Definition
Epistaxis simply refers bleeding from the nose or into the nasal cavity. It is a common condition in all the age groups and often presents as a medical emergency. Nasal bleeding is a sign and not a disease so every attempts should be made to find the cause of the bleed.
Causes of epistaxis
The causes of epistaxis can be broadly classified into local and systemic causes.
a) Local causes:
i) Trauma: nose picking resulting in fingernail trauma, injuries to nose, facial fracture, hard blowing of nose
ii) Infections: rhinitis, sinusitis, nasal diphtheria and granulomatous conditions of the nose
iii)Foreign bodies: maggots, leeches, beans and metals in nasal cavity of child resulting in rhinolith
iv) Anatomical deformities: Deviated nasal septum and nasal spurs
v) Drugs: decongestants, topical steroids and
vi) Tumors like angiofibroma and nasopharyngeal carcinoma
b) Systemic causes: hypertension, renal failure, pregnancy, liver cirrhosis, hemophilia, vitamin K deficiency
Brief anatomy of nose
Nasal cavity is rich in vasculature. The blood supply runs just under the nasal mucosa making it prone to trauma.
In majority of cases bleeding occurs through the Little's area also known as Keisselbach's plexus. It is the prominent plexus of vessels just under the nasal mucosa in anterioinferior part of the nasal septum.
Relationship between hypertension and epistaxis:
Since a long period of time, hypertension was considered as the major cause of nasal bleed, but a large number of studies failed to show a direct relationship between hypertension and epistaxis. Even though it lacks direct causal elevated blood pressure is seen in almost all cases of epistaxis admissions which may be due to the anxiety associated with hospital admissions.
Relationship between epistaxis and septal deviation:
Septal deviation is seen in around 70% of the general population. Due to this high prevalence of septal deviation, the high prevalence of epistaxis and deviated septum may be just a coincidence. There is no clear case controlled evidence found in the literature regarding the septal deviation as the cause of epistaxis.
Management of epistaxis
Resuscitation:
If the patient presents with active bleeding, first of al make comfortable and follow the incremental order of sequences.
Most patients present with anterior epistaxis so just pinching the ala of the nose makes sense. Itcompresses the vessels in the keisslebach's plexus and stops the bleeding.
Simultaneously, the forehead and dorsum of the nose should be compressed with an ice pack in order to induce vasoconstriction.
The patients's nasal cavity must be examined with the use of cotton pledgets soaked in vasoconstrictor solutions like oxymetazoline and adrenaline and kept insitu for about 5 minutes.
After 5 minutes the bleeder is localized and we can cautery the bleeder with the use of topical agents like beads of silver nitrate and chromic acid .
If the bleeder is not localized, we can pack the nasal cavities by using a ribbon gauze impregnated with topical antibiotic and kept insitu for 48-72 hours and reassess the patients. If the bleeding is controlled by these measures we can safely discharge the patients but if the bleeding continues despite these measures we have to shift the patient to the operation theatre for surgical interventions.
That's all for today. I hope this post about nasal bleed helps for the management of nasal bleed in the community settings.
Consent taken from the patient for use in articles and blogs.
**References **
- https://www.ncbi.nlm.nih.gov/books/NBK435997/ 2) https://my.clevelandclinic.org/health/diseases/13464-nosebleed-epistaxis 3) Scott Brown's otorhinolaryngoly and Head and Neck Surgery 8th edition