Epistaxis (or a nosebleed in plain English) is the relatively common occurrence of hemorrhage from the nose, usually noticed when the blood drains out through the nostrils. There are two types: anterior (the most common), and posterior (less common, more likely to require medical attention). Sometimes in more severe cases, the blood can come up the nasolacrimal duct and out from the eye. Fresh blood and clotted blood can also flow down into the stomach and cause nausea and vomiting. It accounts for only 0.001% of all deaths in the U.S.
The local application of a vasoconstrictive agent has been shown to reduce the bleeding time in benign cases of epistaxis. The drugs oxymetazoline or phenylephrine are widely available in over-the-counter nasal sprays for the treatment of allergic rhinitis, and may be used for this purpose.
Other products available promote coagulation include Coalgan (in Europe) or NasalCEASE (in the US). These are a calcium alginate mesh that is inserted in the nasal cavity to accelerate coagulation. If these simple measures do not work then medical intervention may be needed to stop bleeding, possibly by an otolaryngologist (ENT doctor). In the first instance this can take the form of chemical cautery of any bleeding vessels or packing of the nose with ribbon gauze or an absorbent dressing (called Anterior nasal packing). Such procedures are best carried out by a medical professional. Chemical cauterisation is most commonly conducted using local application of silver nitrate compound to any visible bleeding vessel. This is a painful procedure and the nasal mucosa should be anaesthetised first, preferably with the addition of topical adrenaline to further reduce bleeding. If bleeding is still uncontrolled or no focal bleeding point is visible then the nasal cavity should be packed with a sterile dressing, which by applying pressure to the nasal mucosa will tamponade the bleeding point. Ongoing bleeding despite good nasal packing is a surgical emergency and can be treated by endoscopic evaluation of the nasal cavity under general anaesthesia to identify an elusive bleeding point or to directly ligate (tie off) the blood vessels supplying the nose. These blood vessels include the sphenopalatine, anterior and posterior ethmoidal arteries. More rarely the maxillary or external carotid artery can be ligated. The bleeding can also be stopped by intra-arterial embolization using a catheter placed in the groin and threaded up the aorta to the bleeding vessel by an interventional radiologist. Continued bleeding may be an indication of more serious underlying conditions.
Chronic epistaxis resulting from a dry nasal mucosa can be treated by spraying saline in the nose three times per day, lubricating the nose with ointment/creams like vasoline and installing a humidifer in the bedroom.
Application of a topical antibiotic ointment to the nasal mucosa has been shown to be an effective treatment for recurrent epistaxis. One study found it to be as effective as nasal cautery in the prevention of recurrent epistaxis in patients without active bleeding at the time of treatment (both had a success rate of approximately 50 percent.)
Nosebleeds are rarely dangerous unless prolonged and heavy. Nevertheless they should not be underestimated by medical staff. Particularly in posterior bleeds a great deal of blood may be swallowed and thus blood loss underestimated. The elderly and those with co-existing morbidities, particularly of blood clotting should be closely monitored for signs of shock.
Outcomes of endoscopic sphenopalatine artery ligation for epistaxis: a five-year series from a single institution.(ORIGINAL ARTICLE)(Report)
Feb 01, 2012; Abstract epistaxis is a common emergency seen by the otolaryngologist. A minority of cases require surgical intervention....