Nose Bleeding / Epistaxis

Nose Bleeding / Epistaxis is defined as acute hemorrhage from the nostril, nasal cavity, or nasopharynx. Nose bleeding is classified on the basis of the primary bleeding site as:

• anterior (in the front region of the nose) or
• posterior (from the back area of the nose).

Hemorrhage is most commonly anterior, originating from the nasal septum (bony and cartilaginous wall that separates the 2 sides of the nose). A common source of anterior nose bleeds is from the Kiesselbach plexus (Little’s area), an anastomotic network of vessels on the anterior portion of the nasal septum. Anterior bleeding may also originate anterior to the inferior turbinate. Posterior hemorrhage originates from branches of the sphenopalatine artery in the posterior nasal cavity or nasopharynx.

Causes of epistaxis can be divided into:

• local causes (eg, trauma/injury to the nose, mucosal irritation/nose picking, nasal septal abnormality, inflammatory diseases, tumors),
• systemic causes (eg, blood disorders, bleeding problems, arteriosclerosis, hereditary hemorrhagic telangiectasia), and other rare unknown causes.

Precipitating causes that might prolong nose bleeding include high blood pressure, low platelets, nasal tumours, blood thinners (like aspirin, warfarin), etc.

Clinical control over significant bleeding and maintaining hemodynamic stability should take precedence over obtaining a lengthy history. While controlling the bleed, inquiry about previous epistaxis, hypertension, hepatic or other systemic disease, easy bruising, or prolonged bleeding after minor surgical procedures should be made. Use of medications, especially aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), warfarin, heparin, ticlopidine, and dipyridamole should be documented, as these not only predispose to epistaxis but make treatment more difficult.

Laboratory investigations are recommended in the presence of major bleeding or if a coagulopathy is suspected. These include the international normalized ratio (INR)/prothrombin time (PT), partial prothrombin time (PTT), full blood count (FBC), platelet counts and bleeding time (if platelet dysfunction is suspected).

Management should focus on resuscitation, airway, breathing and circulation. Large bore intravenous cannulas should be inserted for patients with severe nose bleeds. Simple mild nose bleeds usually stop spontaneously with epistaxis first aid.

Cautery: Bleeding from the Little area is frequently treated with silver nitrate cauterization. Manage the vessels leading to the site before managing the actual bleeding site. Avoid random and aggressive cautery and cautery on opposing surfaces of the septum (might lead to septal perforation). Electrocautery using an insulated suction cautery unit may be occasionally required.

Anterior packing: Nasal packing can be used to treat epistaxis that is not responsive to cautery. Traditionally, antibiotic impregnated ribbon gauze is used to pack the nose and tamponade the bleeding. Currently, merocel sponges can be placed into the nose relatively easily and quickly. They should be coated with an antibiotic ointment and can be hydrated with a topical vasoconstrictor. All packings should be removed in 3-4 days. Absorbable materials (eg, Gelfoam, Surgicel, Avitene) may be used in patients with coagulopathy to avoid trauma upon packing removal. For all patients with packing, administer prophylactic antibiotics and instruct them to avoid physical strain for 1 week.

Posterior packing: Epistaxis that cannot be controlled by anterior packing can be managed with a posterior pack. Classically, antibiotic impregnated rolled gauzes are used. Recently, inflatable balloon devices, such as 12F or 14F Foley catheters have become popular because they are easier to place. Avoiding overinflation of the balloon is important because it can cause pain and displacement of the soft palate inferiorly, interfering with swallowing. Regardless of the type of posterior pack, an anterior pack should also be placed. Admit all patients with posterior packing to the hospital for observation.

In general, the patient’s hemodynamic status has to be stabilized, correction of all bleeding abnormalities, and arrest of the active bleeding. The nasal packing would be removed after 48 hours from initial packing. If the initial nasal bleeding was torrential, it might be prudent for the ENT surgeon to remove the nasal packing in the operating theatre under general anaesthesia with a thorough nasal examination, and a view of an endoscopic ligation of the sphenopalatine artery. If the endoscopic technique does not arrest the bleeding, external approaches to the anterior ethmoidal artery and the internal maxillary artery can be done. Embolization of the bleeding arterial vessel may be also done.