Pathophysiology:
Epistaxis can be anterior or posterior. Approximately 90 % of epistaxis is anterior, originating from Kiesselbach plexus, an anastomotic network of vessels on the anterior portion of the nasal septum, also known as Little's area. Nose receives blood supply from both the internal and external carotid arteries.
Age: Most cases of epistaxis occur in children younger than 10 years and in older group between 50-80 years.
2. Trauma:
a. Self-induced trauma from repeated nose picking is the most common cause. This is frequently observed in young children.
b. Facial and nasal trauma commonly leads to epistaxis.
c. Iatrogenic trauma: Nose surgery can cause minor to potential nasal bleed. Bleeding from nose can also occur during nasogastric and nasotracheal intubation.
3. Mucosal irritation: Prolonged inhalation of dry air either due to dry, hot weather or due to home heating systems and topical nasal sprays such as antihistamines and corticosteroids can cause mucosal irritation and epistaxis.
4. Septal abnormality: A deviated nasal septum (DNS) and spurs may disrupt the normal nasal airflow, leading to dryness and epistaxis.
5. Inflammatory disease: Bacterial, viral and allergic rhinosinusitis causes mucosal inflammation and may lead to epistaxis. The bleeding is usually minor. Granulomatosis diseases such as sarcoidosis, tuberculosis, syphilis may cause recurrent epistaxis due to crusting and fragility of mucosa.
6. Children can have epistaxis due to local irritation or recent upper respiratory infection (URI).
7. Bleeding disorders:
a. Congenital bleeding disorders like hemophilia and Von Willebrand disease with a positive family history, easy bruising, or prolonged bleeding from minor trauma or surgery can cause epistaxis.
b. Acquired bleeding disorders due to the diseases like splenomegaly, thrombocytopenia, platelet disorders, liver disease, renal failure, or secondary due to medication like oral contraceptives (OCP) or chronic alcohol use predispose to epistaxis.
8. Hypertensive patients are more prone to epistaxis due to vascular fragility.
9. Vascular abnormalities that may cause epistaxis include:
a. Hereditary hemorrhagic telangiectasia
b. Arteriovenous malformation
c. Benign and malignant tumors
d. Sclerotic vessels
e. Aneurysms
f. Endometriosis
2. If bleeding is recurrent or severe, then
a. Complete blood cell count (including platelet count),
b. Bleeding time
c. Prothrombin time, activated partial thromboplastin time,
d. Liver function tests, and
e. Studies to evaluate the fluid status and relevant systemic diseases are needed.
• Anterior packing: Nasal packing can be used to treat epistaxis that is not responsive to cautery. Sometimes posterior packing may be required.
Surgical Care:
In most patients with epistaxis, the bleeding responds to cautery and/or packing. For those who still have recurrent or severe bleeding, various surgical options are available.
• Examination under general anesthesia and septoplasty:
• Arterial ligation: The specific bleeding vessel(s) to be ligated. In general, the closer the ligation is to the bleeding site, the more effective the procedure tends to be.
a. External carotid artery ligation or embolization.
b. Internal maxillary artery ligation.
c. Ethmoid artery ligation: If bleeding occurs high in the nasal vault, ligation of the anterior and/or posterior ethmoid arteries is required.
2. Avoid blowing nose.
3. On sitting position, firmly press soft parts of the nose together between your thumb and index finger, compressing the pinched parts of the nose against the bones of the face for about 10-15 minutes.
