Introduction
Background
Epistaxis is defined as acute hemorrhage from the nostril, nasal cavity, or nasopharynx. It is a frequent ED complaint and often causes significant anxiety in patients and clinicians. However, more than 90% of patients who present to the ED with epistaxis may be successfully treated by an emergency physician (EP).
Pathophysiology
Epistaxis is classified on the basis of the primary bleeding site as anterior or posterior. Hemorrhage is most commonly anterior, originating from the nasal septum. A common source of anterior epistaxis is the Kiesselbach plexus, an anastomotic network of vessels on the anterior portion of the nasal septum, also referred to as Little's area. It receives blood supply from both the internal and external carotid arteries.1 Anterior bleeding may also originate anterior to the inferior turbinate. Posterior hemorrhage originates from branches of the sphenopalatine artery in the posterior nasal cavity or nasopharynx.
Frequency
United States
Data may be difficult to obtain on the true incidence of epistaxis due to the fact that not all cases are seen in the emergency department.2 However, when multiple sources are reviewed, the lifelong incidence of epistaxis in the general population is about 60%, with less than 10% seeking medical attention.1,3,2
Mortality/Morbidity
- Mortality is rare and is usually due to complications from hypovolemia, with severe hemorrhage or underlying disease states.
- Increased morbidity is associated with nasal packing. Posterior packing can potentially cause airway compromise and respiratory depression. Packing in any location may lead to infection.
Sex
- No sex predilection exists for nosebleeds.
Age
- Bimodal incidence exists, with peaks in those aged 2-10 years and 50-80 years.
Clinical
History
- Controlling significant bleeding or hemodynamic instability should take precedence over obtaining a lengthy history.
- Note the duration, severity of the hemorrhage, and the side of initial bleeding.
- Inquire about previous epistaxis, hypertension, hepatic or other systemic disease, family history, easy bruising, or prolonged bleeding after minor surgical procedures. Recurrent episodes of epistaxis, even if self-limited, should raise suspicion for significant nasal pathology.
- Use of medications, especially aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), warfarin, heparin, ticlopidine, and dipyridamole should be documented, as these not only predispose to epistaxis but make treatment more difficult.
Physical
- Approximately 90% of nosebleeds can be visualized in the anterior portion of the nasal cavity.
- Massive epistaxis may be confused with hemoptysis or hematemesis. Blood dripping from the posterior nasopharynx confirms a nasal source.
- Perform a thorough and methodical examination of the nasal cavity.
- Blowing the nose decreases the effects of local fibrinolysis and removes clots, permitting a better examination. Application of a vasoconstrictor prior to the examination may reduce hemorrhage and help to pinpoint the precise bleeding site. Topical application of a local anesthetic reduces pain associated with the examination and nasal packing.
- Gently insert a nasal speculum and spread the naris vertically. This permits visualization of most anterior bleeding sources.
- A posterior source is suggested by failure to visualize an anterior source, by hemorrhage from both nares, and by visualization of blood draining in the posterior pharynx.
Causes
- Most cases of epistaxis do not have an easily identifiable cause.
- Local trauma (ie, nose picking) is the most common cause, followed by facial trauma, foreign bodies, nasal or sinus infections, and prolonged inhalation of dry air. A disturbance of normal nasal airflow, as occurs in a deviated nasal septum, may also be a cause of epistaxis.
- Iatrogenic causes include nasogastric and nasotracheal intubation.
- Topical nasal drugs such as antihistamines and corticosteroids, especially when applied directly to the nasal septum instead of the lateral walls, may cause mild epistaxis.
- Children usually present with epistaxis due to local irritation or recent upper respiratory infection (URI).
- Oral anticoagulants and coagulopathy due to splenomegaly, thrombocytopenia, platelet disorders, liver disease, renal failure, chronic alcohol use, or AIDS-related conditions predispose to epistaxis.
- Inherited coagulopathies such as von Willebrand disease, hemophilia A, and hemophilia B.1
- The relationship between hypertension and epistaxis is often misunderstood. Patients with epistaxis commonly present with an elevated blood pressure. Epistaxis is more common in hypertensive patients perhaps owing to vascular fragility from long-standing disease. Hypertension, however, is rarely a direct cause of epistaxis. More commonly, epistaxis and the associated anxiety cause an acute elevation of blood pressure. Therapy, therefore, should be focused on controlling hemorrhage and reducing anxiety as primary means of blood pressure reduction.
- Epistaxis is more prevalent in dry climates and during cold weather due to the dehumidification of the nasal mucosa by home heating systems.
