Nosebleed (Epistaxis)
One of the most frequent ear, nose, and throat (ENT) emergencies seen in the emergency room or primary care clinic is epistaxis (nosebleed). Anterior (more popular) and posterior nosebleeds (less frequent, but more likely to need medical attention) are the two types of nosebleeds. The Kiesselbach's plexus (also referred to as Little's area) on the anterior nasal septum is the origin of 90% of anterior nosebleeds. The nasal cavity is supplied by five identified vessels with terminal branches:
- Anterior ethmoidal artery
- Posterior ethmoidal artery
- Sphenopalatine artery
- Greater palatine artery
- Superior labial artery
Kiesselbach's plexus is the watershed area of these five veins, which is located in the anterior nasal septum. Because it is located near the entrance to the nasal cavity, it is exposed to extremes of heat and cold, as well as high and low moisture levels, and is readily traumatized. Because the mucosa over the septum in this location is so thin, it is the most common site of epistaxis. The so-called posterior epistaxis occurs when arteries in the back or superior nasal cavity bleed. Patients on blood thinners, hypertensive patients, and those with underlying blood dyscrasia or vascular disorders are more likely to experience this. The degree of the bleeding and the patient's other medical issues will determine how the patient is treated.
Epistaxis
Epistaxis, also known as nosebleeds, is a common problem that usually goes away on its own or can be treated simply in a medical setting. Some patients' nosebleeds are severe enough to necessitate additional therapy. Doctors have much expertise dealing with epistaxis situations.
Epistaxis Epidemiology
Only four out of every 2.5 million deaths in the United States are caused by nosebleeds. About 60% of people have had a nosebleed at some point in their lives, yet only 10% of nosebleeds are serious enough to require treatment or medical intervention. Children aged 2 to 10 years old and the elderly aged 50 to 80 years old are the most typically affected.
Epistaxis Pathophysiology
The rupture of a blood vessel within the nasal mucosa causes nosebleeds. Rupture can occur spontaneously, as a result of trauma or the use of certain drugs, or as a result of various comorbidities or cancers. The length of the episode can be prolonged if the patient's blood pressure rises. Bleeding duration can be prolonged by anticoagulant drugs and coagulation problems.
The majority of nosebleeds happen in the front of the nose (Kiesselbach's plexus), and a causative vessel can typically be found with a careful nasal inspection.
A posterior nosebleed is defined as bleeding from the back or superior nasal cavity. Woodruff's plexus, which consists of the posterior and superior terminal branches of the sphenopalatine and posterior ethmoidal arteries, is frequently blamed for this. These are frequently difficult to control and are characterized by bleeding from both nostrils or into the nasopharynx, where it is ingested or coughed up, resulting in hemoptysis. Due to the increased difficulty in regulating the bleed, it can cause a greater flow of blood into the posterior pharynx, increasing the risk of airway compromise or aspiration.
Epistaxis Causes
Epistaxis has two types of causes: local and systemic. Moreover, as the patient gets older, the most likely causes of epistaxis will vary. Epistaxis increases in frequency during the winter months, regardless of the cause. Nasal humidification is inhibited by lower humidity and lower temperature. The nasal mucosa has a low local wound healing rate, making it more prone to bleeding.
Epistaxis Local Causes
Trauma, anatomic abnormalities, inflammatory reactions, and intranasal malignancies are the most prevalent local causes of epistaxis.
Epistaxis is most typically found in children as a result of digital trauma. Anterior septal nasal bleeds in children are frequently caused by digital irritation of the Kiesselbach plexus, especially during the winter months. Another cause of epistaxis is the misuse of topical nasal sprays. Intermittent epistaxis can be caused by repeated injury to the septal mucosa epithelium from sprays directed medially. This difficulty can be solved with proper counseling and teaching on how to guide the spray away from the midline septum. Epistaxis can be caused by foreign body trauma. Rhinorrhea may also be present as a result of an infection or foreign body reaction. Epistaxis after surgery is a common occurrence that responds well to conservative treatment. Finally, the use of nasal cannulas can result in epistaxis due to local irritation and nasal drying effects.
Septal deflections, bony spurs, and fractures are some of the underlying anatomic abnormalities in the nose that can cause epistaxis. Any nasal blockage causes the airflow to be disrupted. The drying effect of the turbulent flow anterior to these barriers increases the risk of mucosal disruption and epistaxis. Furthermore, excessive deflections/spurs might cause localized damage to the mucosa of the lateral nasal wall.
Nasal bleeding can be caused by any type of inflammatory or granulomatous condition. Bacterial sinusitis, allergic rhinitis, nasal polyposis, Wegner granulomatosis, TB, and other conditions are common examples.
