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Nosebleed (Epistaxis)

Humza Khizer

Overview

A nosebleed (also called epistaxis) is bleeding from tissues inside the nasal mucus membranes. Blood flow can be heavy or light; from one or both nostrils; and last anywhere between a few seconds and 15 minutes. 
&nbsp;

The location of the nose coupled with the large number of blood vessels in its lining means that nosebleeds are a common occurrence. 60% of people have at least one nosebleed during their lifetime. However, only 10% are severe enough to require medical attention<a href="#accordion">[7]</a>.

Although an episode can be intimidating, they rarely point to a major medical issue. It frequently occurs in children aged 2-10 and adults aged 50-80<a href="#accordion">[7]</a>.

If there&rsquo;s heavy bleeding, or if it involves large blood vessels, or if there are frequently recurring episodes of epistaxis, then it can be dangerous and the individual should seek medical treatment immediately. 
&nbsp;

<ul>
	<li>Anterior (Frontal) Nosebleed</li>
</ul>

This means the nosebleed is in the front of the nose near the lower part of the septum. The small blood vessels present in this spot can break easily, which is why it&rsquo;s the most common type of nosebleed. Fortunately, it&rsquo;s also not serious.

It typically presents in young children and can be treated at home. 
&nbsp;

<ul>
	<li>Posterior (Backward) Nosebleed </li>
</ul>

More commonly observed in adults, this refers to bleeding that occurs deep inside the nose when the large blood vessels situated at the back of the nose and closer to the throat break. Compared to an anterior nosebleed, this one is more dangerous because it can cause significant bleeding and the blood can flow down the back of the throat. Therefore, it&rsquo;s important to get medical assistance immediately. 
&nbsp;

Signs And Symptoms

<ul>
	<li>In children</li>
</ul>

The main sign of a nosebleed in children is blood running or dripping down the nose. If the bleeding is from the mucus membranes at the front of the nose, the child will bleed from only one nostril. However, if the bleeding is higher up in the nasal cavity, there will be bleeding from both nostrils. The child can also complain of pain due to injury or sore tissue inside the nose.&nbsp;

&nbsp;

<ul>
	<li>In Adults</li>
</ul>

Adults may present with bleeding from one or both nostrils, and they may feel blood at the back of the throat accompanied by an urge to swallow frequently. Moreover, coughing up blood or bloody vomit indicate that a large amount of blood was swallowed.

Some individuals also experience symptoms of anemia, i.e., they feel tired or weak, are short of breath or have pale skin, or faint. 
&nbsp;

Causes

A nosebleed occurs when the mucosa erodes and vessels are exposed and consequently break. A majority of bleeds occur anteriorly, arising from Little&rsquo;s area where the Kiesselbach plexus forms on the septum. Sometimes, anterior bleeding originates anterior to the inferior turbinate.

The less frequent incidents of posterior bleeds arise further back in the nasal cavity. They are usually of arterial origin (as compared to the capillary or venous bleeds that occur anteriorly), which is more difficult to control and which poses a greater risk of airway compromise. 
&nbsp;

Nosebleeds can have many different causes, including: 
&nbsp;

<ul>
	<li>Dry Air &ndash; This is the most typical cause of nosebleeds. The condition is prevalent in dry climates as well as during winters when the home heating systems are turned on. Low humidity causes mucosal irritation. Also, frequent scratching or picking at nasal crusting can cause nosebleeds.</li>
	<li>Drugs &ndash; Nasal drugs, such as corticosteroids, antihistamines, and nonsteroidal anti-inflammatory drugs, can cause mucosal irritation, too<a href="#accordion">[8]</a>. A mild episode often arises when these drugs are sprayed or applied directly onto the nasal septum rather than the lateral walls. </li>
</ul>

<ul>
	<li>Trauma &ndash; Repeated nasal picking cause anterior septal mucosal ulceration and, thereby, bleeding. Rarely, nasogastric or nasotracheal tubes cause local trauma leading to epistaxis. Further, patients undergoing facial or nasal surgery can have nosebleeds as well, ranging from minor to severe.</li>
</ul>

