Epistaxis

Editor in Chief: Liudvikas Jagminas, M.D., FACEP [mailto:LJagminas@mhri.org] Phone: 401-729-2419

Overview
An epistaxis is the relatively common occurrence of hemorrhage (bleeding) from the nose, usually noticed when it drains out through the nostrils. There are two types: anterior (the most common), and posterior (less common, and more severe). 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 only accounts for .001% of all deaths in the U.S.

Etiology
The cause of nosebleeds can generally be divided into two categories, local and systemic factors.

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
 * 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.

Systemic factors

 * Drugs - Aspirin, Fexofenadine/Allegra/Telfast, warfarin, ibuprofen, clopidogrel, isotretinoin, desmopressin and others
 * Alcohol (due to vasodilation)
 * Allergies
 * Blood dyscrasias
 * Heart failure (due to an increase in venous pressure)
 * Hematological malignancy
 * Hypertension
 * Infectious diseases
 * Malnutrition (especially anemia)
 * Narcotics
 * Vascular disorders
 * Nose-picking (especially in children)
 * Muscle tightness as caused by scoliosis (the tightened muscles cause blood vessels to become constricted, resulting in nosebleeds from the same side as the tightened muscles).

Complete Differential Diagnosis of Epistaxis
In alphabetical order.


 * Alcoholism
 * Allergic Rhinitis
 * Aortic isthmus stenosis
 * Aplastic Anemia
 * Arteriosclerosis
 * Arteriovenous malformation
 * Avitaminosis C
 * Bleeding septal polyp
 * Chronic hepatitis
 * Cirrhosis
 * Coagulopathy
 * Coarctation of the aorta
 * Disseminated Intravascular Coagulation (DIC)
 * Drugs such as aspirin, clopidogrel, coumadin, heparin, enoxaparin, bivalirudin, fondaparinux, eptifibatide, abciximab, tirofiban
 * Dry climate
 * Dust
 * Erythrocythemia
 * External trauma
 * Forceful nose blowing
 * Hemophilia
 * Hemorrhage of Kiesselbach's area
 * Hypertension
 * Infection
 * Influenza
 * Internal trauma
 * Juvenile nasopharyngeal fibroma
 * Leukemia
 * Liver failure
 * Malaria
 * Measles
 * Multiple Myeloma
 * Nasal diphtheria
 * Nasal foreign body
 * Nasal fractures
 * Nasal polyps
 * Nasal syphilis
 * Neoplasm
 * Nose picking
 * Osler's Disease
 * Other trauma to the face
 * Pancytopenia
 * Postoperative
 * Psittacocis
 * Repeated cocaine use
 * Rhinitis sicca
 * Scarlet Fever
 * Septal deviation or perforation
 * Sinus fracture
 * Sinusitis
 * Snakebites
 * Streptococcal infection
 * Telangiectasias
 * Thrombocytopathy
 * Thrombocytopenia
 * Typhoid Fever
 * Uremia
 * Vapors
 * Vitamin K Deficiency
 * Von Willebrand's Disease
 * Waldenstrom's Macroglobulinemia
 * Wegener's Granulomatosis
 * Werlhof's Disease
 * Winter months

History and Symptoms

 * History of nasal irritation or trauma
 * Allergy symptoms
 * Rhinorrhea
 * Bleeding in other areas
 * Exposure
 * Sinus/tooth pain
 * Previous epistaxis
 * Inciting factors
 * Frequency

Ear Nose and Throat (ENT)

 * Evidence of setpal perforation
 * Washing area may increase visibility
 * Blood in mouth (without obvious nasal bleed) indicative of a posterior bleed

Laboratory Findings

 * Complete blood count (CBC)
 * Platelet count
 * Prothrombin time (PT)
 * Partial thromboplastin time (PTT)

MRI and CT

 * CT scan of nasal area and sinus may be indicated

Other Diagnostic Studies

 * Bone marrow biopsy
 * Biopsy of suspicious areas

Pathophysiology
All nosebleeds are due to tears in the mucosal lining and the many small blood vessels it contains. Fragility or injury may cause the tears, while inflammation, coagulation problems and other disorders may make the injury harder to repair.

Medical
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. 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 up to three times per day.

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.

As a summary; first aid of epistaxis include:


 * Tilt head forward, apply continuous pressure by pinching nares together to avoid posterior blood drainage (5-10 minutes)
 * Apply silver nitrate to bleeding vessel (if identified)
 * Possible blood transfusions
 * Platelet transfusion, vitamin K, fresh frozen plasma, clottin factor replacement for bleeding disorders (if necessary)
 * Possible ENT consult

Surgical or device based therapy

 * Nasal balloon or Foley catheter for posterior bleeds