Epistaxis (nose bleed), whether spontaneous or otherwise, is experienced by up to 60% of people sometime in their lifetime, with approximately 6% requiring medical attention.

Nosebleed medical term (Epistaxis)

Epistaxis definition

Epistaxis (nosebleed) is defined as bleeding from the nasal cavity and/or nasopharynx and may be classified as anterior or posterior.

One of the most frequent ear, nose, and throat (ENT) problems seen in the emergency room or primary care is epistaxis (nosebleed). 

It is seldom fatal, but it can cause substantial worry, particularly among parents of tiny children. The majority of nosebleeds are harmless, self-limiting, and spontaneous, but others might be recurring. Many unusual reasons are also mentioned.

There are five named vessels whose terminal branches supply the nasal cavity:

1. Anterior ethmoidal artery
2. Posterior ethmoidal artery
3. Sphenopalatine artery
4. Greater palatine artery
5. Superior labial artery

Kiesselbach's plexus is formed by the region of convergence of the five veins corresponding to these arteries in the anterior nasal septum. This is located near the entrance to the nasal cavity and is thus vulnerable to extremes of heat and cold, as well as high and low moisture levels, and is readily traumatized.

Because the mucosa above the septum in this region is very thin, it is the site of the bulk of epistaxis. Rarely, arteries in the posterior or superior nasal cavity will bleed, resulting in "posterior" epistaxis.

This is particularly prevalent in anticoagulant individuals, hypertensive people, and those with underlying blood dyscrasia or vascular abnormalities. Management will be determined by the degree of the bleeding and the patient's other medical issues.

Pathophysiology

Bleeding generally happens when the mucosa is damaged, exposing arteries that then rupture.

Over 90% of bleeds occur anteriorly and originate in Little's region, where the Kiesselbach plexus develops on the septum. The Kiesselbach plexus is the junction of vessels from the ICA (anterior and posterior ethmoidal arteries) and the ECA (sphenopalatine and internal maxillary arteries).

Rather than the copious pumping of blood seen from an arterial origin, these capillary or venous bleeds create a continuous oozing. Anterior bleeding can also start before the inferior turbinate.

Posterior bleeds occur further back in the nasal cavity, are often more copious, and are frequently of arterial origin (eg, from branches of the sphenopalatine artery in the posterior nasal cavity or nasopharynx). A posterior source increases the risk of airway impairment, blood aspiration, and difficulties controlling bleeding.

Risk factors of Epistaxis

There are multiple risk factors for the development of epistaxis and it can affect any age group, but it is the elderly population with their associated morbidity who often require more intensive treatment and subsequent care. This condition most commonly affects children ranging from 2 to 10 years old and the elderly ranging from 50 to 80 years old.

What causes a nosebleed?

Epistaxis has two etiologies: local and systemic. Furthermore, as the patient ages, the most prevalent causes of epistaxis vary. However, one consistency across etiologies is that epistaxis becomes more common throughout the winter months.

Nasal humidification is inhibited by reduced humidity and temperature. The nasal mucosa has poor local wound healing and is hence more prone to bleeding.

Local causes:

• Digital manipulation
• Trauma
• Chronic nasal cannula use
• Deviated septum

Systemic causes:

• Hypertension
• Vascular malformations
• Alcoholism
• Coagulopathies (von Willebrand disease, hemophilia)

Hemophilia A, hemophilia B, and von Willebrand disease are the most prevalent hereditary bleeding diseases linked with epistaxis. Hemophilia A and B are caused by deficits in factor VIII and factor IX, which are both essential components of the coagulation cascade.

Von Willebrand disease is caused by a qualitative or quantitative deficit in the von Willebrand factor, a glycoprotein required for factor VIII to function properly. These diseases are inherited in a sex-linked manner; only men are afflicted.

A preoperative work-up that identifies these diseases has the potential to save a patient's life during surgery. In these cases, desmopressin and cryoprecipitate can be used both prophylactically and therapeutically.