Also, children tend to insert small battery cells from electronic devices (e.g., video games and calculators) into their nostrils. Not only it causes irritation and bleeding, but it can also cause chemical alkali burn and, thereby, local tissue necrosis, when the batteries start to leak. 
&nbsp;

Other common causes of nosebleeds include:

<ul>
	<li><a href="https://merisehat.pk/disease/allergies">Allergies</a></li>
	<li>Common <a href="https://merisehat.pk/disease/cold-flu">colds </a>(upper respiratory infections) and sinusitis, particularly episodes that result in a lot of sniffling, sneezing, and blowing of the nose</li>
	<li>The forceful blowing of the nose</li>
	<li>Illicit drugs, including cocaine</li>
	<li>Supplement/alternative medicines, including vitamin E</li>
	<li>Chemical allergens, such as ammonia</li>
	<li>High altitudes where the air is thin</li>
	<li>Septum deviation (an abnormal shape of the wall that separates the two sides of the nose)</li>
	<li>Bacterial, viral, or allergic rhinosinusitis causes inflammation and leads to epistaxis</li>
	<li>Granulomatosis conditions, like Wegner granulomatosis, sarcoidosis, <a href="https://merisehat.pk/disease/tuberculosis">tuberculosis</a>, and syphilis cause friable mucosa and lead to recurrent epistaxis</li>
	<li>Infants with <a href="https://merisehat.pk/disease/gerd-56">GERD </a>can have epistaxis due to inflammation&nbsp;</li>
	<li>Alcoholism</li>
	<li>Congenital bleeding disorders such as hemophilia and von Willebrand disease</li>
	<li><a href="https://merisehat.pk/disease/hypertension-57">High blood pressure</a></li>
	<li><a href="https://merisehat.pk/disease/migraines-73">Migraine</a></li>
	<li><a href="https://merisehat.pk/disease/atherosclerosis">Atherosclerosis</a></li>
	<li>Benign and malignant tumors, including intranasal rhabdomyosarcoma and juvenile nasal angiofibroma, along with symptoms of unilateral nasal obstruction and rhinosinusitis</li>
	<li>Acquired coagulopathies, including liver disease and thrombocytopenia</li>
	<li>Nasal polyps</li>
	<li>Immune thrombocytopenia</li>
	<li>Leukemia</li>
	<li>Hereditary hemorrhagic telangiectasia</li>
	<li>Pregnancy</li>
	<li>Blood clotting disorders 
	&nbsp;</li>
</ul>

NOTE: Most nosebleeds don&#39;t need to be treated by a doctor. However, if the nosebleed persists for more than 20 minutes or occurs after a major injury, you should visit a doctor. This can signify internal bleeding or a broken nose, for instance. 
&nbsp;

Diagnosis

To begin with, the doctor needs to know:

<ul>
	<li>The duration of the nosebleed</li>
	<li>Approximately how much blood was lost</li>
	<li>Frequency of nosebleeds</li>
	<li>Whether one or both nostrils are affected 
	&nbsp;</li>
</ul>

Additionally, the doctor will ask about any prescription and over-the-counter medications the individual is taking, such as aspirin and medications for allergies and colds. They will also ask about the use of alcohol and any illegal drugs as well as any family history of blood disorders.

&nbsp;

Next, they will perform a physical exam to determine the cause of the nosebleed. The doctor may use topical medicines to constrict blood vessels and anesthetize or numb the lining of the nose.

Moreover, they will clean the inside of the nose of crusts and clots. This is not painful, but it can be irritating. If a significant volume of blood was lost or a blood condition is suspected to be the cause of the nosebleed, they will recommend further tests, including CT scans, blood tests, and X-rays to look for nasal tumors, bleeding disorders, or blood vessel abnormalities. 
&nbsp;

Treatment

As always, first pay attention to the ABCs (Airway, Breathing, and Circulation). Extreme epistaxis may, on occasion, require endotracheal intubation.

