History
Controlling significant bleeding or hemodynamic instability should always take precedence over obtaining a lengthy history.
Ask specific questions about the severity, frequency, duration, and laterality of the nosebleed. Determine whether the bleed occurs after exercise or during sleep or is associated with a migraine. Determine whether hematemesis or melena has occurred because posterior bleeding in particular may present in this fashion.
Inquire about precipitating and aggravating factors and methods used to stop the bleeding. Most nosebleeds are reported as spontaneous events and are frequently related to nose picking or other trauma; therefore, investigate the various possibilities.
Foreign bodies inserted in the nose may also present with epistaxis, but bleeding may be less and accompanied by foul or purulent discharge if the object has been retained for some time. A unilateral nasal discharge suggests the presence of a foreign body.
Children easily can insert small batteries from electronic devices (eg, calculators, watches, handheld video games) into their nostrils. Not only can local irritation and bleeding result, but these can leak and cause a chemical alkali burn that may result in local tissue necrosis. Severe complications (eg, nasal stenosis) can result from batteries. Removal is a priority; removing the batteries within 4 hours of insertion is best.
In addition to obtaining a head and neck history with an emphasis on nasal symptoms, elicit a general medical history concerning relevant medical conditions, current medications, and smoking and drinking habits.
Inquire about previous epistaxis, hypertension, hepatic or other systemic disease, easy bruising, or prolonged bleeding after minor surgical procedures. A history of frequent recurrent nosebleeds, easy bruising, or other bleeding episodes should make the clinician suspicious of a systemic cause and prompt a hematologic workup. Obtain any family history of bleeding disorders or leukemia.
Children with severe epistaxis are more likely to have required nasal cauterization, an underlying coagulopathy, a positive family history of bleeding, and anemia. Although unusual, children with bleeding disorders (eg, von Willebrand disease) can occasionally have normal coagulation profiles. More than 1 sample may be required to notice the abnormality due to biologic variability throughout the day.
Use of medications—especially aspirin, NSAIDs, warfarin, heparin, ticlopidine, and dipyridamole—should be documented, as these not only predispose to epistaxis but make treatment more difficult. Particularly in children, include investigation of suspicion of accidental ingestion (eg, accidental ingestion of rat poison in toddlers).
Physical Examination
Before evaluating a patient with epistaxis, have sufficient illumination, adequate suction, all the necessary topical medications, and cauterization and packing materials ready. Remove all packings, even though bleeding may not be active. The importance of obtaining adequate anesthesia and vasoconstriction if time permits cannot be overemphasized. A comfortable patient tends to be more cooperative, allowing for better examination and more effective treatment.
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 (eg, 0.05% oxymetazoline) before the examination may reduce hemorrhage and help to pinpoint the precise bleeding site. A topical anesthetic (eg, 4% aqueous lidocaine) reduces pain associated with the examination and nasal packing. Clots are then suctioned out to permit a thorough examination.
Gently insert a nasal speculum (see the image below) and spread the naris vertically. Begin the examination with inspection, looking specifically for any obvious bleeding site on the septum that may be amenable to direct pressure or cautery. This permits visualization of most anterior bleeding sources. Anterior bleeds from the nasal septum are most common type, and the site can frequently be identified if bleeding is active.
If an anterior source cannot be visualized, if the hemorrhage is from both nares, or if constant dripping of blood is seen in the posterior pharynx, the bleeding may be from a posterior site. After placement of an anterior pack, and, if bleeding is noted in the pharynx with the anterior pack in place, strongly consider a posterior bleed.
Massive epistaxis may be confused with hemoptysis or hematemesis. Blood dripping from the posterior nasopharynx confirms a nasal source. Approximately 90% of nosebleeds can be visualized in the anterior portion of the nasal cavity.
Fiberoptic endoscopy may be performed with a flexible or (preferably) rigid endoscope to inspect the entire nasal cavity, including the nasopharynx. The rigid endoscope is preferred because of its superior optics and its ability to allow endoscopic suction and cauterization.
Examine the skin for evidence of bruises or petechiae that may indicate an underlying hematologic abnormality.
Assess vital signs. Although high blood pressure rarely, if ever, causes epistaxis on its own, it may impede clotting. Check blood pressure, and complete a workup if high blood pressure is present. Persistent tachycardia must be recognized as an early indicator of significant blood loss requiring intravenous (IV) fluid replacement and, potentially, transfusion.
Complications
Complications of epistaxis may include the following:
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Sinusitis
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Septal hematoma/perforation
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External nasal deformity
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Mucosal pressure necrosis
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Vasovagal episode
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Balloon migration
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Aspiration
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Posterior epistaxis from the left sphenopalatine artery.
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Resolved posterior epistaxis after endoscopic cauterization of the left sphenopalatine artery.
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Nasal speculum.
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Vaseline gauze packing.
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Expandable (Merocel) packing (dry).
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Nasal vascular anatomy
Tables
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- Overview
- Presentation
- DDx
- Workup
- Treatment
- Approach Considerations
- Manual Hemostasis
- Humidification and Moisturization
- Cauterization
- Nasal Packing
- Arterial Ligation
- Embolization
- Palliative Therapy for Hereditary Hemorrhagic Telangiectasia
- Complications of Treatment
- Dietary Measures
- Activity Restriction
- Prevention of Epistaxis
- Consultations
- Long-Term Monitoring
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- Guidelines
- Medication
- Questions & Answers
- Media Gallery
- References