Environmental factors:

• Allergies
• Environmental dryness (more common in winter months)

Medications:

• NSAIDs (ibuprofen, naproxen, aspirin)
• Anticoagulants (warfarin)
• Platelet aggregation inhibitors (clopidogrel)
• Topical nasal steroid sprays
• Supplement/alternative medications (vitamin E, ginkgo, ginseng)
• Illicit drugs (cocaine)

The nose being a prominent feature on the face is highly susceptible to craniofacial injury. According to the study by Japhet, et al. (2011) most of the patients with epistaxis from trauma were victims of road traffic injury.

Trauma being the most common cause of epistaxis can partly explain the frequency of this problem in males. According to the study by Japhet, et al. (2011), males are disproportionately on the road in search of economic activity, thereby making them more prone to such accidents. The high incidence of traumatic epistaxis resulting from road traffic crashes in the study calls for urgent preventive measures targeting at reducing the occurrence of road traffic crashes (RTC's) in order to reduce the incidence of epistaxis in this region.

While epistaxis is a frequent spontaneous issue, uncommon etiologies such as neoplasms or vascular malformations should always be considered, especially if accompanying symptoms such as unilateral nasal obstruction, discomfort, or other cranial nerve impairments are present.

Vascular and cardiovascular diseases such as congestive heart failure, arteriosclerosis, and collagen abnormalities can also be contributing factors to epistaxis. A well-known association between hereditary hemorrhagic telangiectasia and epistaxis has been determined.

Hereditary hemorrhagic telangiectasia, or Osler-Rendu-Weber disease, has an autosomally dominant inheritance pattern with incomplete penetrance. Its presenting symptom is usually epistaxis secondary to telangiectasias of the nasal mucosa. Genetic mutations involving growth factor-beta result in fragile, injury-prone vessels with deficiencies in elastic tissue and smooth muscle.

Hypertension and epistaxis

The connection between hypertension and epistaxis is frequently misinterpreted. Patients with epistaxis frequently have high blood pressure. Epistaxis is more prevalent in hypertensive individuals, possibly due to vascular fragility caused by long-term illness.

However, hypertension is seldom a direct cause of epistaxis. Epistaxis and the anxiety that comes with it are more likely to induce an abrupt rise in blood pressure. As the main way of lowering blood pressure, therapy should focus on managing bleeding and reducing anxiety.

Excessive coughing can cause nasal venous hypertension in people with pertussis or cystic fibrosis.

Nosebleed and headache

Headaches and epistaxis, or nosebleeds, are rather frequent. Nosebleeds are caused by blood vessels in the nose that have burst or ruptured. A headache with a nosebleed might indicate a small problem, such as hay fever, or something more serious, such as anemia, or a low red blood cell count.

Epidemiology

Only four of the 2.4 million fatalities in the United States are caused by nosebleeds. Approximately 60% of people have had a nosebleed at some point in their lives, and only 10% of nosebleeds are serious enough to need treatment/medical intervention. They are more prevalent in youngsters aged 2 to 10 years old and the elderly aged 50 to 80 years old. 

Pathophysiology of nosebleeds

The rupture of a blood artery within the nasal mucosa causes nosebleeds. Rupture can occur spontaneously, as a result of trauma or the use of certain medicines, or as a result of various comorbidities or cancers. A rise in the patient's blood pressure may lengthen the episode. Anticoagulant medicines and coagulation problems can potentially lengthen the bleeding duration.

The majority of nosebleeds occur in the anterior portion of the nose (Kiesselbach's plexus), and an etiologic vessel is typically visible on thorough nasal inspection.

A posterior nosebleed is a type of bleeding that occurs from the rear or upper nasal cavity. This is typically assumed to be caused by bleeding from the Woodruff's plexus, which is composed of the posterior and superior terminal branches of the sphenopalatine and posterior ethmoidal arteries.

