Epistaxis (Nosebleed) – Causes, Symptoms, Treatment

Epistaxis (nosebleed) is one of the most common ear, nose, and throat (ENT) emergencies that present to the emergency department or the primary care clinic. There are two types of nosebleeds: anterior (more common), and posterior (less common, but more likely to require medical attention). The source of 90% of anterior nosebleeds is within Kiesselbach’s plexus (also known as Little’s area) on the anterior nasal septum. There are five named vessels whose terminal branches supply the nasal cavity:

• 1) Anterior ethmoidal artery
• 2) Posterior ethmoidal artery
• 3) Sphenopalatine artery
• 4) Greater palatine artery
• 5) Superior labial artery

The watershed area of these five vessels is in the anterior nasal septum, comprising Kiesselbach’s plexus. This lies at the entrance to the nasal cavity and so is subject to extremes of heat and cold, and of high and low moisture, and is easily traumatized. The mucosa over the septum in this area is especially thin, making this the site of the majority of epistaxis. More rarely, vessels in the posterior or superior nasal cavity will bleed, leading to the so-called “posterior” epistaxis. This is more common in patients on anticoagulants, patients who are hypertensive, and patients with underlying blood dyscrasia or vascular abnormalities. Management will depend on the severity of the bleeding and the patient’s concomitant medical problems.[rx][rx][rx]

Pathophysiology

Nosebleeds are caused by the rupture of a blood vessel within the nasal mucosa. Rupture can be spontaneous, initiated by trauma, use of certain medications, and/or secondary to other comorbidities or malignancies. An increase in the patient’s blood pressure can increase the length of the episode. Anticoagulant medications, as well as clotting disorders, can also increase the bleeding time.

Most nosebleeds occur in the anterior part of the nose (Kiesselbach’s plexus), and an etiologic vessel can usually be found on careful nasal examination.

Bleeding from the posterior or superior nasal cavity is often termed a posterior nosebleed.  This is usually presumed due to bleeding from Woodruff’s plexus, which are the posterior and superior terminal branches of the sphenopalatine and posterior ethmoidal arteries. These are often difficult to control and are associated with bleeding from both nostrils or into the nasopharynx, where it is swallowed or coughed up, presenting as hemoptysis.  It can generate a greater flow of blood into the posterior pharynx and have a higher risk for airway compromise or aspiration due to increased difficulty in controlling the bleed.

Causes of  Epistaxis (Nosebleed)

There are multiple causes of epistaxis which can be divided into local, systemic, environmental, and medication-induced.

• Nasal fractures are caused by physical trauma to the face. Common sources of nasal fractures include sports injuries, fighting, falls, and car accidents in the younger age groups, and falls from syncope or impaired balance in the elderly.^[rx]

Local causes:

• Digital manipulation
• Deviated septum
• Trauma
• Chronic nasal cannula use

Systemic causes:

• Alcoholism
• Hypertension
• Vascular malformations
• Coagulopathies (von Willebrand disease, hemophilia)

Environmental factors:

• Allergies
• Environmental dryness ( more common in winter months)

Medications:

• NSAIDs (ibuprofen, naproxen, aspirin)
• Anticoagulants (warfarin)
• Platelet aggregation inhibitors (clopidogrel)
• Topical nasal steroid sprays
• Supplement/alternative medications (vitamin E, ginkgo, ginseng)
• Illicit drugs (cocaine)

While epistaxis is a very common spontaneous problem, rarer etiologies such as neoplasms or vascular malformations must always be in the differential diagnosis, particularly if additional symptoms such as unilateral nasal obstruction, pain, or other cranial nerve deficits are noted.[rx][rx][rx]

Symptoms of Nasal Bony Fractures

Symptoms of a broken nose include bruising, swelling, tenderness, pain, deformity, and/or bleeding of the nose and nasal region of the face.

• Pain or tenderness, especially when touching your nose
• Swelling of your nose and surrounding areas
• Bleeding from your nose
• Bruising around your nose or eyes
• Bruising, swelling and tenderness around the nose
• A deformed, twisted or crooked nose
• Blockage of one or both nostrils
• A deviated septum
• A bruise-like discoloration under the eyes
• Crooked or misshapen nose
• Difficulty breathing through your nose
• Discharge of mucus from your nose
• Feeling that one or both of your nasal passages are blocked

The patient may have difficulty breathing, or excessive nosebleeds (if the nasal mucosa are damaged). The patient may also have bruising around one or both eyes.

Diagnosis of Epistaxis (Nosebleed)

History and Physical

The history should include duration, severity, frequency, laterality of the bleed, inciting event, and interventions provided prior to seeking care.  Inquire about anticoagulant, aspirin, NSAID, and topical nasal steroid use. Obtain a relevant family history, particularly relating to coagulopathy and vascular/collagen disease, as well as any history of drug and alcohol use.

Prepare proper equipment and proper personal protective equipment (PPE) before beginning the physical examination.  Equipment may include a nasal speculum, bayonet forceps, headlamp, suction catheter, packing, silver nitrate swabs, cotton pledgets, and topical vasoconstrictors and anesthetic. Have the patient in a seated position in an exam chair in a room with suction available. Carefully insert the speculum and slowly open the blades to visualize the bleeding site. A headlight is essential to allow for hands-free illumination, and clot may need to be suctioned from the nasal cavity to identify the bleeding source.

