What is Epistaxis (Nosebleed)?
A nosebleed, also known as Epistaxis, is a common emergency that may require a visit to the emergency room or a primary care clinic. Mostly, there are two types of nosebleeds: frontal (common) and posterior (rare but more often requires serious medical attention). Around 90% of front nosebleeds start from a specific area in the front of the nasal partition called Kiesselbach’s plexus (or Little’s area). There are five main blood vessels that lead to the nose:
1. Anterior ethmoidal artery
2. Posterior ethmoidal artery
3. Sphenopalatine artery
4. Greater palatine artery
5. Superior labial artery
These five vessels intersect in the front part of the nasal partition, making up Kiesselbach’s plexus. Sitting at the entrance of the nose, this spot is exposed to extreme changes in heat and moisture, making it easy to get injured. The thin and delicate tissue layer covering this area makes it more susceptible to bleed, causing most nosebleeds. However, more rarely, there can be bleeding from the back or the upper part of the nasal cavity, leading to a posterior nosebleed. This tends to be more common in those taking blood thinners, people suffering from high blood pressure, and those with abnormal blood or vessel conditions. How the nosebleed is treated depends mostly on the severity of the bleed and other health conditions the patient might have.
What Causes Epistaxis (Nosebleed)?
Epistaxis, which is the medical term for a nosebleed, can happen for several reasons. These can be grouped broadly into four categories: local causes, systemic causes, environmental factors, and certain medications.
Local causes are factors directly related to the nose. This could be due to you touching or picking your nose, having a deviated septum (an off-center wall separating the nasal passages), an injury or trauma to the nose, or using a nasal cannula (a device used to deliver supplemental oxygen) regularly.
Systemic causes are related to your overall health or body systems. This includes problems like alcoholism, high blood pressure, strange blood vessel shape or numbers (vascular malformations), and blood clotting disorders (coagulopathies) such as von Willebrand disease or hemophilia.
Environmental factors can also contribute to nosebleeds. These include allergies, particularly those affecting the nasal passage, and dry weather conditions, which are often more common during winter.
Lastly, some medications can cause nosebleeds. This includes common pain relievers like ibuprofen, naproxen, aspirin, blood-thinning drugs (anticoagulants) like warfarin and platelet aggregation inhibitors like clopidogrel. Using topical nasal steroid sprays and certain dietary supplements or alternative medications like vitamin E, ginkgo, ginseng, as well as the misuse of certain illicit drugs like cocaine can also put you at risk.
While nosebleeds are typically random and harmless, it’s still important to keep in mind the less common reasons, like tumors or vascular malformations. If you’re experiencing additional symptoms, like one-sided nasal blockage, pain, or cranial nerve problems, it could be signalling something more serious.
Risk Factors and Frequency for Epistaxis (Nosebleed)
Nosebleeds are hardly ever life-threatening. In fact, they were the cause of only 4 out of the 2.4 million deaths in the United States. Around 60% of people have had a nosebleed at some point in their lives, but only 10% of these were serious enough to need medical attention. Nosebleeds are most common in young children aged 2 to 10, and in older adults between the ages of 50 and 80.
Signs and Symptoms of Epistaxis (Nosebleed)
When talking to a patient with a nosebleed, it’s important to ask about how long they’ve been bleeding, how severe it is, how often it happens, whether the bleeding is on one or both sides, what might have caused it, and what they’ve done to try and stop it. It’s also recommended to ask if they’re taking any blood thinners, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), or nasal steroids. Make sure to get family history information related to coagulation issues, diseases affecting the blood vessels or collagen, and the patient’s history of drug and alcohol use.
Before physically examining a patient with a nosebleed, make sure you have all the necessary equipment and are wearing the appropriate personal protective gear. Tools needed may include:
- A nasal speculum
- Bayonet forceps
- A headlamp
- A suction catheter
- Packing materials
- Silver nitrate swabs
- Cotton pledgets
- Topical vasoconstrictor
- Anesthetic
The patient should be seated in an examination chair in a room equipped with a suction device. You’ll gently insert a speculum into the nose to get a clear view of the source of the bleeding. A bright light attached to your forehead, or headlamp, is crucial to light up your working area without using your hands. Sometimes, a blood clot may need to be suctioned out to clearly identify the bleeding site.
A nosebleed that happens in the back part of the nose – a posterior nosebleed – can be tricky because it’s not easy to see. You might suspect it if there’s active bleeding in the back of the throat (posterior pharynx), but no visible bleeding vessel within the nose. The use of a nasal endoscope – a flexible tube with a camera on the end – greatly improves chances of finding where the blood is coming from.
