Epistaxis (Nose Bleeding): Causes, Treatment, Modern Concept

Article by Dr Raghuram Y.S. MD (Ay) & Dr Manasa, B.A.M.S
Epistaxis means bleeding from the nose.
Word Derivation – The word epistaxis is derived from Greek word ‘epistazo’ which means ‘to bleed from the nose’. It has 2 root words i.e.
Epi = above, over
Stazo = to drip (from the nostrils)
Epistazo = to drip (blood) from above (nose) i.e. blood dripping from nose 

Symptoms

Chief symptom –
Blood drains out (bleeding) through your nostrils
A nosebleed or epistaxis is not a disease by itself. It is a symptom of some other disease. The seriousness of nosebleed depends on the causes. Below mentioned are the common signs that indicate a nosebleed –

• Appearance of blood from one or both nostrils
• Feeling of block in the nasal passages
• Feel of presence of fluid at the back of the throat or nose
• Necessity to swallow frequently because of a blocked feeling in nasal passages
• Presence of reddish-brown particles on the tissue after wiping the nose
• Difficulty in breathing
• Facial pain and numbness
• High fever and chills
• Feeling of choking
• Nasal deformity
• Problem in vision
• Dizziness or lightheadedness
• Spells of fainting
• Difficulty in hearing
• Swelling of nose and cheeks
• Pallor
• Seizures
• Nausea and vomiting
  

  

Types

Anterior nosebleed (bleeding is evident as it flows through nostrils) – bleeding comes from the front of the nose, common in dry climates or during winter months. In these months dehydration of nasal membranes take place due to dry and heated indoor air.

Posterior nosebleed (bleeding occurs on the posterior part of nasal passage, bleeds inwards into the throat, may need immediate medical attention) – bleeding has its origin back and higher up the nose in an area where arteries supply blood to the nose. The bleeding in this condition is heavier. They are more serious and are common in adults.
Read related: Epistaxis (Nosebleed): Prevention Tips, Home Remedies, Ayurvedic Treatment

Other conditions –
Bleeding from Naso-lacrimal duct – In severe cases of nosebleed, bleeding occurs through naso-lacrimal duct, a passage which connects the nasal passages with the eye. Here, the blood comes up the naso-lacrimal duct and then bleeds out from the eye.

Fresh and or clotted blood may flow down into the stomach and cause nausea and vomiting.

Causes, differential diagnosis

Causes of Epistaxis (Nosebleed) – Differential diagnosis
Local Factors –
Blunt injury to the nose – Caused by sharp blow to the face (punch injury), may or may not be associated with nasal fracture
Contact or injury by foreign body / bodies – Nose getting injured while nose-picking with fingers, Placing sharp or blunt instrument in the nose
Inflammatory reaction – Acute respiratory tract infections, chronic sinusitis, rhinitis, exposure to environmental irritants
Anatomical deformities – Septal spurs, hereditary hemorrhagic telangiectasia
Insufflated drugs – Cocaine
Intranasal tumors – Nasopharyngeal carcinoma, Nasopharyngeal angiofibroma
Low relative humidity – Low humidity of inhaled air especially during cold winter seasons
Nasal Canula – Provision of oxygen tends to dry the nasal mucosa
Nasal Sprays – Prolonged use of or improper use of nasal steroids in the form of sprays
Middle ear barotrauma –  Descent in aircraft, Ascent in scuba diving
Nasal surgery- Septoplasty and functional endoscopic sinus surgery

Systemic Factors

Infectious disease – Common cold
Hypertension – High Blood Pressure
Anemia – Less than normal red cell count or hemoglobin in the blood
Malignancy (hematological) – Leukemia, Blood cancer
Idiopathic thrombocytopenic purpura (ITP) – Autoimmune disorder of blood platelets, presents with excessive bruising and bleeding
Hemophilia – Disorder in which blood doesn’t clot properly, genetic disorder caused by missing or defective factor VIII, a clotting protein
Vascular disorders – Diseases pertaining to blood vessels
Hereditary Hemorrhagic Telangiectasia (Osler-Weber-Rendu Syndrome) – Autosomal dominant genetic disorder that leads to abnormal blood vessel formation in skin, mucous membranes and often in organs like lungs, liver, brain
Blood Dyscrasias – Disease affecting blood cells or platelets, morbid condition resulting from presence of abnormal material in blood

Thrombotic Thrombocytopenic Purpura – Rare blood disorder characterized by clotting in small blood vessels of the body (thromboses)
Von Willebrand Disease – Bleeding (blood clotting) disorder caused by low levels of clotting protein in the blood

Connective Tissue Disease – Diseases affecting connective tissues, includes a set of diseases like Systemic Sclerosis, Systemic Lupus Erythmatosus, Dermatomyositis, Polymyositis, etc

Vitamin Disorders – Deficiency of Vitamin C and Vitamin K
Chronic Liver Disease – Alcoholic Cirrhosis or Cirrhosis causes deficiency of factor II, VII, 1X & X
Heart Failure – Due to increase in venous pressure
Pregnancy – Due to hormonal changes and hypertension associated with pregnancy
Tumors – Causing mediastinal compression and subsequent raised venous pressure

