- Clinical science
Epistaxis is the medical term for a nosebleed, which is a common presenting complaint in the emergency room. The most common site of bleeding is an area on the nasal septum called Little's region, where the vessels supplying the nasal mucosa anastomose with each other. Bleeding from this region causes blood to flow out through the nostrils (anterior epistaxis). Rarely, epistaxis may not be apparent because blood runs down the throat (posterior epistaxis). The most common causes of epistaxis include nose picking, a foreign body in the nasal cavity, and a dry nose. Usually, the bleeding stops on its own, but severe epistaxis may occur with hypertension, bleeding disorders, and/or following severe traumatic injury. Immediate measures to control epistaxis include elevation of the upper body, application of ice packs, and pinching the nose. If bleeding does not subside, the nasal cavity must be packed and the patient must be referred to an ENT surgeon.
- Nasal trauma
- Foreign body in the nose
- Dry nose (rhinitis sicca)
- Nasal septal defects (e.g., deviated nasal septum , septal perforation)
- Infections (e.g., granulomatous diseases such as rhinosporidiosis)
- Tumors of the nasopharynx and/or paranasal sinuses (e.g., juvenile angiofibroma)
- Vascular malformations (e.g., nasal hemangioma, )
- Medications, drugs (e.g., topical corticosteroids, cocaine)
- ↑ Hydrostatic pressure gradient within the vessels of the nasal cavity
- Vicarious menstruation
In most cases, the exact cause of epistaxis remains unknown (idiopathic epistaxis). While a single episode of epistaxis usually does not require any investigation, recurrent epistaxis must be investigated for an underlying cause (e.g., a bleeding disorder!).
|Type of epistaxis||Anterior epistaxis||Posterior epistaxis|
|Clinical features|| || |
|Relative frequency|| || |
|Peak incidence|| || |
|Most common site of bleeding|
Because of the location of posterior epistaxis, it is a common cause of life-threatening hemorrhages!
- if the patient is hemodynamically unstable
- Keep the patient calm.
- Elevate the upper body and bend the patient's head forward.
- Apply cold packs and sustained, direct pressure by pinching the nose at the nostrils for 5–10 minutes in order to occlude the bleeding vessel.
- Apply topical vasoconstrictors (e.g., oxymetazoline, phenylephrine)
- If epistaxis continues after 10–15 minutes
- If epistaxis persists: arterial embolization or endoscopic ligation of the bleeding vessel
Nasal packs, if left in place for more than 24 hours, can cause toxic shock syndrome!
- Definition: a hereditary, systemic vasculopathy characterized by telangiectasia on the skin and mucosa, particularly in the area of the face (nose, lips, tongue)
- Pattern of inheritance: autosomal dominant
- Pathophysiology: mutations in genes which code for TGF-β receptors lead to structural defects in the vessel wall → postcapillary venous pooling → formation of small and large arteriovenous shunts
- Recurrent epistaxis
- Telangiectasia involving the skin and mucous membranes (including GI tract)
- Pulmonary and/or hepatic arteriovenous shunts
- In the case of epistaxis: See “Therapy” above.
- Skin telangiectasia can be treated by laser therapy or by injection of sclerosing agents.
- Embolization is used to treat large pulmonary and hepatic AV fistulas.