Index
Also called a nosebleed is defined as bleeding from the nostril, nasal cavity, or nasopharynx.
The condition is relatively common due to the location of the nose in the middle of the face and the number of blood vessels found in the nose.
Nosebleeds are due to the bursting of a blood vessel inside the nose. This can be spontaneous or caused by trauma.
Nosebleeds are rarely life-threatening and usually stop on their own.
Approximately 60% of the population will be affected by epistaxis, and 6% will require professional medical attention.
The cause of nosebleeds is typically idiopathic (unknown) but can also result from trauma, drug use, tumors, or nasal / sinus surgery.
Local trauma is the most common cause, followed by facial trauma, foreign bodies, nasal infections, and prolonged inhalation of dry air.
Vascular tumors and malformations are also important causes of nosebleeds.
Epistaxis is also associated with septal perforations (holes in the nasal septum).
Types of epistaxis
Nosebleeds can be divided into two categories based on the bleeding site: anterior (in the front of the nose) or posterior (in the back of the nose).
- Anterior nosebleed: Most nosebleeds are anterior, where the blood comes out of the wall between the two nasal canals (septum) inside the nose. This vulnerable area, called Little’s area, is rich in sensitive blood vessels that are delicate and prone to damage.
- Posterior nosebleed: This rare type of nosebleed occurs when bleeding originates from the nasal cavity, located inside the nose between the brain and the roof of the mouth. Most posterior nosebleeds tend to be more severe than anterior nosebleeds, so that medical attention may be necessary.
Anatomy
The nasal cavity is highly vascular and has an ample blood supply.
Blood is supplied through the internal and external carotid systems.
The significant blood arteries in the nasal cavity include the anterior and posterior ethmoid arteries and the sphenopalatine arteries.
More than 90% of nosebleeds occur in the anteroinferior (lower front) nasal septum (a wall that divides the nose between the left and right sides) in an area known as Kiesselbach’s plexus, named for Wilhelm Kiesselbach, an otolaryngologist German.
The Keisselbach plexus is located on the anterior nasal septum and is formed by an anastomosis of 5 arteries:
- Anterior ethmoidal artery (from the ophthalmic artery).
- Posterior ethmoidal artery (from the ophthalmic artery).
- Sphenopalatine artery (terminal branch of the maxillary artery).
- Great palatine artery (of the maxillary artery).
- Septal branch of the superior labial artery (from the facial artery).
Approximately 5% to 10% of epistaxis is estimated to arise from the posterior nasal cavity in an area known as Woodruff’s plexus.
Woodruff’s plexus is located on the posterior medial turbinate and is mainly composed of the connection of the branches of the internal maxillary artery, namely the posterior nasal, the sphenopalatine, and the ascending pharyngeal arteries.
Posterior hemorrhages generally originate from the lateral wall and more rarely from the nasal septum.
Causes of epistaxis
The causes of epistaxis can be divided into local causes, systemic causes, and idiopathic (unknown) causes.
Local factors
Trauma or injury to the mucosa and septum of turbinates is a common cause of epistaxis.
Blowing the nose too hard can result in trauma to the blood vessels.
The excessive use of certain medications such as nasal decongestants, illegal drugs such as cocaine, and the excessive or inappropriate use of nasal sprays.
Excessive cleaning or poking of the nose and repeated irritation from the tips of the nasal vials often lead to extensive bleeding due to mucosal injury.
Certainly, traumatic deformation and fractures of the nose and surrounding structures can cause bleeding.
Another common cause of nosebleeds is infection and inflammation of the mucosa.
Sinusitis, upper respiratory infections, and allergies can damage the respiratory lining to irritation.
Climate changes, hot climates with low humidity, and dry climates can cause dryness and cracking of the nasal lining, leading to nosebleeds.
In addition, septal deviations (folds in the wall that divide the nose between two sides), nasal fractures, and septal perforations (holes through the septum) can cause irregular nasal airflow, causing dryness and bleeding in some cases.
Causes due to medical treatment, such as endoscopic sinus surgery, skull base surgery, and orbital surgery, can also cause severe epistaxis.
