Epistaxis (Nosebleeds )

Epistaxis ( nosebleeds ) is bleeding from the nasal cavity.

How common- Most common ENT emergency presentation in primary care Up to 60 % of the population will suffer from epistaxis atleast once in their lifetime
But -only 6 % will require medical attention Bimodal age distribution ( ↑ ed prevalence in children and aged )
Most cases in age group 2-10 and 50-70 yrs
Rare below age 2 and may indicate serious illness like leukaemia or injury More common in winter No racial or gender predilection Allergic rhinitis and use of nasal medications can be risk factors

Classified as Anterior or Posterior- division lies at the piriform aperture

Anterior – Most are anterior ~ 90 % Usually from Kiesselbach plexus- rich vascular anastomosis located at anterior nasal septum called Littles area ( see below ) Kiesselbachs plexus gets blood supply from both internal and external carotid artery Usually from one nostril

Posterior-Approximately 10 % Origin is from the posterior nasal cavity or nasopharynx More commonly arterial in origin Pose greater risk of airway compromise , aspiration and difficulty in management More common in older people Blood running into the throat or from both nostrils

Topical treatment –Naseptin is chlorhexidine + neomycin Reduces crusting and vestibulitis As effective as nasal cautery Mupirocin is an alternative

Assess airway , breathing and circulation

History-Onset , frequency , duration , triggers One or both nostrils Previous episodes Measures used to control previous bleeds Trauma ( incl nose picking ) Previous nasal surgery Medical history eg
hypertension
clotting disorders
hepatic impairment Medications
antiplatelets
anticoagulants Social history
smoking , alcohol
cocaine use

Examination Check nasal passage -ensure lighting and use a nasal speculum Pay attention to septum and Little’s area Scabbed , excoriated areas FBC/ Haematocrit if anaemia suspected Coagulation profile
○ PT
○ APTT
○ Platelet function studies Other bloods if an underlying medical cause suspected Imaging – usually not required 
(unless suspected cancer , trauma etc suspected )

Sit with upper body tilted forward and mouth open Pinch the cartilaginous ( soft ) part of the nose firmly and hold it for 10-15 minutes without releasing the pressure while the patient breathes through mouth

Issue naseptin qds x 10 days or bd x 2 weeks Issue mupirocin bd/tds for 5-7 days if allergic to neomycin, peanut or soya Consider further referral if a serious cause is suspected

cautery-Silver nitrate Electrocuatery. packing -Anterior packing eg Rapid Ehino Posterior packing eg balloon catheter

Posterior nasal bleed suspected eg profuse bleeding both nostrils and bleeding site not identified- admit to hospital

causes- Inflammation- infection ( eg chronic sinusitis ) , allergic rhinosinusitis ) , nasal polyps Nose picking ( epistaxis digitorum !! ) Foreign body Trauma Nasal septum deviation Tumours eg 
malignant squamous cell carcinoma
benign – angiofibroma, septal angioma
Polyps Nasal oxygen therapy ( drying of nasal mucosa )

Medications –topical corticosteroids topical antihistamines solvent inhalation ( huffing ) cocaine snorting anticoagulation antiplatelets excessive alcohol consumption

cardiovascular-Congestive heart failure Mitral stenosis Coarctation of aorta SVC obstruction

Coagulopathies-thrombocytopenia platelet dysfunction Von Willerbrand’s disease leukaemia haemophilia splenomegaly renal failure AIDS liver disease

Granulomatous disorders- Wegeners disease Sarcoidosis Syphilis TB , SLE Periarteritis nodosa

Environmental-Dry cold conditions Altitude Humidity Circadian rhythm – peaks AM and late afternoon

Hypertension –May contribute but this theory is controversial Conflicting evidence Hypertension is common in people who present with epistaxis

Vascular-Sclerotic vessels Heridetary haemorrhagic telengiectasia AV malformation Neoplasm Aneurysms Septal perforation / deviation endometriosis

iatrogenic-Surgery ( eg ENT/ maxillofacial / ophthalmic ) Nasal apparatus ( eg NG tube )

Referral-Men aged 12-20 consider angiofibroma ( rare ) Symptoms which suggest cancer as
○ nasal obstruction ( unilateral )
○ facial pain
○ hearing loss
○ visual symptoms as proptosis or diplopia
○ persistent lymphadenopathy People > 50 ↑ chances of nasal , sinus and nasopharyngeal cancers Chinese origin – high incidence of nasopharyngeal cancer Telengiectasia and family h/o hereditary haemorrhagic telengiectasia Children less than 2 yrs
○ epistaxis rare in this group
○ may be associated with serious underlying illness eg leukaemia
○ refer to paediatrics

complications of nasal packing- Failure Toxic shock syndrome Blockage of 
○ nasolacrimal duct → epiphora
○ sinus drainage → acute sinusitis
○ nasal airway → hypoxia Nasovagal reflex Sleep apnoea Packing may get displaced into oropharynx → acute airway obstruction Removal may induce bleeding

References-References
 Epistaxis BMJ Best Practice EM Basic- Epistaxis accessed via 
http://embasic.org/wp-content/uploads/2015/02/47
_Epistaxis-Show-Notes.pdf An update on epistaxis RACGP Volume 44 , No 9, September 2015 Pages 653-659 Soto-Galindo GA , Trevino Gonzalez JL ( 2017 ) Epistaxis Diagnosis and Treatment Update : A Review Ann Otolaryngol Rhinol 4 (4) : 1176 Epistaxis BMJ 2012 ;344e1097 Management of Epistaxis Corry J.Kucik, LT, MC, USN et al AFP January 15, 2005 Epistaxis – www.lifeinthefastlane.com Epistaxis Rodney J.Schlosser , M.D N Engl J Med 2009 ;360:784-9 Pope LER, Hobbs CGL Epistaxis: an update on current management Postgraduate Medical Journal 2005;81:309-314. Epistaxis ( nosebleeds ) CKS NHS


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