These are sometimes difficult to manage and are characterized by bleeding from both nostrils or into the nasopharynx, where it is swallowed or vomited up, resulting in hemoptysis. Due to the increased difficulty in regulating the hemorrhage, it might cause a larger flow of blood into the posterior pharynx and a higher risk of airway obstruction or aspiration.

Types of epistaxis

There are two types of nosebleeds: anterior (more common), and posterior (less common, but more likely to require medical attention).

Anterior epistaxis (anterior nosebleed)

Most nosebleeds occur in the anterior part of the nose (Kiesselbach's plexus), and an etiologic vessel can usually be found on careful nasal examination. Epistaxis is most commonly encountered in the pediatric population next to digital trauma.

Digital irritation to Kiesselbach plexus is a very common source of anterior septal nose bleeds in children, especially during the winter months.

Causes of anterior epistaxis (anterior nosebleed) include:

• Improper use of topical nasal sprays resulting in repeated trauma to the epithelium of the septal mucosa from sprays directed medially can cause intermittent epistaxis.
• Trauma from a foreign body can elicit epistaxis.
• Rhinorrhea may also be present secondary to an associated foreign body reaction or infection.
• Postsurgical epistaxis is a common phenomenon that is usually amenable to basic treatments.
• Lastly, the use of nasal cannula can cause epistaxis secondary to their local irritation as well as effects of nasal drying.
• Septal deflections, bony spurs, and fractures are underlying anatomic deformities in the nose that can predispose a patient to epistaxis.
• Any form of the inflammatory or granulomatous disease within the nasal cavity can cause bleeding. Common examples include bacterial sinusitis, allergic rhinitis, nasal polyposis, Wegner granulomatosis, tuberculosis, and sarcoidosis.

Finally, suspicion should arise for intranasal neoplasms/vascular malformations involving recurrent nose bleeds, especially ones with no known causes. Some examples of intranasal masses that can initially present with epistaxis are inverted papillomas, angiofibromas, aneurysms, encephaloceles, hemangiomas, adenocarcinomas, and esthesioneuroblastomas.

Posterior epistaxis (posterior nosebleed)

Bleeding from the posterior or superior nasal cavity is often termed a posterior nosebleed.  This is usually presumed due to bleeding from Woodruff's plexus, which are the posterior and superior terminal branches of the sphenopalatine and posterior ethmoidal arteries.

The symptoms of posterior epistaxis may include:

• Often difficult to control.
• It is associated with bleeding from both nostrils or into the nasopharynx.
• It is swallowed or coughed up, presenting as hemoptysis. 
• It can generate a greater flow of blood into the posterior pharynx.
• Have a higher risk for airway compromise or aspiration due to increased difficulty in controlling the bleeding.

Nose bleed during pregnancy

Pregnant women are more prone to get nosebleeds because of increased blood volume, which can cause nasal arteries to burst. Pregnancy has a lot of strange side effects, including nosebleeds. One in every five patients experiences nosebleeds (epistaxis) during pregnancy, compared to 6% of women who do not.

Nose bleeding in children

Dry air, nose picking, nasal allergies, or other factors that irritate the fragile blood vessels in the front of the nose cause the majority of nosebleeds in children. If a kid suffers frequent nosebleeds or has recently begun taking a new medicine, a parent should contact a doctor or pediatrician. ‏

Nose bleed while sleeping

The causes of nosebleeds during sleep are the same as those that cause them during the day: dried nasal membranes produced by dry air, allergies, colds, and other upper respiratory illnesses that destroy the fragile nasal membrane lining your nose.

Diagnosis of Epistaxis

It is critical in treatment to distinguish between an anterior and a posterior. Direct vision using a nasal speculum and a light source can be used to diagnose anterior hemorrhage. A topical spray containing anesthetic and epinephrine may be beneficial for vasoconstriction in order to stop bleeding and aid in the identification of the cause.

Typically, posterior bleeding is diagnosed after all other attempts to reduce anterior bleeding have failed. Active bleeding into the posterior pharynx in the absence of an identifiable anterior source is a clinical characteristic of posterior bleeding; high-flow posterior bleeds may cause blood to emerge from both nares.

