Epistaxis
Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management
Definition
Epistaxis refers to bleeding from the nasal mucosa, commonly due to disruption of the vascular supply in the nasal cavity.
Aetiology
- Local causes: trauma (nose picking, facial injury), dry air, nasal infections, nasal tumours.
- Systemic causes: hypertension, anticoagulant use, bleeding disorders (e.g., haemophilia, von Willebrand disease).
- Medications: aspirin, warfarin, direct oral anticoagulants (DOACs), corticosteroid nasal sprays.
- Environmental factors: cold, dry climates or irritants like smoke and pollution.
Pathophysiology
- Most nosebleeds arise from Kiesselbach’s plexus (anterior epistaxis), a vascular rich area in the nasal septum.
- Posterior epistaxis, originating from branches of the sphenopalatine artery, is less common but more severe.
- Disruption of these blood vessels leads to mucosal bleeding, which may be exacerbated by underlying coagulopathies or systemic hypertension.
Risk Factors
- Hypertension.
- Use of anticoagulants or antiplatelet therapy.
- Chronic nasal dryness or irritation.
- Bleeding disorders (e.g., haemophilia, von Willebrand disease).
- Frequent upper respiratory infections.
Signs and Symptoms
- Unilateral or bilateral nasal bleeding: varying severity.
- Blood dripping from the nostril or into the throat: indicative of anterior or posterior origin.
- Recurrent episodes: may suggest an underlying disorder.
- Haemodynamic instability: in severe cases, leading to hypotension and tachycardia.
Investigations
- Clinical examination: anterior rhinoscopy to identify the bleeding source.
- Full blood count (FBC): assess for anaemia or underlying haematological conditions.
- Coagulation profile: indicated if a bleeding disorder or anticoagulant use is suspected.
- Blood pressure measurement: assess for hypertensive contribution.
- Nasal endoscopy: for recurrent or severe epistaxis.
Management
1. Initial First Aid Measures:
- Pinch the soft part of the nose: apply continuous pressure for at least 10–15 minutes.
- Leaning forward: prevents blood from flowing into the throat.
- Cold compress: applied to the bridge of the nose to constrict blood vessels.
2. Medical Management:
- Topical cream: naseptin for minor cases.
- Cauterisation: silver nitrate for visible bleeding points.
- Nasal packing: anterior or posterior nasal packing for uncontrolled bleeding.
- Correction of underlying conditions: manage hypertension or adjust anticoagulant therapy.
3. Surgical Management:
- Endoscopic arterial ligation: in refractory cases.
- Embolisation: for persistent posterior epistaxis.
4. Referral:
- ENT specialist: for recurrent, severe, or posterior epistaxis.
- Haematology: if a bleeding disorder is suspected.
- Cardiology: if hypertension is a contributing factor.