4. Lean forward slightly with the head tilted forward to avoid blood entry into the throat.
5. Breathe orally in a relaxed manner.
6. Take care of blood pressure.
7. Applying ice to nose and cheeks may be tried, but have little effect.
8. Almost all nasal bleeding stopped by this compression. Once your nasal bleeding stopped, take following precautions:
a. Rest with head elevated at 30 to 45 degrees.
b. Do not blow your nose or put anything into it.
c. If you have to sneeze, open your mouth so that the air will escape out the mouth and not through the nose.
d. Do not strain during bowel movements.
e. Do not strain or bend down to lift anything heavy.
f. Do not smoke.
g. Stay on a soft, cool diet. No hot liquids for at least 24 hours.
h. Apply some form of lubricating ointment for the inside of the nose.
i. If re-bleeding occurs, try to clear the nose of clots by sniffing in forcefully. You can temporarily use a nasal decongestant spray, such as Afrin. These types of sprays constrict blood vessels.
j. Repeat the compression manoeuvre to stop the nose bleed. If bleeding persists, call the doctor and/or visit to the emergency room
2. Lidocaine 4% (Xylocaine): When used with vasoconstrictors, their effect is prolonged and the pain threshold increased.
3. Mupirocin ointment 2% (Bactroban nasal): It helps to prevent local infection and provide local moisturization. Usage is 0.5 g each nostril twice daily for 5 days.
4. Silver nitrate: Coagulates cellular protein and removes granulation tissue. It also has antibacterial effects. It cauterizes supplying blood vessels.
2. Avoid vigorous nose blowing or sneezing.
3. Sneeze with open mouth to reduce the force of the sneeze.
4. Do not use digital manipulation in nose.
5. Avoid smoking and drinking.
6. Avoid hot and spicy foods and drink plenty of fluids.
7. Avoid strenuous activities.
8. Avoid taking hot showers.
9. Avoid sporting activities which have the risk of being hit on the nose.
10.Limit blood thinners like aspirin & other NSAIDs, vitamin E, heparin, garlic, ginger and ginseng.
11. Avoid oral contraceptives (OCP).
12. Do not strain at bowel movements. Take laxative, if necessary.
13. Avoid allergic triggers such as wheat or dairy products if you are susceptible.
14. Maintain humidity of house by keeping humidifier in bedroom, especially if house is very dry.
2. Use a few drops of castor oil, vitamin E or zinc oxide in nose daily to prevent recurrence of nosebleed.
3. Crush an onion and smell it repeatedly.
4. Use the juice of Durva (Dhub) grass as nasal drop.
5. Use 3-4 drops of freshly prepared Indian Gooseberry (Amla) juice into the nostrils.
6. Use the juice of fresh pomegranate (Anar) flowers or leaves as nasal drop.
7. A small piece of camphor (Kapur) mixed with the juice of green coriander leaves may be used as nasal drop.
8. Powder of alum mixed with ghee can also be used as nasal drops.
9. A tsp of Chawanaprasa with milk twice daily may also provide relief.
10. Lemon is a very good antiseptic and also helps in fast coagulation of the blood. Use a drop or two of lemon juice in the affected nose to stop bleeding.
11. Apple cider vinegar is useful to stop nosebleed. Soak a small cotton ball in the vinegar and pack it lightly into the nostril.
Age: Most cases of epistaxis occur in children younger than 10 years and in older group between 50-80 years.
Causes:1. Idiopathic causes: Approximately 10% of patients with epistaxis have no identifiable causes.
2. Trauma:
a. Self-induced trauma from repeated nose picking is the most common cause. This is frequently observed in young children.
b. Facial and nasal trauma commonly leads to epistaxis.
c. Iatrogenic trauma: Nose surgery can cause minor to potential nasal bleed. Bleeding from nose can also occur during nasogastric and nasotracheal intubation.
3. Mucosal irritation: Prolonged inhalation of dry air either due to dry, hot weather or due to home heating systems and topical nasal sprays such as antihistamines and corticosteroids can cause mucosal irritation and epistaxis.
4. Septal abnormality: A deviated nasal septum (DNS) and spurs may disrupt the normal nasal airflow, leading to dryness and epistaxis.
5. Inflammatory disease: Bacterial, viral and allergic rhinosinusitis causes mucosal inflammation and may lead to epistaxis. The bleeding is usually minor. Granulomatosis diseases such as sarcoidosis, tuberculosis, syphilis may cause recurrent epistaxis due to crusting and fragility of mucosa.