If necessary, labs such as a complete blood cell count (CBC), type and cross match, and coagulation tests can be done; however, this should not delay the management of an active bleed. Imaging modalities such as x-rays and computed tomography have no role in the treatment of active epistaxis that is urgent or emergent.

If there is a suspicion of a bleeding issue, the bleeding time is a useful screening test. If the patient is on warfarin or if liver disease is suspected, obtain the international normalized ratio (INR)/prothrombin time (PT). As needed, get the activated partial thromboplastin time (aPTT).

In most cases, direct visualization with a well-directed light source, a nasal speculum, and nasal suction should suffice for visual assessment. However, computed tomography (CT) scanning, magnetic resonance imaging (MRI), or both may be recommended to examine the surgical anatomy and detect the existence and degree of rhinosinusitis, foreign bodies, and neoplasms. If a tumor is suspected as the origin of the bleeding, a nasopharyngoscopy may be done.

How to stop a nosebleed?

Begin with a primary survey and address the airway, making sure it is patent. Next, look for signs of hemodynamic compromise. In patients with significant bleeding, get large-bore intravenous access and labs. If there is a problem with drug use, reverse blood clotting as needed.

All patients with moderate to severe nasal bleeding should be given two large-bore intravenous lines and a crystalloid infusion. It is critical to monitor oxygen and hemodynamic stability.

The management of epistaxis is well summarized in an age-old dictum: resuscitate the patient, establish the bleeding site, stop the bleeding, and treat the cause of epistaxis.

Medical therapy, conservative therapy, surgical therapy, and arterial embolization are the four treatment options for epistaxis. 

Non-surgical

Non-surgical approaches have been reported to stop the bleeding in more than 80-90% of cases. Treatment for anterior bleeding can be initiated with direct pressure for at least 10 minutes.

Have the patient apply constant direct pressure by pinching the nose over the cartilaginous tip (instead of over the bony areas) for a few minutes to try to control the bleed.

• Severe nosebleed:

Dealing with a patient with active severe epistaxis can be bloody. The key to controlling most epistaxis is to find the site of the bleeding and cauterizing it with silver nitrate or bipolar diathermy.

The goal of treatment includes hemostasis, short hospital stay, low complication, and cost-effectiveness of the method of therapy.

Anterior nasal packing with gauzed glove finger packing was the most frequent modality of treatment.

If that is ineffective, vasoconstrictors such as oxymetazoline or thrombogenic foams or gels can be employed.

Cautery and nasal packing are examples of conservative treatments. Nasal cautery can be done both chemically and thermally. Chemical cautery employs the topical application of silver nitrate, whereas thermal cautery employs Bovie electrocautery.

If the bleeding location is anterior and therefore visible, cautery can be done at the bedside or in the clinic setting following sufficient topical anesthetic. More posterior locations may necessitate general anesthesia and the use of an operating room.

Anterior or posterior nasal packs are used for nasal packing. When medical treatment and cautery fail, an anterior pack is used after identifying anterior nasal bleeding. The packing agent is chosen based on the physician's preference and the patient's degree of comfort. All packs should be coated with antibiotic ointment and apply sufficient pressure to the site of the bleeding.

To prevent toxic shock syndrome and other related illnesses, packs should be placed in place for no longer than 5 days. Antibiotics should be taken orally for as long as the packs are in the nose. Epistaxis should stop when an anterior pack is placed, and there should be no active bleeding down the posterior oropharynx. After successful anterior pack implantation, patients can be discharged home and securely maintained on an outpatient basis.

Surgical therapy

Surgical therapy for epistaxis has largely been supplanted by the use of arterial embolization. Procedures used for bleeds that are refractory to medical and conservative therapy include internal maxillary artery (IMA), anterior ethmoid artery, and external carotid artery ligation.