Tumors of the nasal cavity, sinuses, and nasopharynx can also lead to recurrent bleeding.
In general, recurrent nosebleeds on one side should be evaluated endoscopically (scoping) with or without imaging studies to detect a tumor.
Systemic factors
Hypertension, inherited hemorrhagic telangiectasia, blood thinners such as aspirin, clopidogrel, warfarin, and a variety of conditions that cause vasculitis such as Wegener’s granulomatosis are common systemic factors associated with epistaxis.
Epistaxis is also associated with blood disorders, patients with lymphoproliferative disorders, immunodeficiency, and liver failure.
Thrombocytopenia (low platelet levels) is associated with nosebleeds.
Spontaneous mucous membrane bleeding may occur at platelet levels of 10,000 to 20,000.
Platelet deficiency can also result from chemotherapy, antibiotics, malignant tumors, hypersplenism, and some drugs.
Platelet dysfunction can occur in patients with liver failure, kidney failure, calcium deficiency, vitamin C deficiency, and in patients taking aspirin and non-steroidal anti-inflammatory drugs.
Clotting factor abnormalities can lead to frequent and recurrent epistaxis.
Bleeding disorders such as von Willebrand disease (most common), factor VIII deficiency (hemophilia A), factor IX deficiency (hemophilia B), and factor XI deficiency are all common primary coagulopathies.
Additionally, patients with recurrent nosebleeds should be questioned about using complementary and alternative medications such as Ginkgo Biloba and Vitamin E, which can increase their risk of bleeding.
Symptoms
Nosebleeds occur when blood comes out of the nose.
Blood flow from the nose can range from light (a few drops) to heavy (profuse) and can come out of either nostril.
A nosebleed feels like a slight discharge coming out, much like having colds when standing up.
If you are lying down, fluid can be felt to collect in the back of the throat before blood begins to flow out of the nose.
Although most nosebleeds are not severe, it is essential to be careful when heavy bleeding occurs.
Heavy bleeding is often accompanied by palpitations, shortness of breath, pale skin, nausea, and vomiting when the blood is swallowed.
Diagnosis of epistaxis
Most nosebleeds are not severe and do not require immediate medical attention.
However, in the cases mentioned below, it is best to seek medical help immediately:
- When the bleeding involves a large amount of blood.
- When the nosebleed is accompanied by shortness of breath.
- When you feel weak during or after the nosebleed.
- When the nosebleed does not stop after 30 minutes, even with compression.
- When the bleeding results from an injury, such as a trauma or accident.
- When the patient is less than two years old.
In most people, nosebleeds are self-diagnosed and treated at home.
However, the doctor’s recommendation should be taken if the nosebleeds are severe and do not respond to home remedies or first aid measures.
The doctor may perform the following tests:
- Blood test.
- Medical history.
For diagnosis, a doctor will evaluate the nosebleed in terms of severity.
In stable patients, evaluation begins with a complete history to determine the cause and possible exacerbating factors of epistaxis.
In patients with recurrent or refractory bleeding, treatment history of previous episodes of epistaxis should be obtained.
In addition, patients with severe or recurrent epistaxis should undergo laboratory tests to assess their hemodynamic states and coagulation profiles.
For this, the medical history that describes the following will be evaluated:
- The frequency of occurrence.
- If the bleeding is from one or both nostrils.
- The amount and duration of the bleeding.
- The ability to stop bleeding with first aid.
- The sensation of blood in the back of the throat is the first knowledge of the hemorrhage (more suggestive of later bleeding).
- Presence of trauma.
- History of upper respiratory infections and sinusitis.
- Allergic rhinitis or chronic runny nose.
- Bleeding disorders such as easy bruising or bleeding or a family history of bleeding disorder.
- Recent surgery.
- Nasal obstructive symptoms.
- Progressive obstructive symptoms after trauma or surgery.
- Medicines used such as aspirin and ibuprofen.
- Exposure to airborne irritants and toxic chemicals, including cigarette smoke.
- Substance abuse such as cocaine or other drugs can be subjected to nasal abuse, such as heroin or methamphetamine.