Testing for Epistaxis (Nosebleed)
Knowing whether a nosebleed (medical term: epistaxis) is coming from the front or the back of the nose is important in determining how to manage it. If it’s a front (anterior) bleed, doctors can often see the source with a special tool called a nasal speculum and a light source. To help with this, they may use a spray that both numbs the area and shrinks (constricts) the blood vessels. This not only helps to control the bleeding but also makes it easier to see where it’s coming from.
A back (posterior) nosebleed is usually diagnosed if methods to control a front bleed don’t work. Signs that it might be a posterior bleed can include active bleeding towards the back of the throat and the absence of a visible source at the front of the nose. Sometimes, high-flow back bleeds may cause blood to flow out of both nostrils.
If needed, the doctor might order blood tests, such as a full blood count, blood typing, and tests to check how well your blood is clotting. However, these shouldn’t delay the treatment of an active nosebleed. Imaging methods like X-rays or CT scans don’t usually play a role in treating an active nosebleed in urgent or emergency situations.
Treatment Options for Epistaxis (Nosebleed)
The first course of action when dealing with a nosebleed, particularly a severe one, is to ensure that the person can breathe properly. Once that’s confirmed, doctors then check for signs of severe blood loss, like faintness or rapid heartbeat. If severe bleeding is present, doctors would insert large tubes into the person’s veins to deliver fluids and possibly reverse any blood clotting that might be happening. It’s crucial to continuously check and maintain oxygen levels and blood pressure in patients with severe nosebleeds.
If the bleeding occurs in the front part of the nose, the first treatment usually involves applying direct pressure to the area for at least 10 minutes. This can be done by the patient pinching the soft, lower part of their nose for a few minutes to stop the bleeding. If this doesn’t work, doctors might use medications that constrict blood vessels or substances that help blood clot to control the bleeding. However, before starting treatment, doctors must make sure to remove all blood clots because these can prevent medication from reaching the bleeding vessel or cause issues if packing (stopping bleeding through stuffing material into the nose) is necessary.
If the nosebleed does not stop with these treatments, doctors may examine the inside of the nose to pinpoint the bleeding vessel and use a chemical called silver nitrate to burn and seal it. This process is known as cauterization. However, they have to be careful not to use this on both sides of the nose’s internal dividing wall (septum) to avoid creating a hole. In severe cases, they might insert a special material or devices into the nose to apply pressure and stop the bleeding.
If the doctors can’t stop the bleeding or if it’s coming from the back or upper part of the nasal cavity, they might use a longer device for packing that can apply pressure to these areas. However, this should only be attempted by experienced medical professionals as it might require hospital admission and close monitoring, and it carries a higher risk of complications like tissue damage, infection, low oxygen levels, or sudden slowing of the heart rate.
If all these measures fail, doctors might need to protect the person’s airway by inserting a tube into their lungs (intubation), and consult a specialist to block the problematic blood vessels through a procedure known as embolization. If this service isn’t available, a specialist called an otolaryngologist could do a surgical procedure to clamp off the involved arteries in the operation room.
What else can Epistaxis (Nosebleed) be?
Epistaxis, or nosebleeds, can be caused by a number of different conditions. These could include:
- A nasal tumor
- Disseminated intravascular coagulation (DIC) – a condition affecting the blood’s ability to clot
- Hemophilia – a genetic disorder that prevents blood from clotting normally
- Von Willebrand disease – another clotting disorder
- Rhinitis – inflammation of the inside of the nose
- A foreign object stuck in the nose
- Drug toxicity – some drugs, such as warfarin or some nonsteroidal anti-inflammatory drugs (NSAIDs), can lead to nosebleeds
Recovery from Epistaxis (Nosebleed)
Once the bleeding has been stopped, it’s essential that you arrange a follow-up appointment within 1 week. This can be with your regular doctor or with an otolaryngologist, a doctor who specializes in conditions related to the ear, nose, and throat. If any packing material has been put into your nose to help stop the bleeding, it’s important to leave it in place for 3 to 5 days before it’s removed.
You should begin taking an antibiotic that works against staphylococcal bacteria to avoid a serious illness known as toxic shock syndrome. It’s crucial that any underlying health issues that might have contributed to the bleeding, such as high blood pressure or a blood disorder (coagulopathy), are managed before you leave the hospital. If you have high blood pressure, the aim should be to lower your systolic blood pressure to less than 120 mm Hg.
Finally, it’s recommended that you use a saline solution in both nostrils. This helps keep any nasal packing moist and makes it easier to remove when the time comes.
