Nosebleed (Epistaxis)

Nosebleeds, also known as epistaxis, are instances of bleeding from the nose. While common and generally benign, they can sometimes indicate more serious underlying conditions.

Causes

Nosebleeds can occur due to various reasons. Common causes include trauma from nose picking, blunt trauma, or insertion of foreign objects, particularly in children. Environmental factors such as low humidity, respiratory infections, and chronic sinusitis can also lead to nosebleeds. Other causes include:

• Coagulopathy: Conditions like thrombocytopenia, Von Willebrand's disease, haemophilia, leukaemia, HIV, and chronic liver disease.
• Dietary Factors: Sulphur dioxide and sulphites as food preservatives, naturally occurring salicylates in some fruits and vegetables.
• Inflammatory Diseases: Granulomatosis with polyangiitis, systemic lupus erythematosus.
• Medications/Drugs: Anticoagulants (warfarin, heparin), insufflated drugs (cocaine), and nasal sprays.
• Neoplastic Causes: Tumours such as squamous cell carcinoma, adenoid cystic carcinoma, melanoma, and nasopharyngeal carcinoma.
• Traumatic Factors: Anatomical deformities, blunt trauma, foreign bodies, surgery, and leech infestation.
• Vascular Issues: Hereditary hemorrhagic telangiectasia, angioma, and aneurysms of the carotid artery.

Two children boxing, the one on the right having a nosebleed due to a punch to the face, in Vecsés, Hungary in November 2006

Symptoms

The primary symptom of a nosebleed is bleeding from the nose, which can flow down into the stomach, causing nausea and vomiting. In more severe cases, blood may come out of both nostrils and may even cause low blood pressure. Rarely, blood can flow up through the nasolacrimal duct and out of the eyes, producing bloody tears.

A three-year-old child with a minor nosebleed from falling and hitting his face on the floor

Diagnosis

Diagnosis of a nosebleed is typically made through direct observation. Differential diagnoses to consider include bleeding from the lungs, esophageal varices, or vomiting blood.

Treatment

Initial Management

Most anterior nosebleeds can be managed by applying direct pressure to the soft anterior part of the nose for at least five minutes. Tilting the head forward helps decrease nausea and airway obstruction due to blood dripping into the airway. Vasoconstrictive medications like oxymetazoline can also be used.

Clip used to stop a nosebleed

Applying pressure to the nasal ala

Lateral view of applying pressure to the nasal ala

Chemical Cauterisation

For persistent bleeding, chemical cauterisation using silver nitrate may be employed. This involves burning and sealing off the bleeding area. A topical anaesthetic is usually applied before cauterisation.

Nasal Packing

If pressure and cauterisation are ineffective, nasal packing is the next step. Dissolvable nasal packing materials, such as surgicel and gelfoam, promote blood clots and dissolve after a few days. Non-dissolvable packing, like Merocel and Rapid Rhino, often requires removal by a medical professional after 24-72 hours. Complications of non-dissolvable packing include abscesses, sinusitis, and toxic shock syndrome.

Surgical Intervention

Persistent bleeding despite nasal packing may necessitate surgical intervention. Endoscopic evaluation under general anaesthesia can help identify and ligate the bleeding vessels. Intra-arterial embolisation is another option, though more expensive.

Tranexamic Acid

Tranexamic acid, which promotes blood clotting, can be administered topically, orally, or intravenously.

Prevention

Preventative measures for nosebleeds include maintaining a humidified environment and applying petroleum jelly to the nasal nares. Individuals prone to nosebleeds should use over-the-counter nasal saline sprays and avoid vigorous nose-blowing.

The arteries that supply Kiesselbach's plexus (responsible for anterior nosebleeds)

Self-assessment MCQs (single best answer)

Which of the following is NOT a common cause of nosebleeds?

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Which condition is associated with coagulopathy and can lead to nosebleeds?

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Which of the following is a recommended initial management step for anterior nosebleeds?

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Which type of nasal packing is designed to dissolve after a few days?

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What is the purpose of using silver nitrate in the treatment of nosebleeds?

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Which of the following medications can promote blood clotting in the treatment of nosebleeds?

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Which vascular issue can cause nosebleeds?

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Which complication is associated with non-dissolvable nasal packing?

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Which environmental factor can lead to nosebleeds?

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Which of the following is a preventative measure for nosebleeds?

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