A careful physical examination is essential to identify the site of bleeding. A physical examination of:
- Vital signs (blood pressure to observe hypo or hypertension and heart rate).
- The airway.
- The mental state of the patient.
- With the help of a nasal speculum, the nose checks for trauma or evidence of a foreign body and identifies the source of bleeding (anterior versus posterior, right versus left).
- The revision of posterior bleeding is usually seen as bleeding along the posterior pharynx.
- The nasal septum is to examine for the presence of a septal hematoma.
- Evidence of signs of hematologic disease such as petechiae.
- Presence of other medical conditions such as hypertension, arteriosclerosis, coagulopathies, hepatosplenomegaly, lymphadenopathy, inherited hemorrhagic telangiectasia, and other vascular abnormalities.
In more than 90% of cases, it is due to blood vessels in the anterior septum in a region known as a small area.
Here, the terminal branches of the superior labial branch of the facial artery, the anterior ethmoidal artery, and the sphenopalatine artery anastomosis from the Kiesselbach plexus, given its anterior location, is susceptible to scabs and finger trauma.
Epistaxis arising from the upper aspect of the nose is rare and is usually the result of facial trauma or sinonasal surgery.
The blood supply to this region comes from the anterior and posterior ethmoid arteries.
These arteries are derived from the ophthalmic artery, a terminal branch of the internal carotid artery.
Although both the anterior and posterior ethmoidal arteries are at risk, the anterior ethmoidal artery is most commonly the source of epistaxis.
On the posterior aspect of the nose, an anastomotic network (i.e., Woodruff’s plexus) accounts for the majority of the remaining cases of epistaxis.
Woodruff’s plexus is derived from the posterior septal artery, a branch of the sphenopalatine artery.
In addition, there is a crossover between the right and left arterial systems, and these collateral vessels on the contralateral side of the nose can also be a source of bleeding.
Traditionally, the management of epistaxis is broadly classified according to location.
However, factors such as the severity and cause of the bleeding, as well as the general health of the patient, also contribute.
Recent advances in endoscopic techniques, interventional radiology, and hemostatic devices and materials have added to the myriad of options available, and there is no longer a simple algorithm.
Decision-making requires a thorough understanding of the advantages and limitations of various treatment options, clinical experience, and ancillary resources.
Treatment
There is no single definitive treatment for nosebleeds, and many factors, such as the severity of the bleeding, the use of blood thinners, and other medical conditions, can play a role in the treatment used.
Epistaxis treatment may include local pressure (i.e., pinching the nose, low over the fleshy portion, not too high over the bony part).
Petroleum jelly or another ointment can also be gently applied to the front of the nose with a Q-tip daily to help moisturize the nose and prevent dryness.
The use of nasal decongestants such as oxymetazoline or neo synephrine.
Chemical silver nitrate cautery is also used to control epistaxis not controlled by local application of pressure.
When these methods are ineffective, anterior or posterior packing may be necessary.
The packaging can be absorbable or non-absorbable.
For complicated nosebleeds, one treatment method is angiographic embolization of the internal maxillary artery.
It has a 71% to 95% success rate. Still, the procedure carries a risk of stroke, ophthalmoplegia (limitation of eye movement), facial nerve palsy (not being able to move half of the face), and bruising (blood clots) in the catheterization site.
Also, revascularization (reopening of the blood vessel) after embolization is not uncommon.
Direct surgical ligation or clipping is a growing popular alternative to embolization.
The traditional approach to anterior and posterior ethmoidal artery ligation is through an external facial incision, but other methods have been described, including a corner-eye system.
Endoscopic sphenopalatine artery ligation through the nose has been proposed as an ideal treatment for certain nosebleeds. It brings a more excellent arterial supply to the nasal cavity at a point closer to bleeding.
Thus it minimizes the risk of persistent bleeding from another circulation and preserves the patient from a transoral incision.
One review found a 92% to 100% success rate with endoscopic sphenopalatine artery ligation.
The failures of this technique are attributed to the inability to identify all branches of the sphenopalatine artery or the significant dissection that may be required in a patient with suboptimal coagulation properties.
