TOPIC INDEX  
 

EPISTAXIS (Bleeding form Nose)

 

Epistaxis is defined as any bleeding from the nostril, nasal cavity, or nasopharynx. It is a very common problem in children and sometimes in adults too. This is a very common emergency department complaint and often promotes significant anxiety in patients and clinicians. However, an emergency physician may successfully treat more than 90% of patients who present to the emergency department with epistaxis

 

Pathophysiology

 

 

 

This picture shows prominent anterior (up-front) septal vessels, which will bleed easily. 

 

Inside of the nose is covered with moist, delicate skin (mucous membrane) that has a rich supply of blood vessels. There are two areas that are often implicated in nosebleeds where a plexus of anastomotic vessels can be found, One in the front, mobile part of the septum – midline partisan in nose - which is called as Little’s area About 90% of nosebleeds originate from the nasal septum and erupt when the relatively thin nasal mucosa overlying a dilated septal vessel dries, scabs, and falls (or is picked) off. Woodruff's plexus is the second common sit of bleeding, which is located over the posterior middle turbinate. In these cases, the site of bleeding is higher and deeper within the nose and the blood flows primarily down the back of the throat. Only rarely, a nosebleed is life threatening or actually fatal. In most cases of life-threatening nosebleeds, some underlying health problem (hypertension, a bleeding disorder, use of anticoagulant medication) is working against the clotting process. 

Common risk factors for nosebleeds include:

Nosebleeds also commonly are caused by trauma, such as nose picking, forceful blowing of the nose

a)             Hot, dry climate — Nose bleeds are more common in hot, dry climates as these climates lead to drying of the nasal mucosa, stasis of secretions, infection and inflammation which leads to increased vascularity as well as cracking of the mucosa, both of which increase chances of bleeding.

b)             Colds and allergies — Both upper respiratory tract infections and allergies trigger nasal inflammation, which can increase the risk of bleeding. Strenuous nose blowing to clear the nose also can cause a nose to bleed or to start bleeding again after a nosebleed has been controlled.

c)              A deviated septum — A nasal septum that is shifted away from the midline (deviated) produces an uneven airflow pattern within the nostrils. The altered airflow pattern causes the skin on one side of the nasal septum to become dry and cracked, increasing the risk of bleeding. These bleeding episodes are usually incited by local intranasal factors such as deviated nasal septum with crusting, drying, and subsequent ulceration.

d)             Exposure to irritating chemicals —cigarette smoke, even passive cigarette smoke. Workers also may develop nosebleeds from on-the-job exposure to sulphuric acid, ammonia, gasoline or other chemical irritants.

e)             Medical conditions — Examples include chronic renal disease (kidney failure), thrombocytopenia (low levels of the blood platelets needed for clotting) and hereditary bleeding disorders, such as haemophilia. Despite a strong association with nasal haemorrhage, hypertension is rarely a direct cause of epistaxis. Vascular fragility secondary to chronic hypertension probably increases occurrence of epistaxis in these patients. In arteriosclerosis and hypertension, bleeding may be heavier.

f)               Heavy alcohol use — Alcohol seems to interfere with the normal activity of platelets in the blood, and this increases the time needed for blood clots to form. It also makes superficial blood vessels dilate, making them more likely to bleed.

g)             Medications that interfere with blood clotting — These include prescription anticoagulants (blood-thinners) and nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen (Advil, Motrin and others).

Prevention:

You can help to prevent nosebleeds by:

·       Not picking your nose

·       Gently Blow your nose one by one, not both at the same time.

·       Keep your mouth open, when you have sneezing.

·       Not smoking

·       Using a humidifier if your indoor climate is dry

·       Applying a dab of butter / petroleum jelly to the inside of your nostrils before bedtime

·       Avoid aspirin and other non steroidal anti inflammatory drugs like Diclofenic sodium, Ibu brufen etc.  

First Aid:

If you are bleeding from the front of your nose, begin by trying the following first-aid measures:

·       Sit up so your head is above the level of your heart, lean forward slightly and breathe through your mouth.

·       Pinch the entire front of your nose, just above your nostrils, and hold it for ten minutes.

·       Apply an ice pack or a plastic bag of crushed ice to your nose to slow the blood flow.

·       After you have pinched your nose for ten minutes, release it to see if bleeding continues.

·       If your nose is still bleeding, pinch it for an additional 10 minutes.

·       After 10 minutes, release your nose again. If you are still bleeding, go to the emergency department to seek medical help.

Treatment

When simple first aid does not stop a nosebleed, your doctor may treat the problem by:

  • Cauterising (sealing off) the injured blood vessel with a chemical, such as silver nitrate, or with an electric probe
  • Packing your nose with gauze or tampon.
  • Applying medication directly to the inside of your nose to stop the bleeding
  • Using other methods, such as cryo therapy (using cold temperature to freeze the site of bleeding), laser therapy (using a laser beam to seal the bleeding blood vessel) or, in rare cases, embolization (injecting a special plug into the bleeding vessel to block blood flow) or surgery to ligate bleeding vessels.
  • Ligating the internal maxillary artery and its branches or packing the posterior part of the nasal cavity is required to control the bleeding
  • Do not pick your nose after cauterization. It takes seven to ten days to completely heal the torn blood vessels. If you pick your nose you will peel the scab off and cause another nosebleed.
  • After cauterization, you will get scab in nose. Do not peel off. Allow it to fall off by it self. You can apply some cream, butter or Vaseline to avoid dryness and help to prevent irritation and healing.

Prognosis

With a little patience and localized pressure, most of uncomplicated anterior nosebleeds respond to simple first-aid measures. But if it is recurrent, please get advise from your doctor. Even the rare nosebleed that requires a doctor's care usually can be treated successfully with cauterisation, packing, or another option.

In general, hospital treatment for a severe nosebleed is most likely in people older than 60. Among those who use anticoagulants to treat circulatory problems, nosebleeds can be a persistent problem.

 
 
© 2004 , All Rights Reserved