Epistaxis

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.

Local causes

• Nasal trauma
  • Nose picking (common cause)
  • Fractures to the middle third of the face, base of the skull, or the nasal septum
• 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, hereditary hemorrhagic telangiectasia)
• Medications, drugs (e.g., topical corticosteroids, cocaine)
• ↑ Hydrostatic pressure gradient within the vessels of the nasal cavity
  • Coarctation of the aorta
  • SVC obstruction (e.g., mediastinal tumors)
  • High altitude, decompression sickness (Caisson disease)

Systemic causes

• Bleeding disorders
  • Anticoagulant and/or aspirin therapy
  • Von Willebrand disease
  • Severe thrombocytopenia; (e.g., ITP, leukemia, dengue)
  • Hemophilia
• Hypertension
• 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!).

References:^[1][2][3][4]

Type of epistaxis	Anterior epistaxis	Posterior epistaxis
Clinical features	Bleeding through the anterior nasal aperture	Bleeding through the posterior nasal aperture Bleeding is therefore not obvious but can be identified by examining the posterior pharyngeal wall, which appears blood-stained The patient may swallow large amounts of blood and present with hematemesis. Failure of anterior packing to control bleeding is highly suggestive of posterior epistaxis
Relative frequency	∼ 90% of cases	∼ 10% of cases
Peak incidence	More common among children and young adults	More common among elderly individuals
Most common site of bleeding	Kiesselbach's plexus (Little's region): Anteroinferior region of the nasal septum in which four arteries anastomose (the anterior ethmoidal artery, sphenopalatine artery, greater palatine artery, and superior labial artery)	Woodruff's plexus: Posteroinferior region of the lateral nasal cavity, formed by the anastomoses of the sphenopalatine artery (branch of the maxillary artery) and pharyngeal artery.

Because of the location of posterior epistaxis, it is a common cause of life-threatening hemorrhages!

References:^[2][4]

1. Immediate measures
   • Fluid resuscitation 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)
2. If epistaxis continues after 10–15 minutes
   • First-line: cauterization of the bleeding vessel using silver nitrate or electrocautery.
   • Second-line: nasal packing using gauze impregnated with paraffin and antibiotics (covering for Staphylococcus aureus).
     • Anterior epistaxis: anterior nasal packing
     • Posterior epistaxis: posterior nasal packing
3. If epistaxis persists: arterial embolization or endoscopic ligation of the bleeding vessel
   • Anterior ethmoidal artery for anterior epistaxis
   • Sphenopalatine artery for posterior epistaxis

Nasal packs, if left in place for more than 24 hours, can cause toxic shock syndrome!

References:^[5][4][6][7]

• 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
• Clinical features:
  • Recurrent epistaxis
  • Telangiectasia involving the skin and mucous membranes (including GI tract)
  • Pulmonary and/or hepatic arteriovenous shunts
• Treatment
  • 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.
• Complications
  • High-output cardiac failure
  • Paradoxical emboli → brain abscess and/or stroke
  • Chronic GI bleeding → anemia

References:^[8][9]