Khaberni - The newsletter of the Institute of Family Health Care (from the institutes of the King Hussein Foundation) discusses today, Monday, epistaxis or nosebleed, which is considered one of the most common conditions that doctors face in emergency departments and ENT clinics.
The Institute's newsletter aims to review the anatomical structure of the nose, the most important causes of epistaxis, diagnostic methods, treatment steps, and potential complications, in addition to prevention methods.
Epistaxis is defined as the discharge of blood from the nasal cavity, which may originate from the anterior part of the nose or from the posterior part. In most cases, the bleeding is minor and stops spontaneously, but in some cases, it may become severe and life-threatening, especially in the elderly or those suffering from chronic diseases such as high blood pressure or blood clotting disorders. Studies indicate that about 60% of people may experience a nosebleed at least once in their lives, while only 10% of them require medical intervention.
The Vascular Anatomy of the Nose:
To understand epistaxis, one must know the blood supply to the nose, as the nasal mucosa is rich in capillaries coming from both the internal and external carotid arteries.
1. The anterior part of the nasal septum (Kiesselbach's plexus or Little's area):
- It is the most common source of bleeding especially among children and adolescents.
- It consists of a network where branches of a group of four arteries meet.
2. The posterior part (Woodruff's plexus):
- Less common but more dangerous and difficult to control.
- Usually occurs in older adults, often associated with high blood pressure or vascular diseases.
- Primarily fed by branches of the greater palatine artery.
Anterior epistaxis is usually easier to control, while the posterior type requires specialized intervention.
Causes of Epistaxis:
Causes can be divided into local and systemic:
Local Causes:
- Trauma: Most common in children due to nose picking (inserting a finger). It may also occur due to fractures or accidents.
- Infections: Such as sinusitis or allergic or viral rhinitis.
- Environmental factors: Dry air, indoor heating, or being at high altitudes.
- Foreign bodies: Especially in children.
- Tumors: Such as nasopharyngeal angiofibroma (common in adolescent males) or rare malignant tumors.
- Medical causes: Following nasal surgeries or endoscopy or nasogastric tube insertion.
Systemic Causes:
- High blood pressure: Most linked to severe or recurrent bleeding.
- Blood clotting disorders: Such as hemophilia or von Willebrand disease, or acquired disorders like liver diseases.
- Medications: Especially blood thinners (warfarin, aspirin, clopidogrel) and nonsteroidal anti-inflammatory drugs.
- Hereditary vascular diseases: Such as hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease).
Symptoms and Signs:
- Bleeding from one or both nostrils.
- In case of posterior bleeding, the patient may complain of blood descending to the pharynx and mouth with a possibility of bloody vomiting.
- Sometimes appears as black stool (melena) due to swallowing blood.
- It is important to pay attention to accompanying symptoms such as headache, dizziness, loss of consciousness, or signs of anemia.
Clinical Examination:
- Examination of the nasal cavity using an endoscope or anterior rhinoscopy to determine the location of the bleeding.
- Evaluating blood pressure, pulse, and the general condition of the patient.
- In case of suspicion of posterior bleeding or a tumor, examination using rigid or flexible endoscopy is required.
Diagnosis:
- Diagnosis is primarily clinical.
- Laboratory tests: Complete blood count, coagulation tests, and liver function tests especially in cases of recurrent or severe bleeding.
- Imaging: Rarely used except in cases of suspected fractures or tumors, which may include CT scans or MRI.
Treatment:
The treatment intervention depends on the severity and location of the bleeding, and is implemented in gradual steps:
1- First Aid:
- Tilt the patient's head forward while sitting to prevent swallowing blood.
- Compressing the nose for a continuous 10–15 minutes.
- Applying cold compresses or ice on the bridge of the nose to help constrict the vessels.
2 - Minor Medical Interventions:
- Use of vasoconstrictor drops (oxymetazoline or phenylephrine).
- Chemical cauterization with silver nitrate if the bleeding point is identified.
- Electrocautery in refractory cases.
- Use of topical drugs like tranexamic acid.
3 - Nasal Packing:
- Anterior packing: With gauze moistened with petroleum jelly or ready-made plugs.
- Posterior packing: Using a balloon or special gauze, often requiring hospital admission.
4 - Surgical Interventions:
- Artery ligation by endoscopy: Such as the sphenopalatine or ethmoidal arteries.
- Embolization: When previous methods fail.
- Surgical intervention for severe septal deviation or tumors.
Complications:
- Blood loss and hemorrhagic shock in severe cases.
- Airway obstruction especially in posterior bleeding.
- Infections such as sinusitis or toxic shock syndrome after packing.
- Septal perforation due to cauterization or prolonged pressure.
Prevention:
- Moisturizing the nose using saline sprays or humidifiers.
- Avoid picking or blowing the nose forcefully.
- Controlling blood pressure.
- Monitoring patients using blood thinners and adjusting their doses.
- Health education about first aid in case of bleeding.
