Introduction to Epistaxis

Nosebleed, or epistaxis, may either be a primary disorder or occur secondary to another condition. Such bleeding in children generally originates in the anterior nasal septum and tends to be mild. In adults, such bleeding is most likely to originate in the posterior septum and can be severe. Epistaxis is twice as common in children as in adults.

Causes
Epistaxis usually follows trauma from external or internal causes: a blow to the nose, nose picking, or insertion of a foreign body. Less commonly, it follows polyps; acute or chronic infections, such as sinusitis or rhinitis, that cause congestion and eventual bleeding from capillary blood vessels; or inhalation of chemicals that irritate the nasal mucosa. It may also follow sudden mechanical decompression (caisson disease) and violent exercise.

Predisposing factors
Such factors include anticoagulant therapy, hypertension, chronic aspirin use, high altitudes and dry climates, sclerotic vessel disease, Hodgkin’s disease, neoplastic disorders, scurvy, vitamin K deficiency, rheumatic fever, blood dyscrasias (hemophilia, purpura, leukemia, and anemias), and hemorrhagic telangiectasia.

Signs and symptoms
Blood oozing from the nostrils usually originates in the anterior nose and is bright red. Blood from the back of the throat originates in the posterior area and may be dark or bright red (it’s commonly mistaken for hemoptysis because of expectoration).
Epistaxis is generally unilateral, except when caused by dyscrasia or severe trauma. In severe epistaxis, blood may seep behind the nasal septum; it may also appear in the middle ear and corners of the eyes.

Associated effects
Clinical effects depend on the severity of bleeding. Moderate blood loss may produce light-headedness, dizziness, and slight respiratory difficulty; severe hemorrhage causes hypotension, rapid and bounding pulse, dyspnea, and pallor. Bleeding is considered severe if it persists longer than 10 minutes after pressure is applied. If severe, blood loss can be as great as 1 L/hour in adults.

Diagnosis
Although simple observation confirms epistaxis, inspection with a bright light and nasal speculum is necessary to locate the site of bleeding.

Relevant laboratory values include:

• gradual reduction in hemoglobin and hematocrit (commonly inaccurate immediately after epistaxis because of hemoconcentration)
• decreased platelet count in a patient with blood dyscrasia
• prothrombin time and partial thromboplastin time showing a coagulation time twice the control because of a bleeding disorder or anticoagulant therapy.

Diagnosis must rule out underlying systemic causes of epistaxis, especially disseminated intravascular coagulation and rheumatic fever. Bruises or concomitant bleeding elsewhere probably indicates a hematologic disorder. 

A nasopharyngeal angiofibroma may present as recurrent epistaxis.

Treatment
Different treatment measures are used for anterior and posterior bleeding. Drug therapy, transfusions, and surgery may also be necessary.
Local measures
For anterior bleeding, treatment consists of application of a cotton ball saturated with epinephrine to the bleeding site and external pressure, followed by cauterization with electrocautery or a silver nitrate stick. If these measures don’t control the bleeding, petroleum gauze nasal packing may be needed.
For posterior bleeding, treatment includes use of a nasal balloon catheter to control bleeding effectively, gauze packing inserted through the nose, or postnasal packing inserted through the mouth, depending on the bleeding site. (Gauze packing generally remains in place for 24 to 48 hours; postnasal packing remains in place for 3 to 5 days.)
Other measures
Antibiotics may be appropriate if the packing must remain in place for longer than 24 hours. If local measures fail to control bleeding, additional treatment may include supplemental vitamin K and, for severe bleeding, blood transfusions and surgical ligation or embolization of a bleeding artery.