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Epistaxis - A greater understanding of nosebleeds

Ear, Nose and Throat | July 2, 2014 | Author: The Super Pharmacist

nose, ENT, bleed, saline, nasal

Epistaxis - A greater understanding of nosebleeds

Epistaxis is the medical term for a nosebleed. Most cases of epistaxis are of a minor self-limiting nature, in some instances however, the nosebleed can be severe or recurrent. Nosebleeds are so common almost everyone either has had an episode or witnessed one. This article explores the causes of epistaxis and how it can be managed.

Epidemiology of epistaxis

Epidemiology refers to the study of the distribution of a disease in the population. The epidemiology of epistaxis shows that minor episodes are so common, over half the population has suffered at least one over their lifetime, however, only a fraction of these (about 10%) required medical attention. Epistaxis affects more frequently either the young (less than 10 years old) or the people over the age of 50 years, and is somewhat more common in men. Having said that, anyone can have a nosebleed.

Types of epistaxis

The two basic types of nosebleeds are defined by the site of origin in the nose. Before we can understand the types, we should know a few things about the structure of the nose.

Nose Anatomy

Types of epistaxisAs you must have noticed, the nose is not a single cavity, it is two cavities, located up each nostril. The two cavities are separated by a partition which you can feel with the tip of your finger. This is called the nasal septum. The inner wall of each cavity is the nasal septum; the outer wall is formed by the lateral wall of the nose.

The entire nose inside is lined by a moist membrane called the mucosa which contains blood vessels and capillaries.

The two basic types of nosebleeds are Anterior epistaxis and Posterior epistaxis.

  • Anterior epistaxis results when mucosal blood vessels in the anterior part (nearer the front) of the nasal septum are damaged and bleed. This accounts for almost 90% of the nosebleeds and is easier to control. It is usually unilateral (one-sided) though bleeding can occur bilaterally (from both sides of the nose).
  • Posterior epistaxis results when mucosal blood vessels on the posterior part of the lateral wall of the nose get damaged and bleed. Around 10% of epistaxis cases are posterior bleeds. Posterior epistaxis is harder to control and has a greater chance of being bilateral. Also the blood can make its way into the throat and mouth. A person with a posterior bleed is at greater risk of spitting, swallowing or aspirating blood.

Causes of epistaxis

The majority of nosebleeds are so inconsequential, they are hardly ever reported. However for some, the sight of blood, especially from the nose of a child is a cause of distress and alarm, and when this becomes a recurring problem, it mandates a search for the cause of the bleeding. There are so many conditions and diseases that can present with epistaxis fortunately most of these are rare. Only the more common causes are listed below:

Local causes are factors which affect the nose directly resulting in bleeding. They are not widespread diseases of the blood or body.

Causes of epistaxisNose-picking is a frequent cause of nosebleeds in children. The mechanism evidently is direct trauma to the mucosa. 

Foreign bodies in the nose are common in children and can cause bleeding. Examples are small toy parts and beads. 

Mucosal drying will occur in cold, dry winters or getting back into dry, heated rooms. 
 

Trauma to the face and nose can lead to epistaxis. A nasal fracture has to be ruled out.

Infections of the nose (rhinitis) or sinuses (sinusitis) are another common cause of epistaxis. Some people will notice that they have recurrent nosebleeds whenever they catch a cold.

Systemic causes are generalised diseases and disorders of the body, especially of blood and circulation, which have epistaxis as one of their manifestations.

Hypertension has a dual relation to epistaxis; it can be its cause or effect. Blood pressure can rise as the body responds to the haemorrhage (bleeding), on the other hand, raised blood pressure can underlie epistaxis. In an elderly patient, a difficult to control and recurring nosebleed is frequently associated with uncontrolled hypertension.

Medications like aspirin and NSAIDs (non-steroidal anti-inflammatory drugs) can prolong the time it takes for blood to clot. If a person experiencing nosebleeds is on any such medication, he/she should consult the doctor about alternatives until the bleeding is controlled.

Bleeding disorders are of many types. There is usually a long history of repeated episodes of difficult to manage epistaxis. Other suggestive features such as easy bruising and excessive bleeding from minor wounds are often present. A complete workup is required.