A posterior nosebleed is not easy to visualize and may be suggested by active bleeding into the posterior pharynx without a visualized vessel on nasal examination. Nasal endoscopy greatly increases the success in identifying the bleeding source.

Evaluation

Differentiating an anterior or posterior is key in management. Diagnosis of anterior bleeding is can be made by direct visualization using a nasal speculum and light source. A topical spray with anesthetic and epinephrine may be helpful for vasoconstriction to help control bleeding and to aid in the visualization of the source. Usually, the diagnosis of posterior bleeding is made after measures to control anterior bleeding have failed. Clinical features of posterior bleeding can include active bleeding into the posterior pharynx in the absence of an identified anterior source; high-flow posterior bleeds may cause blood to emanate from both nares. Labs may be obtained if necessary, including a complete blood cell count (CBC), type and cross match, and coagulation studies, though should not delay treatment of an active bleed. Imaging such as x-ray or computed tomography have no role in the urgent or emergent management of active epistaxis.

Treatment of Epistaxis (Nosebleed)

Start with a primary survey and address the airway, ensure the airway is patent.  Next, assess for hemodynamic compromise. Obtain large-bore intravenous access in patients with severe bleeding and obtain labs. Reverse blood clotting as necessary, if there is a concern with medication use.[rx][rx][rx]

All patients with moderate to severe nose bleeding should have two large-bore intravenous lines and infusion of crystalloid. The monitoring of oxygen and hemodynamic stability is vital.

Treatment for anterior bleeding can be started with direct pressure for at least 10 minutes. Have the patient apply constant direct pressure by pinching the nose over the cartilaginous tip (instead of over the bony areas) for a few minutes to try to control the bleed. If that is ineffective, vasoconstrictors such as oxymetazoline or thrombogenic foams or gels can be employed. It is important to remove all clot with suction before any attempt at treatment is made. The reasons are twofold: 1) Clot will prevent any medication from reaching the vessel itself and 2) if packing becomes necessary, the clot can be pushed into the nasopharynx and aspirated. If topical treatments are unsuccessful, proceed with nasal examination to identify and cauterize the vessel with silver nitrate. If this too is unsuccessful, anterior nasal packing is necessary. This can be performed with absorbable packing material such as surgicel or fibrillar, or with devices such as anterior epistaxis balloons, or nasal tampons (Rapid Rhino). If silver nitrate is used to cauterize a septal blood vessel, only use it on one side of the septum to prevent septal perforation. Thermal coagulation is painful and should rarely be attempted in an emergent setting.

Traditional petrolatum gauze can be used if one does not have access to balloons or tampons.

If none of this is successful, the bleeding may be from the posterior or superior nasal cavity. Symptoms can include active bleeding from both nostrils or active bleeding present in the posterior pharynx. Longer (7.5cm) nasal tampons are available that provide some more posterior pressure and can be employed in this situation. Formal posterior nasal packing should only be performed by experienced personnel as it requires admission and telemetry monitoring, and sometimes intubation. It is associated with higher rates of complications like pressure necrosis, infection, or hypoxia, and may trigger a nasal-cardiac reflex (sudden bradycardia after nasal packing – if this occurs, remove the pack immediately). Foley catheters can be used by experienced personnel to tamponade a posterior bleed. If a posterior pack is placed, a formal petrolatum gauze anterior pack must be placed as well to create a closed, tamponaded space in the nasopharynx.

If all of these measures are unsuccessful, the patient should be intubated for airway protection and interventional radiology consulted emergently for embolization. If this service is unavailable, operative ligation of the sphenopalatine and ethmoid arteries can be performed in the operating room by an otolaryngologist.

Complications

• Septal hematoma
• Septal abscess
• Avascular necrosis of nasal septal cartilage leading to saddle deformity
• Nasal obstruction
• Blowout fractures: Extraocular muscle entrapment and diplopia
• Nasolacrimal duct injury: Due to the close relationship of the duct to the nasal bones
• Fracture of cribriform plate and cerebrospinal fluid (CSF) rhinorrhoea
• Inability to reduce: Fractures that cannot be reduced by closed techniques are candidates for open reduction.[rx]
• Airway compromise and hemorrhage.[rx]
• Nasofrontal duct and or lacrimal duct disruption as a result of direct damage or due to displaced fracture segments.[rx]
• Facial deformity, as full correction of telecanthus or nasal depression can be difficult to achieve, and some patients will retain a degree of asymmetry. Depending on the surgical approach, patients may experience temporary or permanent paralysis and or anesthesia of the forehead. Scars that cannot be hidden in the hairy scalp or skin folds may be prominent.[rx]
• Infection of the incision site, soft tissues, and meninges are recognized complications from these injuries.[rx]
• Mucocele formation is a complication of sinus or lacrimal drainage disruption and can become infected.[rx]
• Mental health, as patients with facial injuries are at greater risk of developing post-traumatic stress disorder or anxiety-related disorders. Particularly those who were victims of assault.[rx]

References