Epistaxis

Defination

Acute haemorrhage from the nostril, nasal cavity or nasopharynx.

Pathophysiology

• Anterior haemorrhage : From the kiesselbach plexus of vessels located at the anterior portion of the nasal septum (Little's area). Accounts for 90% of bleeds.
• Posterior haemorrhage: From the posterir nasal cavity.

Epidemiology

• Frequency : 1 in 7 people in the US
• No gender predeliction
• Biomodal occurrence : age 2-10 and 50-80
• Occurs more frequently in colder months and dry colder climates or dry hot weather.
• Mortality : Rare, usually due to complaications from hypovolaemia with severe haemorrhage.
• Morbidity : Infection from nasal packing.

Cause

• Local
• Trauma

1. Picking
2. nasal surgery
3. dry hot weather
4. external trauma

• Septal abnormality

1. septal deviation
2. nasal spurs
3. nasal perforation

• Inflammation

1. Viral infection
2. bacterial infection
3. granulomatous disease (eg. TB, Sarcoidosis, etc)

• Tumours
• Blood dyscrasias
• arteriosclerosis
• Idiopathic (10%)

Management

History

• severity
• frequency
• duration
• aggravating factors
• methods used to stop the bleeding
• head & neck history
• Past medical history : eg. hypertension, arteriosclerosis,coagulopathies, liver disease.
• medication : eg warfarin, aspirin.

Examination

• ABCs
• Apply digital pressure for 5-10 minutes
• Bend forward, spit out any blood which has tracked down into the mouth. Do not tilt the head backward as this will cause the blood to enter the mouth and be swallowed and may induce vomiting.
• ice pack applied ti the forehead or bridge of the nose may be helpful.

If bleeding persists, nasal packing will need to be performed by the doctor under good visual, lighting and suction. nasal packs consist of ribbons of gauze soaked in vasoconstrictor agents such as lignocaine, adrenaline, cocaine and oxymetazoline. The are left in site for 48-72 hours after which time the patient will be examined by an ENT specialist.