The first thing is to sit upright and lean forward, firmly pinching the soft part of the nose for 10-15 minutes at least. Sitting or standing, instead of lying down, reduces the blood pressure in the blood vessels and, consequently, reduces further bleeding.

It&rsquo;s important to NOT lie down flat or put the head between the legs as that will cause the blood to go into the throat and cause nausea and vomiting, and even diarrhea. Therefore, lean forward and breathe through the mouth; this is to ensure that the person spits out any blood they feel accumulating in their mouth or throat. Use a damp washcloth or tissue to catch the blood.

&nbsp;

The next step is to apply an ice pack covered by a towel to the bridge of the nose to constrict blood vessels, slowing down bleeding and alleviating some discomfort.

If the bleeding stops, it may not warrant medical attention. As a precaution, in that case, DO NOT: 
&nbsp;

<ul>
	<li>Blow or rub the nose for several days</li>
	<li>Bend over</li>
	<li>Strain or lift anything heavy 
	&nbsp;</li>
</ul>

However, in some cases, nosebleeds do require professional aid. The following nosebleed treatments may differ based on the nature and cause of the nosebleed: 
&nbsp;

<ul>
	<li>Removing A&nbsp;Foreign Body</li>
</ul>

The doctor can remove the foreign object if that is the problem. For instance, batteries can lead to severe complications, like nasal stenosis, thus, removing the object should be a priority. It&rsquo;s recommended to remove the batteries within 4 hours of insertion<a href="#accordion">[8]</a>.

<ul>
	<li>Cauterization</li>
</ul>

A local anesthetic spray is first used to numb the inside of the nose. The procedure involves electrocautery or applying a chemical substance like silver nitrate to seal the bleeding vessel.

<ul>
	<li>Nasal Packing</li>
</ul>

The doctor inserts gauze, nasal sponges, or inflatable latex balloons to create pressure at the site of the bleed. The substance is left in place for 24-48 hours before the doctor removes it.

<ul>
	<li>Medication Adjustments/new Prescriptions</li>
</ul>

It&rsquo;s usually recommended to reduce the number of blood-thinning medications the patient&rsquo;s taking at the time. Additionally, they&rsquo;ll be prescribed medications to control blood pressure, like Lysteda&acirc;, a medication that helps blood clot<a href="#accordion">[6]</a>.

<ul>
	<li>Surgery</li>
</ul>

If the nosebleed is due to a deviated septum, the doctor will recommend a surgical correction. Similarly, a broken nose will need to be repaired surgically. An arterial ligation is also an option in case severe nosebleeds recur frequently. 
&nbsp;

IMPORTANT!

It&rsquo;s a medical emergency if:

<ul>
	<li>The bleeding is heavy and the person has lost a lot of blood</li>
	<li>The bleeding is continuous and it&#39;s been longer than 20 minutes</li>
	<li>The nosebleed occurred after a serious injury, like a car accident</li>
	<li>The person is having difficulty breathing</li>
	<li>The person has swallowed a large amount of blood 
	&nbsp;</li>
</ul>

Most nosebleeds are not serious. However, frequent or severe nosebleeds can be a sign of more significant health issues and should be investigated. Excessive bleeding that lasts for a long time can also cause further issues, like: 
&nbsp;

<ul>
	<li>Anemia</li>
	<li>Aspiration</li>
	<li>Sinusitis</li>
	<li>Cerebral abscess</li>
	<li>Hypovolemia in heavy bleeding 
	&nbsp;</li>
</ul>

Anyone can experience a nosebleed, but it mostly affects:

<ul>
	<li>Children aged 2-10 </li>
	<li>Elderly</li>
	<li>People with blood clotting disorders, such as hemophilia<a href="#accordion">[9]</a></li>
	<li>People using blood thinners, such as aspirin, or anticoagulants, such as warfarin<a href="#accordion">[9]</a>&nbsp;</li>
	<li>Colds, sinusitis, and allergies</li>
</ul>

Epistaxis is also more frequent in people who have hypertension. 
&nbsp;

