Epistaxis

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What is epistaxis? - Epistaxis refers to bleeding from the nose. 

How common is epistaxis?

Epistaxis is a common complaint which usually causes serious concerns to those concerned and their relatives. However, it is difficult to state how common it is as close to 90% of cases stops spontaneously and may not be formally reported. Therefore, it may not require medical attention. Only those with severe episode and those with recurrence usually report to the hospital for treatment and these are those who make the statistics.

How dangerous is epistaxis?

In most cases, epistaxis is not a life-threatening condition as it is self-limiting, meaning it resolves on its own, though it may be recurrent. 

What are the categories of epistaxis?

Epistaxis is divided into two categories: anterior bleed and posterior bleed, based on the site the blood is coming from (upper or lower part of the nostril).

How is epistaxis diagnosed?

You may have been having episodes of repeated nose bleeds which may or may not have been provoked. This bleeding may be minimal or massive. Your doctor will examine you and in the process, note the site where the blood is coming from. The cause may be found in the process (e.g. trauma).

Light source is necessary for visualization, with a nasal speculum used to expose the nasal cavity. Nasopharyngoscopy (using an instrument with lens and light attached to visualize the nostrils) may be necessary when a tumour is suspected to have caused the bleeding. Most times, the cause may not be immediately obvious from examination, so investigations may be necessary,

What investigations are necessary for epistaxis?

  1. Complete blood count – This is necessary to know you blood level (packed cell volume), the platelet count and white blood cells. 
  2. Packed cell volume (PCV) reveals how much blood is left in the body. This may give a clue to how much blood has been lost.
  3. Platelet is part of the products required for blood clotting. Its level reveals the ability of blood to clot.
  4. White blood cell count is a pointer to whether there is infection or not.
  5. Bleeding time – May be necessary if there is suspicion of bleeding disorder.
  6. Prothrombin time – This is necessary if liver disease is suspected or you are on a medication like warfarin (antithrombotic medication). 
  7. CT / MRI – When bleeding persists, either of these or both may be necessary to assess the nasal cavity for foreign body or tumour (swelling)

How is epistaxis treated?

While transporting the patient to the hospital, or while waiting for specific intervention, life-saving measures that may be applied include:

  1. Slight upward tilting of the face.
  2. Application of pressure to the nostrils by squeezing them together with a thumb and a finger for about 5 to 10 minutes. These measures are effective in reducing or stopping blood flow from the nostrils completely in up to 90% of patients. Avoid releasing the digital pressure intermittently before the stipulated time. 
  3. Moisturization – In cases where nose bleeding is caused by excessive dryness of the environment, nasal saline spray or the use of gauze or cotton wool moistened with saline in the nostril may help. Humidifying the environment such as using a mist vaporizer to spray water in the room may be helpful. Application of petroleum jelly cream to the nasal mucosal may also be of help. 

Medical treatment

  1. Adrenalin treatment – Gauze that is wet with adrenalin 1:10,000 may be applied to the affected nostril. The adrenalin content helps in constricting the bleeding vessels, thereby resulting in resolution of the bleeding.
  2. Cauterization – This refers to sealing up or burning the bleeding site with heat or cold instrument or using electrical current or chemical agent for the same purpose. The vessel leading to the bleeding site is targeted in this treatment. After the procedure, the site should be kept wet with saline spray and local antibiotics. Strenuous activities should be avoided within the first 5-10 days so as to allow for healing of the site and avoid recurrence of bleeding episodes. Avoid touching the area of treatment while healing is taking place. If bleeding occurs while the scar is falling from the treatment site, adrenalin-soaked gauze may be helpful in constricting the vessels and stopping the bleeding. 
  3. Nasal packing – This may be enough to stop bleeding in majority of cases. This helps to compress and block the bleeding vessels, especially with addition of agents that constrict the blood vessels such as adrenalin. Adequate pain relief is necessary for the procedure, especially for patients that need posterior packing. The packing may be removed after 12 hours.
  4. Pain control – This may be necessary to reduce the discomfort posed by the nasal pack, especially for posterior bleeding as this may cause much discomfort. Drugs like aspirin, Ibuprofen, Diclofenac and other drugs in this category {non-steroidal anti-inflammatory drugs (NSAIDs)} should be avoided as they work against the platelets which are needed for blood clots. 
  5. Antibiotics – This is usually added to prevent infection of the nose (rhinosinusitis), as blood is a culture medium for bacteria. This may be in form of oral drug or topical / local.
  6. Treat underline medical problem – Identified underline medical problems should be treated e.g. anti-hypertensive drugs for hypertension; vitamin K for those with deficiency in it; correction of bleeding disorder etc.

Surgical treatment

This may be necessary if you have recurrent or severe bleeding which medical treatment cannot take care of. Some of the surgical procedures used are as follows:

  1. Ligation (cutting off) of arterial supply – The location of the bleeding will determine which blood vessel to ligate. Cutting off the vessel supplying the bleeding site tends to resolve the bleeding.
  2. Embolization (blocking the arterial supply) – This entails the use of chemical agent to block the vessel supplying the bleeding site.

How can epistaxis be Prevented?

To prevent epistaxis, avoid the following:

  1. Direct trauma to the nose – Those engaging in sports that may lead to significant impact to the nose should use nose protection
  2. Dry environment – In hot and dry weather, the use of saline spray or humidifier may reduce the tendency for the nostrils to get dry to the extent of bleeding.
  3. Nose-picking – This is common in children. They should be discouraged from picking their nostrils. Though this is a difficult task, keeping their nails well trimmed always may reduce the trauma inflicted on their nostrils when nose-picking.
  4. Drugs within the reach of children – Drugs like aspirin, ibuprofen etc have effects on blood clotting. Ingestion of these drugs in high quantity may result in inappropriate bleeding like nose bleeding. Therefore all drugs should be appropriately kept, out of reach no children.
  5. Excessive blowing of nose – Aggressive nose blowing should be avoided. Also, endeavour to open mouth while sneezing to reduce the pressure of air passing through the nostrils.
  6. Hot and spicy food – This kind of food makes an individual to sneeze, sometimes aggressively. This may result in nose bleed.
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