- Vascular abnormalities that contribute to epistaxis may include the following:
- Sclerotic vessels
- Hereditary hemorrhagic telangiectasia
- Arteriovenous malformation
- Neoplasm
- Aneurysms
- Septal perforation, deviation
- Endometriosis
More on Epistaxis |
 Overview: Epistaxis |
| Differential Diagnoses & Workup: Epistaxis |
| Treatment & Medication: Epistaxis |
| Follow-up: Epistaxis |
| Multimedia: Epistaxis |
| References |
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References
Cummings CW. Epistaxis. In: Cummings: Otolaryngology: Head and Neck Surgery. 4th ed. Philadelphia, Pa: Elsevier, Mosby; 2005:Chap 40.
Gifford TO, Orlandi RR. Epistaxis. Otolaryngol Clin North Am. Jun 2008;41(3):525-36, viii. [Medline].
Schlosser RJ. Clinical practice. Epistaxis. N Engl J Med. Feb 19 2009;360(8):784-9. [Medline].
Douglas R, Wormald PJ. Update on epistaxis. Curr Opin Otolaryngol Head Neck Surg. Jun 2007;15(3):180-3. [Medline].
Teymoortash A, Sesterhenn A, Kress R, et al. Efficacy of ice packs in the management of epistaxis. Clin Otolaryngol Allied Sci. Dec 2003;28(6):545-7. [Medline].
Badran K, Malik TH, Belloso A, Timms MS. Randomized controlled trial comparing Merocel and RapidRhino packing in the management of anterior epistaxis. Clin Otolaryngol. Aug 2005;30(4):333-7. [Medline].
Cassisi NJ, Biller HF, Ogura JH. Changes in arterial oxygen tension and pulmonary mechanics with the use of posterior packing in epistaxis: a preliminary report. Laryngoscope. Aug 1971;81(8):1261-6. [Medline].
Choudhury N, Sharp HR, Mir N, Salama NY. Epistaxis and oral anticoagulant therapy. Rhinology. Jun 2004;42(2):92-7. [Medline].
Cook PR, Renner G, Williams F. A comparison of nasal balloons and posterior gauze packs for posterior epistaxis. Ear Nose Throat J. Sep 1985;64(9):446-9. [Medline].
Corbridge RJ, Djazaeri B, Hellier WP, Hadley J. A prospective randomized controlled trial comparing the use of merocel nasal tampons and BIPP in the control of acute epistaxis. Clin Otolaryngol Allied Sci. Aug 1995;20(4):305-7. [Medline].
Fairbanks DN. Complications of nasal packing. Otolaryngol Head Neck Surg. Mar 1986;94(3):412-5. [Medline].
Fuchs FD, Moreira LB, Pires CP, et al. Absence of association between hypertension and epistaxis: a population-based study. Blood Press. 2003;12(3):145-8. [Medline].
Guarisco JL, Graham HD 3d. Epistaxis in children: causes, diagnosis, and treatment. Ear Nose Throat J. Jul 1989;68(7):522, 528-30, 532 passim. [Medline].
Hashmi SM, Gopaul SR, Prinsley PR, Sansom JR. Swallowed nasal pack: a rare but serious complication of the management of epistaxis. J Laryngol Otol. May 2004;118(5):372-3. [Medline].
Herkner H, Havel C, Mullner M. Active epistaxis at ED presentation is associated with arterial hypertension. Am J Emerg Med. Mar 2002;20(2):92-5. [Medline].
Karras DJ, Ufberg JW, Harrigan RA, et al. Lack of relationship between hypertension-associated symptoms and blood pressure in hypertensive ED patients. Am J Emerg Med. Mar 2005;23(2):106-10. [Medline].
Keen MS, Moran WJ. Control of epistaxis in the multiple trauma patient. Laryngoscope. Jul 1985;95(7 Pt 1):874-5. [Medline].
Larsen K, Juul A. Arterial blood gases and pneumatic nasal packing in epistaxis. Laryngoscope. May 1982;92(5):586-8. [Medline].
Pope LE, Hobbs CG. Epistaxis: an update on current management. Postgrad Med J. May 2005;81(955):309-14. [Medline].
Singer AJ, Blanda M, Cronin K, et al. Comparison of nasal tampons for the treatment of epistaxis in the emergency department: a randomized controlled trial. Ann Emerg Med. Feb 2005;45(2):134-9. [Medline].
Van Wyk FC, Massey S, Worley G, Brady S. Do all epistaxis patients with a nasal pack need admission? A retrospective study of 116 patients managed in accident and emergency according to a peer reviewed protocol. J Laryngol Otol. Mar 2007;121(3):222-7. [Medline].
Viducich RA, Blanda MP, Gerson LW. Posterior epistaxis: clinical features and acute complications. Ann Emerg Med. May 1995;25(5):592-6. [Medline].
Further Reading
Keywords
epistaxis, nose bleed, nasal hemorrhage, nosebleed, bloody nose, nasal packing, nosebleed treatment, nosebleed causes
