Nosebleed
Douglas G. Browning and Stephen H. Keiser
Nosebleed, or epistaxis, is a common otolaryngologic problem, with 15/10,000 persons requiring physician care annually for this problem, and 1.6/10,000 requiring admission to the hospital for a persistent nosebleed. Most cases occur in patients aged less than 10 years, and the incidence decreases with age (1).
Approach
A. Etiology. Epistaxis results from an interaction of factors that damage the nasal epithelial (mucosal) lining and vessel walls. The causative factors or processes include:
1. Environmental: lack of humidity, warm ambient temperature.
2. Local: direct or indirect trauma, anatomic abnormalities (especially deviated septum), inflammation, allergies, iatrogenic (surgery), neoplasms.
3. Systemic: hypertension, platelet and coagulation abnormalities, blood dyscrasias, disseminated intravascular coagulation, renal failure, alcoholism.
4. Drugs affecting clotting: aspirin, warfarin, heparin, ticlopidine, dipyridamole, NSAIDS, and so on.
5. Other drugs: steroid nasal inhalers, thioridazine, anticholinergics (drying).
6. Hereditary: hereditary hemorrhagic telangectasia (Osler-Weber-Rendu).
7. Idiopathic
Cold, dry air increases cases of epistaxis as demonstrated in countries with seasonal climates where hospital admissions for nosebleed increase significantly during the winter months (2). Regarding the importance of anatomic abnormalities, a study of recurrent epistaxis showed that 81% of patients had septal deviation versus 31% of the control group (3). Although hypertension is often cited as a cause of epistaxis, studies have not usually supported this association (4) (Chapter 7.8). Medications that interfere with clotting, especially aspirin and nonsteriodial antiinflammatory drugs (NSAIDs), are particularly common contributors to epistaxis with up to 75% of patients in some series using them versus less than 10% of controls (5).
B. Special concerns. Rare causes of epistaxis include potentially life-threatening posttraumatic pseudoaneurysm of the internal carotid artery. This entity presents from days to weeks after initial trauma to the base of the skull with a classic triad of unilateral blindness, orbital fractures, and massive epistaxis. Optimal management demands rapid recognition and treatment to give the best functional outcome. Also, epistaxis is the presenting complaint in four of five cases of the rare, but less life-threatening, hereditary hemorrhagic telangiectasias (Osler-Weber-Rendu disease) (5).
History
An assessment of the amount of blood lost is made from the history, including the onset of the bleeding, precipitating factors (including any acute or subacute injury to the nares or cranium), duration and quantity (i.e., number of soaked towels), past history of epistaxis and treatment, and history of blood dyscrasias. In adults, a history of medication use (including NSAIDs, anticoagulants), allergic rhinitis, hypertension, liver disease, ischemic heart disease, diabetes mellitus, and alcohol abuse may influence management. A family history of problems with epistaxis should be obtained. Be alert to the possibility of an intranasal foreign body in children with epistaxis with unilateral nasal discharge or foul odor.
Physical examination
The blood supply to the nose arises from the internal maxillary and facial arteries via the external carotid artery and the anterior and posterior ethmoid arteries via the internal carotid. The anteroinferior septum (Little’s area) is supplied by a confluence of both systems known as “Kiesselbach’s plexus.” Little’s area is a common site of epistaxis because it is ideally placed to receive environmental irritation (cold, dry air, cigarette smoke) and is easily accessible to digital trauma. Fortunately, this area is easy to access and treat. However, approximately 5% of nosebleeds originate from a posterior nasal source (5); it can be much more difficult to identify a source of epistaxis in this area. Providing effective treatment for obstinate bleeding in this area may also be more uncomfortable for the patient and much more formidable for the health provider.
A. Focused physical examination (PE). When examining the epistaxis patient, first assess vital signs for hypotension, orthostasis, and hemodynamic instability. After examining the face for any obvious signs of recent injury, it is important to visualize as much of the nasal vestibule as possible. It is imperative to keep the patient’s head upright, for if he or she tilts backward, then only the roof of the nasal cavity will be seen. The nasal speculum should be held in a horizontal position to allow an optimal view of the nasal septum, which is the site of most bleeding.
Visualization of the bleeding can be done by direct illumination of the area, or sometimes more easily by indirect illumination using a head mirror. Suction may be needed to remove clots, fresh blood, or mucous to visualize the bleeding. Direct nasopharyngoscopy with endoscopy (using a topical anesthetic such as Cetacaine or lidocaine gel) may be necessary, especially if the source of the bleeding is extremely posterior. Topical vasoconstrictors such as phenylephrine or oxymetazoline can be useful in decreasing the rate of bleeding in order to visualize the area (and may sometimes help achieve long-term cessation of the bleeding).
B. General PE. Depending on the patient’s history, it may be important to proceed to a more general PE with a special focus on the skin to look for petechiae, telangectasias, hemangiomas, and ecchymoses (Chapter 15.3).
Testing
A. Clinical laboratory tests. If bleeding is minor and not recurring, no testing is needed. For more vigorous bleeding or recurrent epistaxis, consider a complete blood count (CBC) with platelet count, bleeding time, prothrombin time, partial thromboplastin time, and possibly blood type and crossmatch for hypovolemic shock or severe anemia. Testing stool for occult blood may help to assess chronicity as will assessing the red cell mean corpuscular volume. The CBC can detect blood dyscrasias as well as anemia. An elevated bleeding time may imply aspirin use, von Willebrand’s disease, and many platelet-based bleeding disorders. Coagulation times can be elevated in coagulation factor diseases, but more often they implicate liver disease.
B. Imaging. Sinus radiographs or a limited CT scan of the sinuses may also be considered if concern exists for benign neoplasms or malignancy. Rarely, angiography may also be indicated for diagnosing (and treating) vascular lesions.
Diagnostic assessment
For most cases of acute epistaxis, treatment should occur simultaneously with the diagnostic assessment. However, for persistent or recurrent nosebleeds, it is important to look further for the underlying cause of the problem by performing a careful history and evaluating the problem with expedient laboratory evaluations, appropriate imaging, or further consultation when necessary to rule out more malignant causes.
References
1. Pfaff JA, Moore GP. Epistaxis. In: Rosen P, Barkin R, Danzl DF, et al, eds. Emergency medicine: concepts and clinical practice, 4th ed. St. Louis: Mosby-Year Book, Inc., 1998:2725–2727.
2. Tomkimon A, Bremmer-Smith A, Craven C, et al. Hospital epistaxis admissions and ambient temperature. Clin Otolaryngol 1995;20:239–240.
3. O’Reilly BJ, Simpson DC, Dharmeratnam R. Recurrent epistaxis and nasal septal deviation in young adults. Clin Otolaryngol 1996;21:82–84.
4. Weiss NS. Relationship of high blood pressure to headache, epistaxis and selected other symptoms. N Engl J Med 1972;287:631–633.
5. Tan LK, Calhoun KH. Epistaxis. Med Clin North Am 1999;83:43–56.
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
Other Book Chapters Related to Nose symptoms
Read excerpts from these other book chapters related to Nose symptoms:
Medical Books Excerpts
- Nasal flaring
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- Nosebleed
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2008 Williams & Wilkins.
More About Causes of Nose symptoms
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