but in many cases, blood pressure returns to normal following treatment of acute bleeding. Repeat evaluation for clinically significant hypertension and treatment should be performed following control of epistaxis and removal of any packing.

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Treatment

Most cases of anterior epistaxis may be successfully treated by direct pressure on the site by compression of the nares continuously for 15 minutes. Venous pressure is reduced in the sitting position, and slight leaning forward lessens the swallowing of blood. Short-acting topical nasal decongestants (eg, phenylephrine, 0.125–1% solution, one or two sprays), which act as vasoconstrictors, may also help. When the bleeding does not readily subside, the nose should be examined, using good illumination and suction, in an attempt to locate the bleeding site.

Topical 4% cocaine applied either as a spray or on a cotton strip serves both as an anesthetic and a vasoconstrictor. If cocaine is unavailable, a topical decongestant (eg, oxymetazoline) and a topical anesthetic (eg, tetracaine or lidocaine) provide similar results. When visible, the bleeding site may be cauterized with silver nitrate, diathermy, or electrocautery.

A supplemental patch of Surgicel or Gelfoam may be helpful with a moisture barrier, such as petroleum-based ointment, to prevent drying and crusting. Warfarin may be continued in the setting of controlled epistaxis, although resorbable packing may preferable in these patients.

Occasionally, a site of bleeding may be inaccessible to direct control, or attempts at direct control may be unsuccessful. In such cases, there are a number of alternatives. When the site of bleeding is anterior, a hemostatic sealant, pneumatic nasal tamponade, or anterior packing may suffice. There are a number of ways to do this, such as with several feet of lubricated iodoform packing systematically placed in the floor of the nose and then the vault of the nose, or with various manufactured products designed for nasal tamponade.

About 5% of nasal bleeding originates in the posterior nasal cavity. Such bleeds are more commonly associated with atherosclerotic disease and hypertension. If an anteriorly placed pneumatic nasal tamponade is unsuccessful, it may be necessary to consult an otolaryngologist for a pack to occlude the choana before placing a pack anteriorly.

In emergency settings, double balloon packs (Epistat) may facilitate rapid control of bleeding with little or no mucosal trauma. Because such packing is uncomfortable, bleeding may persist, and vasovagal syncope is quite possible, hospitalization for monitoring and stabilization is indicated.

Opioid analgesics are needed to reduce the considerable discomfort and elevated blood pressure caused by a posterior pack.

Surgical management of epistaxis, through ligation of the nasal arterial supply (internal maxillary artery and ethmoid arteries) is an alternative to posterior nasal packing.

Endovascular embolization of the internal maxillary artery or facial artery is also quite effective and can allow very specific control of hemorrhage. Such alternatives are necessary when packing fails to control life-threatening hemorrhage. On very rare occasions, ligation of the external carotid artery may be necessary.

After control of epistaxis, the patient is advised to avoid straining and vigorous exercise for several days. Nasal saline should be applied to the packing frequently to keep the packing moist. Avoidance of hot or spicy foods and tobacco is also advisable, since these may cause nasal vasodilation.

Avoiding nasal trauma, including nose picking, is an obvious necessity. Lubrication with petroleum jelly or bacitracin ointment and increased home humidity may also be useful ancillary measures.

Finally, antistaphylococcal antibiotics (eg, cephalexin, 500 mg orally four times daily, or clindamycin, 150 mg orally four times daily) are indicated to reduce the risk of toxic shock syndrome developing while the packing remains in place (at least 5 days).

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