Nosebleed (Epistaxis)

Definition

Nosebleed, medically known as epistaxis, is bleeding from the nose. It can occur spontaneously or be induced by trauma. Epistaxis is classified into anterior and posterior based on the site of bleeding.

Aetiology

Common causes of nosebleeds include:

Local trauma (e.g., nose picking, blunt trauma)
Dry or cold air causing nasal mucosa dryness
Upper respiratory infections
Allergic rhinitis
Medications (e.g., anticoagulants, antiplatelet agents, nasal corticosteroids)
Systemic conditions (e.g., hypertension, coagulopathies)
Nasal septum deformities (e.g., deviated septum)

Pathophysiology

The nasal cavity has a rich blood supply from branches of the internal and external carotid arteries. Anterior nosebleeds typically arise from Kiesselbach's plexus, an area on the anterior part of the nasal septum with numerous blood vessels. Posterior nosebleeds originate from branches of the sphenopalatine artery and are usually more severe.

Risk Factors

Trauma to the nose
Dry air or environmental factors
Use of anticoagulant or antiplatelet medications
Chronic nasal inflammation (e.g., rhinitis, sinusitis)
Hypertension
Bleeding disorders
Nasal anatomical abnormalities

Signs and Symptoms

Common signs and symptoms of nosebleeds include:

Visible bleeding from one or both nostrils
Blood in the throat or spitting up blood
Nasal congestion
Light-headedness or dizziness in severe cases
Swallowing blood leading to nausea or vomiting

Investigations

Clinical history and physical examination
Visual inspection using a nasal speculum
Blood pressure measurement
Blood tests (e.g., complete blood count, coagulation profile) if a bleeding disorder is suspected
Imaging (CT scan) if trauma is suspected or to assess for nasal abnormalities

Management

Primary Care Management

First aid: Pinch the soft part of the nose and lean forward for 10-15 minutes
Nasal packing: Application of nasal tampons or gauze
Naseptin cream: Application to prevent infection and promote healing
Avoidance of nose picking or vigorous blowing: To prevent recurrence
Referral to an ENT specialist if bleeding persists or recurs frequently

Specialist Management

Cautery: Chemical (e.g., silver nitrate) or electrical cautery to seal bleeding vessels
Nasal packing: More extensive packing, possibly under endoscopic guidance
Embolisation: Interventional radiology procedure for posterior epistaxis
Surgical intervention: Ligation of blood vessels if conservative measures fail
Management of underlying causes (e.g., blood pressure control, adjustment of anticoagulant therapy)
Follow-up care to monitor for recurrence and manage any complications

References

NICE. (2024). Epistaxis: Diagnosis and Management. Retrieved from NICE
NHS. (2023). Nosebleed (Epistaxis). Retrieved from NHS
British Medical Journal (BMJ). (2022). Epistaxis: Diagnosis and Management. Retrieved from BMJ
American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). (2021). Clinical Practice Guideline: Nosebleed (Epistaxis). Retrieved from AAO-HNS