Epistaxis.
1. Definition: Epistaxis refers to bleeding from the nose, nasal cavity, or nasopharynx. It is a common emergency presentation, with most cases being minor and self-limiting, although severe bleeding can be life-threatening. resulting from rupture of vessels in the nasal mucosa.
2. Etiopathogenesis: Causes are categorized as local, systemic, or idiopathic.
Local Causes
- Trauma: Digital manipulation ("nose picking"), blunt facial/nasal trauma, foreign bodies, forceful nose blowing.
- Inflammation/Infection: Acute or chronic rhinitis, rhinosinusitis, common cold.
- Environmental: Low humidity and dry air (common in winter), which causes mucosal drying and cracking.
- Anatomical: Septal deviation or perforation.
- Iatrogenic: Nasal surgery, chronic use of nasal sprays (especially corticosteroids or overuse of decongestants), chronic nasal cannula use.
- Neoplasm: Benign (eg, Juvenile Nasopharyngeal Angiofibroma - especially in adolescent males) or malignant tumors.
Systemic Causes
- Vascular/Cardiovascular: Hypertension, atherosclerosis.
- Coagulopathies (Bleeding Disorders): Hemophilia, Von Willebrand disease, Thrombocytopenia, Telangiectasia
- Medications: Anticoagulants (Warfarin, NOACs), Antiplatelet agents (Aspirin, Clopidogrel), NSAIDs.
3. Classification
- 1. Anterior epistaxis (90–95%)
- From Kiesselbach’s plexus (Little’s area)
- Usually mild, easier to control
- 2. Posterior epistaxis (5–10%)
- From Woodruff’s plexus or sphenopalatine artery branches
- Older patients, hypertensive
- Profuse and recurrent, more dangerous
4. Clinical Picture
Symptoms
- Active nasal bleeding
- Postnasal drip (posterior bleeds)
- Metallic taste
- Hematemesis (from swallowed blood)
Signs
- Anterior bleeding point often visible in Kiesselbach’s area
- Posterior bleeding: blood flowing into pharynx, no visible anterior source
- Septal deviations, perforations
5. Paraclinical and Radiological Examinations
- Complete Blood Count (CBC): To check hemoglobin/hematocrit (for blood loss) and platelet count.
- Coagulation Profile: Prothrombin Time (PT), Activated Partial Thromboplastin Time (aPTT), and International Normalized Ratio (INR) (especially if on Warfarin or suspecting a bleeding disorder).
- Blood typing / Crossmatch: If significant blood loss is expected or patient is hemodynamically unstable.
- Nasal endoscopy: essential for locating bleeding source and detects masses, polyps, foreign bodies
- CT scan of Paranasal Sinuses and Nasopharynx: Indicated if a neoplasm, chronic rhinosinusitis, or trauma is suspected.
6. Treatment Options
- Initial Management/First Aid
- 1. Resuscitation (ABC): Address any signs of shock or airway compromise first.
- 2. Positioning and Compression: Patient should sit up, lean slightly forward, and pinch the soft cartilaginous part of the nose (nostrils) firmly for 10 – 15 minutes. Encourage spitting out any swallowed blood.
- Directed Treatment
- Anterior Epistaxis:
- Identify bleeding site → chemical cautery with silver nitrate
- Electrocautery if necessary
- Anterior nasal packing:
- Ribbon gauze with antibiotic ointment
- Nasal tampons (Merocel)
- Posterior Epistaxis:
- Posterior packing (balloon catheter, Foley catheter)