Arterial embolization

Arterial embolization performed by interventional radiologists is a relatively new technique used to embolize distal branches of the internal maxillary artery (IMA). Under local anesthesia, diagnostic angiograms are performed to assess the vascular anatomy.

Diagnostic angiograms are used to evaluate the vascular anatomy. Brisk bleeds will appear as blushes and can be embolized selectively. Transient hemiparesis, facial paralysis, blindness, columellar necrosis, stroke, and death are all possible consequences, but they are infrequent when operations are performed by skilled surgeons.

Finally, a general rule is that the closer the embolization, the more likely postembolization problems are.

• Arterial ligation

The exact vessel or vessels to be ligated are determined by the location of the epistaxis. In general, the closer the ligation is to the site of bleeding, the more successful the operation. The external carotid artery (ECA) can be ligated while the patient is under local or general anesthesia. Because of the more remote location of operation, internal maxillary artery ligation has a better success rate than ECA ligation.

Consider ligation of the anterior ethmoidal artery, the posterior ethmoidal artery, or both if bleeding occurs high in the nasal vault. An external ethmoidectomy incision is used to access these arteries.

Differential Diagnosis

• Nasal tumor
• DIC
• Hemophilia
• Von Willebrand disease
• Rhinitis
• Foreign body in the nose
• Drug toxicity (Warfarin, NSAIDs)

Postoperative and Rehabilitation Care

Once the bleeding has stopped, it is critical that they schedule a follow-up appointment with their general care physician or an otolaryngologist within one week. If the packaging has been done, it must be left undisturbed for 3-5 days before removal.

To avoid toxic shock syndrome, patients should begin using an anti-staphylococcal medication. Before discharge, underlying reasons must be addressed (strict blood pressure management with a goal SBP of 120 mm Hg, reversal of any coagulopathy, etc.), and patients should apply topical nasal saline in both nares to maintain the packs wet and enable removal.

Prognosis

Epistaxis is just an annoyance for the majority of the general population. However, the condition can occasionally be fatal, especially in older people and those with underlying medical issues. Fortunately, death is uncommon and is generally caused by hypovolemia-related complications such as severe bleeding or underlying illness conditions.

Overall, the prognosis is favorable but varied; however, with adequate treatment, it is good. Most patients are unlikely to rebleed if sufficient supportive care is provided and underlying medical issues are managed. Others may get mild recurrences that resolve on their own or with modest self-treatment. Repacking or more severe therapies may be required for a small number of patients.

Nose bleed prevention

How to Prevent Nosebleeds?

1. Keep the inside of your nose moist. Dryness can cause nosebleeds. 
2. Use a saline nasal product. Spraying it in your nostrils helps keep the inside of your nose moist.
3. Don't smoke.
4. Don't pick your nose.
5. Don't use cold and allergy medications too often.

Conclusion 

Epistaxis is an issue that otolaryngologists frequently encounter. The vast majority of instances are readily handled, but some can be fatal. Understanding vascular anatomy is essential for pinpointing the site of the bleed. Once the site has been determined, proper medicinal, conservative, or surgical treatment can begin.

Patients with anterior nosebleeds can be released if the bleeding is controlled and hemodynamic stability is maintained for at least one hour in the emergency department (ED), and all contributing variables have been medically adjusted. In one week, they should see an otolaryngologist or their primary care physician, and they should start using nasal saline three times a day.

If non-biodegradable packing is utilized, patients should return to the ED or ENT within three to five days for packing removal. If a patient, even a child, requires posterior packing, hospitalization is necessary to monitor for problems, notably cardiac arrhythmias. All anticoagulants should preferably be withdrawn, but if this is not feasible, they should be reversed or withheld to obtain the lowest tolerable dosage.

The use of topical saline sprays or ointments to the nasal mucosa to promote nasal mucosa moisturization can assist to avoid recurring epistaxis. Patients should also be encouraged to avoid hot meals, vigorous activity, blowing their noses, or digital nasal manipulation after discharge.