Epistaxis

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.

Etiology

The cause of nosebleeds can generally be divided into two categories, local and systemic factors, although it should be remembered that a significant number of nosebleeds occur with no obvious cause.

Local factors

• Anatomical deformities, such as septal spurs or Osler-Weber-Rendu Syndrome
• Chemical inhalant
• Inflammatory reaction (eg. acute respiratory tract infections, chronic sinusitis, allergic rhinitis and environmental irritants)
• Foreign bodies
• Intranasal tumors (Nasopharyngeal carcinoma in adult, and nasopharyngeal angiofibroma in adolescent males)
• Nasal prong O₂ which tends to dry the nasal mucosa
• Nasal sprays, particularly prolonged or improper use of nasal steroids
• Narcotics, particularly insufflated cocaine
• Surgery (such as septoplasty and endoscopic sinus surgery)
• Trauma (usually a sharp blow to the face)
• Nose-picking
• Low relative humidity of air breathed occurring especially during winter seasons.
• Otic barotrauma from descent in aircraft or scuba diving.

Systemic factors

• Drugs - Aspirin, Fexofenadine/Allegra/Telfast, warfarin, ibuprofen, clopidogrel, isotretinoin, desmopressin and others
• Alcohol (due to vasodilation)
• Allergies
• Anemia
• Connective tissue disease
• Blood dyscrasias
• Envenomation by mambas, taipans, kraits, and death adders
• Heart failure (due to an increase in venous pressure)
• Hematological malignancy
• Hypertension
• Infectious diseases
• Pregnancy
• Vascular disorders
• von Willebrand's disease

Pathophysiology

Nosebleeds are due to the rupture of a blood vessel within the richly perfused nasal mucosa. Rupture may be spontaneous or initiated by trauma. An increase in blood pressure (eg due to general hypertension) or local blood flow (for example following a cold or infection) will increase the likelihood of a spontaneous nosebleed. Anticoagulant medication and disorders of blood clotting can promote and prolong bleeding. Spontaneous epistaxis is more common in the elderly as the nasal mucosa (lining) becomes dry and thin and blood pressure tends to be higher. The elderly are also more prone to prolonged nose bleeds as their blood vessels are less able to constrict and control the bleeding. The vast majority of nose bleeds occur in the anterior (front) part of the nose from the nasal septum. This area is richly endowed with blood vessels (Kiesselbach's plexus). This region is also known as Little's area. Bleeding further back in the nose is known as a posterior bleed and is usually due to rupture of the sphenopalatine artery or one of its branches. Posterior bleeds are often prolonged and difficult to control. They can be associated with bleeding from both nostrils and with a greater flow of blood into the mouth.

Treatment

The flow of blood normally stops when the blood clots, which may be encouraged by direct pressure applied by pinching the soft fleshy part of the nose. This applies pressure to Little's area, the source of the majority of nose bleeds and promotes clotting. Pressure should be firm and be applied for at least 10 minutes while keeping the head in the neutral position and spitting out any blood which flows into the mouth. There is no benefit to pinching the bridge of the nose or to tilting the head backwards or forwards. Swallowing excess blood can irritate the stomach and cause vomiting. Local application of an ice pack to the forehead or back of the neck or sucking an ice cube has seen widespread practice, but has been shown to not have any statistically significant effects on nasal mucosal blood flow. In the past, it was commonly thought that the ice would help by promoting constriction of local blood vessels and thus reducing blood flow to slow down the bleed. Do not pack the nose with tissues or gauze.

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.

Recurrent nosebleeds may cause anemia due to iron deficiency.

See also

• Kiesselbach's plexus
• Nosebleed section

References

External links

• National Library of Medicine - Describes causes, solutions, and prevention of nosebleeds