Investigations

Minor episodes do not require workup. Moderate to severe episodes are to be investigated. Basic workup will include a complete blood count, followed by a coagulation profile. Specific tests are required to rule out particular causes.

Management of Epistaxis

Mild epistaxis

Management of EpistaxisFor mild nosebleeds, home measures should suffice. An effective method to stop the bleeding is to apply pressure.

  • Apply direct pressure by squeezing the softer, lower part of the nose between your thumb and index finger. Stand over a basin while doing so or at least sit upright, and tilt your head slightly forward. This will prevent the blood from trickling backwards into your throat.
  • Keep applying pressure for at least 10 minutes, without any interruptions to check ongoing bleeding. This will stop the bleeding in the majority of cases.
  • Applying ice-packs around the nose may help.
  • Nasal decongestants such as oxymetazoline and phenylephrine are helpful. Used mostly for allergic rhinitis, these topical sprays can constrict the local blood vessels and help stop bleeding. However they should not be used for more than 3 to 5 days at a stretch.

Other treatment options include using an antibiotic ointment such as bacitracin inside the nose and saline drops/sprays.

Moderate Epistaxis

For more significant nosebleeds, consult with your family physician or general practitioner. If the first-aid measures described above do not help, your doctor can consider further options.

One of these is cauterisation. This can be electrical or chemical with silver nitrate. A local anesthetic is employed prior to the procedure to minimise pain. Cauterisation will not work if there are multiple bleeders that are difficult to localise.

The next step is nasal packing. Anterior and posterior nasal packing is done for anterior or posterior epistaxis respectively. The anterior pack is usually ribbon gauze but it can be some other material such as Merocel. A Foley catheter may be used for posterior packing. Posterior packing can also be done with a gauze roll or special balloon catheters. Nasal packing will control most cases of epistaxis. The pack can stay for about 3 days. Antibiotic cover such as Augmentin Duo (amoxycillin plus clavulanic acid) is provided to prevent infection.

Severe Epistaxis

For severe repeated epistaxis, referral to an ENT specialist (otolaryngologist) will be required. Epistaxis is rarely life-threatening, nonetheless, occasionally a case may present where the bleeding is excessive, recurrent and increasingly difficult to control. Such a nosebleed can be fatal and urgent intervention is required.

When cauterisation and nasal packing do not work the culprit artery has to be tied off (ligated). The ENT surgeon will identify the bleeding vessel and try to ligate it as distally (as close to the bleeding point as possible). If the artery cannot be secured distally, a more proximal (near its origin) ligation is considered. Either distal or proximal, the procedure will require various surgical incisions and approaches.

Newer techniques that are less invasive are endoscopic ligation and angiographic embolisation.

Precautions and Prevention of epistaxis

  • Precautions and Prevention of epistaxisHelp your child overcome a nose-picking habit.
  • Use humidifiers and vaporisers in a dry season.
  • Use saline nasal spray/drops.
  • Manage nasal infections.
  • For people with known hypertension, keep blood pressure under good control.
  • Avoid strenuous physical activity after a nosebleed.
  • Avoid forceful nose blowing after a nosebleed episode.
  • Keep your mouth open while sneezing.

Recent Developments

Endoscopic ligation is a relatively new technique. The blood vessel that needs to be ligated is visualised through a nasal endoscope. The advantage is direct visualisation and a less invasive procedure.

Angiographic embolisation4 is a way of occluding the bleeding vessel. A catheter is passed through the groin up into the arterial branches supplying the nose. The culprit vessel is occluded. The procedure has its associated risks.

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References

Herkner H, Havel C, Mullner M, et al. Active epistaxis at ED presentation is associated with arterial hypertension. Am. J. Emerg. Med. 2002; 20: 92–95.

Pope LER, Hobbs CGL. Epistaxis: an update on current management. Postgrad Med J. 2005;81:309–314.

Asanau A, Timoshenko AP, Vercherin P, Martin C, Prades JM. Sphenopalatine and anterior ethmoidal artery ligation for severe epistaxis. Ann Otol Rhinol Laryngol. 2009;118(9):639–644.

Christensen NP, Smith DS, Barnwell SL, et al. Arterial embolization in the management of posterior epistaxis. Otolaryngol Head Neck Surg. 2005;133:748–753.

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