Drugs – Aspirin, Fexofenadine, Warfarin, Clopidogrel, Prasugrel, Isotretinoin, Desmopressin etc
Alcohol – Due to vasodilatation caused by consumption of excessive alcohol
Envenomation – Venom injected into the body by bite or sting of venomous animals, include that of mambas, taipans, kraits, death adders

Patho-physiology

Patho-physiology of Nasal Bleeding
The nasal mucosa is richly perfused with blood vessels. Therefore it tends to bleed when injured or when there is bleeding from those blood vessels. Nosebleeds or epistaxis occurs when there is rupture of a blood vessel within the nasal mucosa. The rupture of blood vessel may be due to trauma (injury) or may occur spontaneously.

The duration of spontaneous epistaxis tends to increase when there is an increase in blood pressure e.g. general hypertension. This type is more common in elderly people because the nasal mucosa becomes dry and thin. This becomes a suitable platform when there is high blood pressure. The blood vessels in elderly do not constrict easily. Hence in these people prolonged nosebleeds occur and the bleeding cannot be controlled many times. On the other hand, anticoagulant medication and disorders of blood clotting can promote and prolong the duration of bleeding.

Little’s area and anterior bleed – This is a region which is richly supplied with blood vessels called Kiesselbach’s plexus. It is located in the front part (anterior) of the nose. Most of the bleeding from nose (nosebleeds) occurs from this part of the nose from the nasal septum.

Posterior bleed – Bleeding which occurs in the back of the nose is called as posterior bleed. It is usually due to bleeding from the venous plexus called Woodruff’s plexus located in the posterior part of inferior nasal meatus. Posterior bleeds occur for prolonged time and are most of the times difficult to handle and control. Posterior bleeds are sometimes associated with bleeding from both the nostrils. A great flow of blood occurs into the mouth.

Pseudo-Epistaxis – Pseudo means false. Sometimes the nosebleed may not take place from the nose. The blood flowing from other sources of bleeding sometimes passes through the nasal cavity and exits from nostrils. It gives an impression of nosebleed but the source is somewhere else. Thus Pseudo-epistaxis is a condition in which there is bleeding from the nose but is not a true nosebleed i.e. not truly originating from the nasal cavity. Examples – Blood coughed up through the airway and ending up in the nasal cavity, then dripping out of the nostrils.

Treatment

Treatment of Nosebleeds
The below mentioned measures should be done once nosebleed is noted –

Pressure on Little’s Area – Direct pressure should be applied on the soft fleshy part of the nose which comprises of Little’s area (source of majority of nosebleeds) by pinching the area. This promotes clotting of blood. The flow of blood normally stops when the blood clots.

The pressure should be firm. It should be applied for at least 5 minutes (and can be applied up to 20 minutes when bleeding is more and profuse).

Head tilt – Tilting the head forward will help in decreasing the chance of nausea and airway obstruction. This avoids backflow of blood. Swallowing excess blood can irritate the stomach and cause vomiting.

Medications

Local application of vaso-constrictors – e.g. oxymetazoline or phenylephrine, they are available in the form of nasal sprays (ingredients of sprays). They reduce the bleeding time.

Procedures

Medical intervention should be sought if the above said simple measures do not help in controlling the nasal bleeding. The below mentioned measures may be followed –

Cauterization – of bleeding blood vessels using silver nitrate (not useful in heavy bleeding)
Nasal Packing – is of 2 types,
– Anterior nasal packing – gauzes and or balloons are used
– Posterior nasal packing – It is done using Foley catheter. Using this catheter, a balloon is blown, when the balloon is in the back of the throat, traction is applied.

Packing materials include – ribbon gauze, Merocel packing, dissolvable packing materials like surgical etc. Packing is generally left in place for 2-5 days.

Endoscopic evaluation and ligation of blood vessels –
If the bleeding continues in spite of good nasal packing, it suggests a surgical emergency. This condition can be treated by endoscopic evaluation of nasal cavity under general anesthesia to identify an elusive bleeding point. Alternatively, direct ligation (tie off) of blood vessels supplying the nose can be done under endoscopic evaluation.

Intra-arterial embolization – In this a catheter is placed in the groin and threaded up the aorta to the bleeding vessel (to stop the bleeding) by an interventional radiologist.

Other measures –
– Local cooling of head and neck (controversial)
– Applying ice to the nose or forehead (controversial)

Prevention

Antibiotic ointment – is useful for recurrent epistaxis, should be applied to nasal mucosa

Prognosis

About 60% of people have nosebleed at some point of their life
The peak incidences are in those under 10 years of age and over 50 years of age.
Nosebleeds appear to occur more in males in comparison to females.
About 10% of nosebleeds are serious conditions.
Nosebleeds are rarely fatal. They accounted for only 4 of the 2.4 million deaths in the U.S. in 1999.

Just Before Finishing
This article touches upon the causes and treatment of epistaxis vis-à-vis nosebleed or nasal bleeding from the perspective of modern medicine.
Click to Consult Dr Raghuram Y.S. MD (Ayu)