Epistaxis is nose bleeding. Bleeding can range from a trickle to a strong flow, and the consequences can range from a minor annoyance to life-threatening hemorrhage.
Pathophysiology of Epistaxis
Most nasal bleeding is anterior, originating from a plexus of vessels in the anteroinferior septum (Kiesselbach area).
Less common but more serious are posterior nosebleeds, which originate in the posterior septum overlying the vomer bone or laterally on the inferior or middle turbinate. Posterior nosebleeds tend to occur in patients who have preexisting atherosclerotic vessels or bleeding disorders and have had nasal or sinus surgery.
Etiology of Epistaxis
The most common causes of epistaxis are
Local trauma (eg, nose blowing and picking)
Drying of the nasal mucosa
There are a number of less common causes (see table Some Causes of Epistaxis). Hypertension may contribute to the persistence of a nosebleed that has already begun but is unlikely to be the sole etiology.
Some Causes of Epistaxis
Cause* | Suggestive Findings | Diagnostic Approach† |
|---|---|---|
Common | ||
Drying of the mucosa (eg, in cold weather) | Usually visibly dry during examination | Clinical examination alone |
Local trauma (eg, nose blowing, picking, blunt impact) | Apparent by history | Clinical examination alone |
Less common | ||
Usually in older patients | Clinical examination alone | |
History of prior epistaxis or other bleeding sites, such as gingiva | CBC with platelet count, PT/PTT | |
Foreign bodies (mainly in children) | Often recurrent epistaxis with a malodorous discharge from one nostril | Clinical examination alone |
Local infections (eg, vestibulitis, rhinitis) | Crusting in the nasal vestibule, often with local pain and dry mucosa | Clinical examination alone |
Hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome) | Telangiectasias on the face, lips, oral and nasal mucosa, and tips of the fingers and toes Positive family history | Clinical examination alone |
History of trauma (surgery or injury), certain chronic infections, or cocaine use Visible during examination | Clinical examination alone | |
Systemic disorders (eg, AIDS, liver disease) | Presence of known disease Mucosal erosions and hypertrophy | Clinical examination alone |
Tumor (benign or malignant) of the nasopharynx or paranasal sinuses | Mass seen within the nose or nasopharynx Bulging of the lateral nasal wall | CT |
* Epistaxis of any cause is more common among patients with bleeding disorders (eg, thrombocytopenia, liver disease, coagulopathies) and with anticoagulant use. In such patients, bleeding is also often more severe and difficult to treat. | ||
† Clinical examination is always done but is mentioned in this column only when that can be the sole means of diagnosis. | ||
CBC = complete blood count; CT = computed tomography; PT/PTT = prothrombin time/partial thromboplastin time. | ||
Evaluation of Epistaxis
History
History of present illness should try to determine which side began bleeding first; although major epistaxis quickly involves both nares, most patients can localize the initial flow to one side, which focuses the physical examination. Also, the duration of bleeding should be established, as well as any triggers (eg, sneezing, nose blowing, picking) and attempts by the patient to stop the bleeding. Melena may occur, and swallowed blood is a gastric irritant, so patients may also report vomiting blood. Important associated symptoms before onset include symptoms of an upper respiratory infection (URI), sensation of nasal obstruction, and nasal or facial pain. The time and number of previous nosebleeds and their resolution should be identified.
Review of systems should ask about excessive bleeding (particularly related to toothbrushing, phlebotomy, or minor trauma), easy bruising; bloody or tarry stools, hemoptysis, and blood in urine..
Past medical historyshould note presence of known bleeding disorders (including a family history) and conditions associated with defects in platelets or coagulation, particularly cancer, cirrhosis, HIV, and pregnancy. Drug history (prescription, over-the-counter, recreational) should specifically include use of medications that may promote bleeding, such as aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), other antiplatelet medications (eg, clopidogrel), heparin, and warfarin.
Physical examination
Vital signs should be reviewed for indications of intravascular volume depletion (tachycardia, hypotension) and marked hypertension. With active bleeding, treatment takes place simultaneously with evaluation.
During active bleeding, inspection is difficult, so attempts are first made to stop the bleeding as described below. The nose is then examined using a nasal speculum and a bright head lamp or head mirror, which leaves one hand free to manipulate suction or an instrument.
Anterior bleeding sites are usually apparent on direct examination. If no site is apparent and there have been only 1 or 2 minor nosebleeds, further examination is not needed. If bleeding is severe or recurrent and no site is seen, fiberoptic endoscopy may be necessary.
The general examination should look for signs of bleeding disorders, including petechiae, purpura, and perioral and oral mucosal telangiectasias as well as any intranasal masses.
Red flags
In patients with epistaxis, the following findings are of particular concern:
Signs of hypovolemia or hemorrhagic shock
Anticoagulant use
Cutaneous signs of a bleeding disorder
Bleeding not stopped by direct pressure or vasoconstrictor-soaked pledgets
Multiple recurrences of epistaxis, particularly with no clear cause
Interpretation of findings
Many cases of epistaxis have a clear-cut trigger (particularly nose blowing or picking), as suggested by findings (see table Some Causes of Epistaxis).