Finally, recurring nose bleeds, particularly unilateral ones, with no known reason should raise suspicion for intranasal neoplasms and vascular abnormalities. Inverted papillomas, angiofibromas, aneurysms, encephaloceles, hemangiomas, sarcoidosis, adenocarcinomas, and esthesioneuroblastomas are some examples of intranasal tumors that might present with epistaxis.
Epistaxis Systemic Causes
Hypertension, coagulation abnormalities, inherited bleeding diathesis, and vascular/cardiovascular illnesses are the most prevalent systemic causes of epistaxis.
Although the mechanism involved in the link between hypertension and epistaxis is still under debate, the two are undoubtedly related. In cases of severe or refractory epistaxis, hypertension is the most common finding.
The ability to produce clots is important for epistaxis prevention and control. Systemic variables influencing epistaxis include medication-induced coagulation abnormalities and liver failure. Aspirin, clopidogrel, nonsteroidal anti-inflammatory medications, and warfarin are frequent medications linked to epistaxis. Platelet dysfunction is caused by chronic alcohol consumption and renal dysfunction with uremia. Liver function tests and platelet counts are usually within normal ranges in the context of these disorders.
Hemophilia A, hemophilia B, and von Willebrand disease are the most prevalent inherited bleeding disorders linked to epistaxis. Hemophilia A and B are caused by a lack of factor VIII and factor IX, both of which are essential components of the coagulation cascade. Von Willebrand disease is caused by a shortage in the von Willebrand factor, a glycoprotein that is required for factor VIII proper function. Only males are affected by these illnesses, which are hereditary. A preoperative examination that identifies these conditions may be able to avoid life-threatening bleeding during surgery. In these cases, desmopressin and cryoprecipitate can be used prophylactically and therapeutically.
Epistaxis can be caused by vascular and cardiovascular illnesses such as congestive heart failure, arteriosclerosis, and collagen abnormalities. It has been established that hereditary hemorrhagic telangiectasia and epistaxis are related. Osler-Rendu-Weber disease, or hereditary hemorrhagic telangiectasia, is inherited in an autosomal dominant form with incomplete penetrance. Epistaxis due to telangiectasias of the nasal mucosa is frequently the first symptom. Fragile, injury-prone arteries with defects in elastic tissue and smooth muscle are the result of genetic abnormalities involving growth factor-beta.
Epistaxis Symptoms
The duration, intensity, frequency, laterality, triggering event, and interventions provided before seeking care should all be included in the history. Ask about the use of anticoagulants, aspirin, NSAIDs, and nasal steroids. Obtain a related family history, especially in relation to coagulopathy and vascular/collagen disease, as well as any drug or alcohol use history.
Before starting the physical examination, gather the necessary materials and personal protective equipment (PPE). A nasal speculum, bayonet forceps, headlamp, suction catheter, packing, silver nitrate swabs, cotton pledgets, topical vasoconstrictors, and anesthetics are some of the items that may be used. Place the patient in an exam chair in a room that has suction. To view the bleeding location, carefully place the speculum and gently open the blades. To identify the bleeding cause, a headlight is required for hands-free illumination, and a clot may need to be suctioned from the nasal cavity.
Active bleeding into the posterior pharynx without a visible vessel on nasal inspection may indicate a posterior nosebleed, which is difficult to detect. Nasal endoscopy improves the chances of locating the bleeding source.
Epistaxis Diagnosis
It's crucial to know whether you have an anterior or posterior problem. Direct inspection with a nasal speculum and a light source can be used to diagnose anterior bleeding. For vasoconstriction, a topical spray containing anesthetic and epinephrine may be beneficial in controlling bleeding and aiding in the visibility of the source. After attempts to stop anterior bleeding have failed, the diagnosis of posterior bleeding is usually made. Active bleeding into the posterior pharynx in the absence of an anterior source is a clinical hallmark of posterior bleeding; high-flow posterior bleeds can cause blood to come out of both nares. If necessary, lab tests such as a complete blood cell count (CBC), type and crossmatch, and coagulation studies can be performed, although this should not delay the management of an active bleed. In the immediate or emergent care of active epistaxis, imaging such as x-ray or computed tomography has no importance.
Epistaxis Treatment
Medical therapy, conservative therapy, surgical therapy, and arterial embolization are all options for treating epistaxis.
Medical Treatment
Medical treatment serves as both a therapeutic and preventative measure. Epistaxis must first be diagnosed and treated for hypertension and other hematologic causes. The majority of bleeding is relieved with modest direct pressure in the form of a nose pinch once these parameters are addressed. Furthermore, saline nasal irrigation and topical ointment application in the nostrils produce a humidified nasal environment that can help avoid further epistaxis episodes. If the bleeding continues, a topical nasal decongestant with vasoconstriction properties can be administered. Topical decongestants should not be used indefinitely since they can become physiologically addictive.
