Epistaxis (Nosebleed)
Definition:
Bleeding from the nose due to rupture of blood vessels, commonly from Little’s area
(Kiesselbach's plexus).
Aetiology (Causes):
1. Local Causes:
- Trauma: Nose picking, external injury, surgery
- Foreign body
- Infections: Rhinitis, sinusitis
- Tumors: Benign or malignant nasal growths
- Deviated Nasal Septum
- Post-surgical trauma
2. General/Systemic Causes:
- Hypertension
- Blood disorders: Leukemia, Hemophilia, Thrombocytopenia
- Liver disease (affecting clotting)
- Kidney failure (Uremia)
- Vitamin C or K deficiency
3. Physiological Causes:
- Violent exertion or excitement
- Exposure to extreme heat or cold
- Sudden pressure change (e.g., high altitude)
4. Environmental Causes:
- Dry, hot climate causing mucosal dryness
- Sudden changes in altitude/pressure
5. Hormonal Causes:
- Puberty, Pregnancy
- Granuloma gravidarum
- Vicarious menstruation
6. Drugs:
- Anticoagulants: Warfarin, Heparin
- Aspirin
- Nasal sprays: Steroid or decongestants
7. Idiopathic:
- No identifiable cause in many cases
Types:
- Anterior Epistaxis: Common, usually from Little’s area
- Posterior Epistaxis: Less common, more severe, deep bleeding source
Common Site (Involved Vessel):
- Little’s area (anterior part of nasal septum) — rich in capillaries
- Posterior bleeding — sphenopalatine artery, branches of external carotid artery
Clinical Features:
- Active bleeding from nostril
- May have blood in throat (posterior epistaxis)
- History of trauma, hypertension, or drug use
- Signs of blood loss if severe: pallor, rapid pulse, low BP
Investigations and Findings:
1. CBC (Complete Blood Count):
- To check anemia or low platelets
2. BT, CT (Bleeding & Clotting Time):
- Detects clotting problems
3. PT/INR, APTT:
- For coagulation status
4. Liver & Renal Function Tests:
- Detect underlying systemic illness
5. BP Monitoring:
- High BP may be a contributing factor
6. Nasal Examination:
- Bleeding usually found at Little’s area in anterior cases
Management:
A. General Measures:
- Monitor vital signs (BP, pulse)
- If needed, start IV fluids or blood transfusion
B. First Aid:
- Patient sits up, leans forward
- Pinch soft part of the nose (Little’s area) for 10 minutes
- Apply cold compress on nose or neck
- Most mild cases stop here
C. Examination After Bleeding Stops:
- Examine nose using speculum
- Locate bleeding point — usually in Little’s area
Cauterization:
- Used when bleeding point is seen
- Area numbed with xylocaine
- Cauterize with:
• Silver nitrate
• Trichloroacetic acid
• Carbolic acid
Nasal Packing:
1. Anterior Nasal Packing:
- Used if bleeding doesn’t stop by pinching
- Insert lubricated gauze or Merocel pack
- Pack removed in 24–48 hours
- Then cauterize bleeding point if visible
2. Posterior Nasal Packing:
- For posterior bleeding
- Done under sedation or anesthesia
- Uses catheter and gauze pack
- Threads brought out from mouth and nose to hold pack in place
- Also do tight anterior packing
Alternative – Balloon Devices:
- Brighton balloon with two parts:
• Nasopharyngeal balloon
• Anterior nasal balloon
- Inflated to apply pressure on bleeding area
D. Adjuvant Therapy:
- Bed rest and sedation
- Antibiotics if packing is used to prevent infection
- Haemostatic agents: Vitamin C, Vitamin K, Adenochrome, Calcium
E. Surgical Measures:
- If packing fails, ligation may be needed:
• Sphenopalatine artery
• External carotid artery
• Ethmoid artery (via medial eye canthus approach)
F. Treat Underlying Cause:
- Control blood pressure
- Correct blood disorders
- Stop offending drugs
- Treat local nasal conditions like infection or tumor