Testing
To diagnose epistaxis, routine laboratory testing is not required. If patients have symptoms or signs of a bleeding disorder and severe or recurrent epistaxis, a complete blood count (CBC), prothrombin time (PT), and partial thromboplastin time (PTT) should be done.
CT may be done if a foreign body, a tumor, or sinusitis is suspected.
Treatment of Epistaxis
Presumptive treatment for actively bleeding patients is that for anterior bleeding. The need for blood replacement is determined by the hemoglobin level, symptoms of anemia, and vital signs. Any identified bleeding disorders are treated.
Anterior epistaxis
Bleeding can usually be controlled by pinching the nasal alae together for 10 minutes while the patient sits upright (if possible). The patient or a clinician can pinch the nose manually to compress the plexus of vessels in the anterior interior septum. Alternatively, a commercially available nasal clip can be used to pinch the nose. If a nasal clip is not available, a makeshift nasal clip can be fashioned from 4 tongue depressors taped together. Two tongue depressors are then positioned on each side of the nose to pinch the nasal alae.
Copyright © 2023 Merck & Co., Inc., Rahway, NJ, USA and its affiliates. All rights reserved.
If this maneuver is ineffective, a cotton pledget impregnated with a vasoconstrictor (eg, phenylephrine 0.25%) and a topical anesthetic (eg, lidocaine 2%) is inserted and the nose pinched for another 10 minutes. The bleeding point may then be cauterized with electrocautery or silver nitrate on an applicator stick. Cauterizing four quadrants immediately adjacent to the bleeding vessel is most effective. Care must be taken to avoid burning the mucous membrane too deeply; therefore, silver nitrate is the preferred method.
Alternatively, a nasal tampon of expandable foam may be inserted. Coating the tampon with a topical ointment, such as bacitracin or mupirocin, may help as a lubricant and as prophylaxis against infection. If these methods are ineffective, various commercial nasal balloons can be used to compress bleeding sites.
As another alternative, an anterior nasal pack consisting of 1 cm (1/2 inch) petrolatum gauze may be inserted; up to 175 cm (72 inch) of gauze may be required. This procedure is painful, and analgesics are usually needed; it should be done only when other methods are ineffective or unavailable.
Posterior epistaxis
Posterior bleeding may be difficult to control. Commercial nasal balloons are quick and convenient; a gauze posterior pack is effective but more difficult to position. Both are very uncomfortable; IV sedation and analgesia may be needed, and hospitalization is required.
Commercial balloons are inserted according to the instructions accompanying the product.
The posterior gauze pack consists of 10 cm gauze squares folded, rolled, tied into a tight bundle with two strands of heavy silk suture, and coated with antibiotic ointment. The ends of one suture are tied to a catheter that has been introduced through the nasal cavity on the side of the bleeding and brought out through the mouth. As the catheter is withdrawn from the nose, the postnasal pack is pulled into place above the soft palate in the nasopharynx. The second suture, which is left long, hangs down the back of the throat and is trimmed below the level of the soft palate so that it can be used to remove the pack. The nasal cavity anterior to this pack is firmly packed with 1/2-inch petrolatum gauze, and the first suture is tied over a roll of gauze at the anterior nares to secure the postnasal pack. The packing remains in place for 4 to 5 days. An antibiotic (eg, amoxicillin/clavulanate 875 mg orally twice a day for 7 to 10 days) is given to prevent sinusitis and otitis media. Posterior nasal packing lowers the arterial PO2, and supplementary O2 is given while the packing is in place. This procedure is uncomfortable and should be avoided if possible.
On occasion, the internal maxillary artery and its branches must be ligated to control the bleeding. The arteries may be ligated with clips using endoscopic or microscopic guidance and a surgical approach through the maxillary sinus (internal maxillary) or transnasal endoscopic approach (sphenopalatine). Alternatively, angiographic embolization may be done by a skilled radiologist. These procedures, if done in a timely manner, may shorten hospital stay.
Bleeding disorders
In hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome), a split-thickness skin graft (septal dermatoplasty) reduces the number of nosebleeds and allows the anemia to be corrected. Laser (Nd:YAG) photocoagulation can be done in the operating room. Selective embolization is also very effective, particularly if patients cannot tolerate general anesthesia or if surgical intervention has not been successful. New endoscopic sinus devices have made transnasal surgery more effective.
Blood may be swallowed in large amounts and, in patients with severe liver disease, should be eliminated promptly with enemas and cathartics to prevent hepatic encephalopathy. The gastrointestinal tract should be sterilized with nonabsorbable antibiotics (eg, neomycin 1 g orally 4 times a day) to prevent the breakdown of blood and the absorption of ammonia.
Key Points
Most nosebleeds are anterior and stop with direct pressure.
Screening (by history and physical examination) for bleeding disorders is important.
Always ask patients about aspirin, ibuprofen, or anticoagulant use.