Some measures to stop nosebleeds include:

<ul>
	<li>Keep the fingernails short and refrain from picking at the nose frequently.</li>
	<li>Blow the nose as gently as possible.</li>
	<li>Humidify home and office environments.</li>
	<li>Wear a head guard during activities that can cause injury to the head or nose.</li>
	<li>Always follow the instructions on nasal decongestants since excessive use can result in nosebleeds. 
	&nbsp;</li>
</ul>

<div style="border-bottom:none black 1.0pt; padding:0in 0in 11.0pt 0in">
The therapeutic guidelines for treating epistaxis during the COVID-19 pandemic as published by researchers in May 2020 included<a href="#accordion">[5]</a>:&nbsp;&nbsp;&nbsp;
</div>

<div style="border-bottom:none black 1.0pt; margin-left:60px; padding:0in 0in 4.0pt 0in">
<ul>
	<li>Use of disposable equipment is recommended.</li>
	<li>FFP3 or N99 mask is preferred as it allows at least 99% filtration.</li>
	<li>If FFP3 masks are unavailable, opt for N95 or FFP2 masks protected by a surgical mask.</li>
	<li>Use of double nitrile gloves, surgical goggles or face shield, cap and shoe coverings, and gown is advised.</li>
	<li>It&#39;s important to assess general risk factors, like high blood pressure, ongoing therapies with anticoagulant agents or antithrombotic drugs, and coagulation factors.</li>
	<li>Prompt assessment of the severity of nosebleed </li>
	<li>Bidigital compression and the use of antifibrinolytic medications are approved forms of non-invasive treatments before more invasive interventions are employed.</li>
	<li>Use well-demarcated areas within the emergency ward if conventional operating facilities are unavailable for invasive treatment.</li>
	<li>Only experienced clinical teams with proper PPE should be treating epistaxis </li>
	<li>Avoid intervention unless necessary</li>
	<li>If a noninvasive treatment fails, begin with nasal compression or cautery.</li>
	<li>Posterior epistaxis involving sphenopalatine artery ligation should be postponed until COVID-19 testing is performed before surgical intervention.</li>
	<li>Avoid using local anesthetic atomized sprays.</li>
	<li>Post-operative instructions for packing removal or antibiotic prophylaxis should be provided to the patients to minimize the risk of recurrences and optimize outcomes. 
	&nbsp;</li>
</ul>
</div>

Key Points

<ul>
	<li>A nosebleed (also called epistaxis) is bleeding from tissues inside the nasal mucus membranes.</li>
	<li>Numerous factors, including dry air, nose picking, and allergies, can result in nosebleeds. Oftentimes, there is no known reason for nosebleeds.</li>
	<li>Children and the elderly are more prone to nosebleeds.</li>
	<li>It&rsquo;s imperative to consult a physician if the bleeding won&#39;t stop or if the nosebleeds are recurring since this could indicate a more serious problem. 
	&nbsp;</li>
</ul>

[1] Burton MJ, Doree C. Interventions for recurrent idiopathic epistaxis (nosebleeds) in children. Cochrane Database Syst Rev. 2004;(1).

[2] Beran M, Petruson B. Occurrence of epistaxis in habitual nose-bleeders and analysis of some etiological factors. ORL. 1986;48(5):297–303.

[3] Ryu T, Kim DH, Byun SH. Fiberoptic bronchoscopic treatment of blood aspiration and use of sugammadex in a patient with epistaxis: a case report. Medicine (Baltimore). 2018;97(15).

[4] Murer K, Holzmann D, Burkhardt J-K, Soyka MB. An unusual complication of epistaxis: cerebral abscess formation after anterior ethmoidal artery ligation. Case Reports. 2015;2015:bcr2015213389.

[5] Vittorio, Ralli M, Greco A, de Vincentiis M. Clinical Recommendations for Epistaxis Management DurinDuring the COVID-19 Pandemic. Otolaryngol Neck Surg [Internet]. 2020 May 5;163(1):75–7.