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 from 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 | Physical examination alone |
Local trauma (eg, nose blowing, picking, blunt impact) | Apparent by history | Physical examination alone |
Less common | ||
Usually in older patients | Physical 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 | Physical examination Rigid endoscopy |
Illicit drug use (eg, cocaine use)Illicit drug use (eg, cocaine use) | Positive history of using illicit drugs, nasal septal perforation on exam (in extreme cases) | History and physical examination alone Urine toxicology screen |
Local infections (eg, vestibulitis, rhinitis) | Crusting in the nasal vestibule, often with local pain and dry mucosa | History and physical examination |
Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome) | Telangiectasias on the face, lips, oral and nasal mucosa, and tips of the fingers and toes Positive family history | History and physical examination Genetic testing Skin biopsy |
History of trauma (surgery or injury), certain chronic infections, or cocaine useHistory of trauma (surgery or injury), certain chronic infections, or cocaine use Visible during examination | History and physical examination | |
Systemic disorders (eg, advanced HIV infection, liver disease) | Presence of known disease Mucosal erosions and hypertrophy | History and physical examination |
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. | ||
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 can quickly progress to involve both nares. Most patients can localize the initial flow to one side, which helps focus the physical examination. It is important to determine how long the bleeding lasts, identify any potential triggers (such as sneezing, blowing the nose, or picking), and note any efforts made by the patient to halt the bleeding. Swallowed blood may lead to gastric irritation followed by vomiting, hematemesis, or melena. Important associated symptoms before onset include symptoms of an upper respiratory infection (URI), sensation of nasal obstruction, and nasal or facial pain. The timing and frequency of previous nosebleeds and their method of resolution should be identified.
Review of systems should ask about excessive bleeding (particularly related to toothbrushing, phlebotomy, or minor trauma), easy bruising, melena or hematochezia, hemoptysis, and hematuria.
Past medical history should note the presence of known bleeding disorders (including a family history) and conditions associated with defects in platelets or coagulation, particularly cancer, cirrhosis, HIV, and pregnancy. Medication use (prescription, over-the-counter, illicit) should specifically include the 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.should note the presence of known bleeding disorders (including a family history) and conditions associated with defects in platelets or coagulation, particularly cancer, cirrhosis, HIV, and pregnancy. Medication use (prescription, over-the-counter, illicit) should specifically include the 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) or marked hypertension. In patients with active bleeding, evaluation and treatment should occur simultaneously.
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 an instrument or perform suction.
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 bleeding source is visualized, fiberoptic endoscopy may be necessary.
The general examination should look for signs of bleeding disorders, including petechiae, purpura, perioral and oral mucosal telangiectasias, and 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. An endoscopic examination may be required for posterior epistaxis or if a bleeding point is not adequately visualized. Endoscopy may be challenging to perform and the nasal cavity difficult to visualize in case of excessive bleeding.
CT may be done if a foreign body, a tumor, or sinusitis is suspected.
Treatment of Epistaxis
Presumptive treatment for actively bleeding patients is the same as for anterior bleeding. The need for blood replacement is determined by the hemoglobin level, symptoms of anemia, and vital signs. Any underlying bleeding disorders are treated.
Anterior epistaxis
Bleeding can usually be controlled by pinching the nostrils together for 10 minutes while the patient sits upright, if possible. This method applies pressure to the plexus of blood vessels located in the anterior septum and can be performed by either the patient or clinician. If manual pressure is not effective, a commercially available nasal clip can be used to pinch the nose. If a commercial nasal clip is not available, a makeshift nasal clip can be fashioned from 4 tongue depressors taped together (see How To Treat Anterior Epistaxis With Makeshift Nasal Clip).
If pressure fails to control bleeding, topical application of vasoconstrictors and local anesthetics, followed by chemical or electrocautery, is tried. If that fails as well, nasal packing with a tampon of expendable foam may be used. Commercially available nasal balloons are also effective in stemming bleeding. Alternatively, as a last resort, an anterior pack of petrolatum gauze may be attempted; however, this procedure is painful and requires hospitalization. IV sedation and/or analgesia may be required for pain control.
For further procedural guidance on the treatment of anterior nosebleeds, see How To Treat Anterior Epistaxis With Cautery and How To Treat Anterior Epistaxis With Nasal Packing.
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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 place inside the nose. 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. 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.
For further procedural guidance on the treatment of posterior nosebleeds, see How To Treat Posterior Epistaxis With a Balloon.
Bleeding disorders
In hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu 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.
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, nonsteroidal antiinflammatory drug (NSAID) use, or anticoagulant use.Always ask patients about aspirin, nonsteroidal antiinflammatory drug (NSAID) use, or anticoagulant use.