Conservative Treatment
Cautery and nasal packing are examples of conservative treatment. Chemical or thermal cautery can be used for nasal cautery. In chemical cautery, silver nitrate is applied topically, whereas, in thermal cautery, Bovie electrocautery is used. If the bleeding spot is anterior and thus visible, cautery can be done at the bedside or in the clinic after an appropriate topical anesthetic. General anesthesia and an operating room setting may be required for more posterior spots.
Nasal packing can be done from the front or back of the nose. Identification of anterior nasal bleeding is followed by administration of an anterior pack when medical treatment and cautery fail. The choice of packing agent is determined by the physician's preferences and the patient's level of comfort. All packs should be treated with antibiotic ointment and applied with sufficient pressure to the bleeding site. To avoid toxic shock syndrome and other infections, packs should be worn for no longer than 5 days. Antibiotics should be taken orally for as long as the nasal packs are in place. Epistaxis should stop when the anterior pack is placed, and there should be no active bleeding down the posterior oropharynx on inspection. Patients can be sent home after a successful anterior pack insertion and treated safely as outpatients.
After applying an anterior pack, if epistaxis develops in the contralateral nose or bleeding down the posterior oropharynx intensifies, a posterior pack may be needed. Foley catheters and double-balloon nasal packs are examples of posterior packs. The posterior pack's function is to seal the nasopharynx at the choanal entrance and provide support for the anterior pack. Anterior and posterior balloons are included in double-balloon systems. When utilizing a Foley catheter, anterior packing material must be tightly placed against the inflated Foley balloon. When utilizing posterior packs to avoid infection, the same general principles apply. The placement of an anterior/posterior pack, for example, necessitates hospitalization due to the likelihood of complications. Placing a pack in the nasopharynx, for example, can cause apnea and dysrhythmias by triggering the nasopulmonary reflex. Patients should therefore be followed in an intensive care unit or via continuous pulse oximetry and telemetry.
Surgical Treatment
Arterial embolization has largely replaced surgical treatment for epistaxis. IMA, anterior ethmoid artery, and external carotid artery ligation are procedures used for bleeding that are resistant to medical and conservative treatment.
Arterial Embolization
Interventional radiologists use a relatively novel technique called arterial embolization to embolize distal branches of the IMA. Diagnostic angiograms are conducted under local anesthetic to evaluate vascular architecture. 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 procedures are performed by qualified surgeons. Finally, a general rule is that the closer the embolization is to the heart, the more likely postembolization problems are.
How to Treat Epistaxis at Home?
The majority of the time, epistaxis can be treated at home or by a primary care doctor. The first step in stopping a nosebleed is to apply direct pressure to the nose tip with two fingers for 15 to 20 minutes. Sitting up straight, gently leaning forward, and tilting your head forward can prevent blood from reaching the throat. Although these treatments are typically sufficient to halt a nosebleed, topical sprays containing vasoconstrictive drugs or local anesthetics may be used if bleeding persists.
If the nosebleed is severe, prolonged, causes trouble breathing, causes you to vomit due to ingesting a large amount of blood, was induced by a serious traumatic injury, or is caused by a child under the age of two, go to the local emergency department and seek medical assistance.
Epistaxis Prevention
There are a few tips you may apply to prevent nosebleeds. To begin, avoid picking your nose as much as possible, and keep your fingernails short. Especially in the winter and during allergy times, try not to blow your nose too much and just gently. If you're taking cold or allergy medication, make sure you read the package instructions carefully. Next, make sure you're wearing suitable protective headgear if you're doing anything that could harm your nose or head. Finally, abstain from excessive alcohol consumption and smoking.
Epistaxis Prognosis
Epistaxis is an annoyance for the majority of people. However, the problem can be life-threatening in some patients, particularly the elderly and those with underlying medical conditions. Fortunately, death is uncommon and usually results from hypovolemia-related consequences such as severe bleeding or underlying disease conditions.
Overall, the prognosis is favorable but variable; nevertheless, with appropriate treatment, it is excellent. Most patients are rarely rebleeding if they get proper supportive treatment and their underlying medical conditions are managed. Others may experience mild recurrences that go away on their own or with very little self-treatment. Repacking or more intensive treatments may be required in a minority of patients.
Epistaxis caused by dry membranes or minor injury is treated successfully, with no long-term consequences. Patients with Hereditary Hemorrhagic Telangiectasia (HHT) are more likely to have multiple recurrences, independent of treatment. The prognosis for patients who are bleeding due to a hematologic disorder or malignancy is variable. Patients who have had nasal packing have a higher risk of morbidity. Airway compromise and respiratory depression are possible side effects of posterior packing. Infection can occur with packing in any location.
Conclusion
Epistaxis is a problem that otolaryngologists frequently encounter. Although the majority of instances are treatable, some can be life-threatening. The ability to determine the location of the bleed requires knowledge of vascular anatomy. Once the exact location has been determined, medicinal, conservative, or surgical treatment can begin.