6. Children can have epistaxis due to local irritation or recent upper respiratory infection (URI).
7. Bleeding disorders:
a. Congenital bleeding disorders like hemophilia and Von Willebrand disease with a positive family history, easy bruising, or prolonged bleeding from minor trauma or surgery can cause epistaxis.
b. Acquired bleeding disorders due to the diseases like splenomegaly, thrombocytopenia, platelet disorders, liver disease, renal failure, or secondary due to medication like oral contraceptives (OCP) or chronic alcohol use predispose to epistaxis.
8. Hypertensive patients are more prone to epistaxis due to vascular fragility.
9. Vascular abnormalities that may cause epistaxis include:
a. Hereditary hemorrhagic telangiectasia
b. Arteriovenous malformation
c. Benign and malignant tumors
d. Sclerotic vessels
e. Aneurysms
f. Endometriosis
Laboratory Studies:1. Routine laboratory studies are rarely indicated for nose bleeding and are only recommended in the presence of major bleeding or if a coagulopathy is suspected.
2. If bleeding is recurrent or severe, then
a. Complete blood cell count (including platelet count),
b. Bleeding time
c. Prothrombin time, activated partial thromboplastin time,
d. Liver function tests, and
e. Studies to evaluate the fluid status and relevant systemic diseases are needed.
Medical Care:• Cautery: Bleeding from the “Little area” is frequently treated with silver nitrate cauterization. After the bleeding has been controlled, the patient is instructed to use nasal saline spray and antibiotic ointment and to avoid strenuous activities for 7-10 days. NSAIDs are not to be used if at all possible. Digital manipulation of the nose is to be avoided.
• Anterior packing: Nasal packing can be used to treat epistaxis that is not responsive to cautery. Sometimes posterior packing may be required.
Surgical Care:
In most patients with epistaxis, the bleeding responds to cautery and/or packing. For those who still have recurrent or severe bleeding, various surgical options are available.
• Examination under general anesthesia and septoplasty:
• Arterial ligation: The specific bleeding vessel(s) to be ligated. In general, the closer the ligation is to the bleeding site, the more effective the procedure tends to be.
a. External carotid artery ligation or embolization.
b. Internal maxillary artery ligation.
c. Ethmoid artery ligation: If bleeding occurs high in the nasal vault, ligation of the anterior and/or posterior ethmoid arteries is required.
Self-treatment for nasal bleed:1. Do not lie down since it will increase the bleeding due to increase in pressure.
2. Avoid blowing nose.
3. On sitting position, firmly press soft parts of the nose together between your thumb and index finger, compressing the pinched parts of the nose against the bones of the face for about 10-15 minutes.
4. Lean forward slightly with the head tilted forward to avoid blood entry into the throat.
5. Breathe orally in a relaxed manner.
6. Take care of blood pressure.
7. Applying ice to nose and cheeks may be tried, but have little effect.
8. Almost all nasal bleeding stopped by this compression. Once your nasal bleeding stopped, take following precautions:
a. Rest with head elevated at 30 to 45 degrees.
b. Do not blow your nose or put anything into it.
c. If you have to sneeze, open your mouth so that the air will escape out the mouth and not through the nose.
d. Do not strain during bowel movements.
e. Do not strain or bend down to lift anything heavy.
f. Do not smoke.
g. Stay on a soft, cool diet. No hot liquids for at least 24 hours.
h. Apply some form of lubricating ointment for the inside of the nose.
i. If re-bleeding occurs, try to clear the nose of clots by sniffing in forcefully. You can temporarily use a nasal decongestant spray, such as Afrin. These types of sprays constrict blood vessels.
j. Repeat the compression manoeuvre to stop the nose bleed. If bleeding persists, call the doctor and/or visit to the emergency room
Commonly used medications in epistaxis:1. Oxymetazoline 0.05% (Afrin): It acts as topical vasoconstrictors in the nasal mucosa. Usually used in combination with lidocaine 4% to provide effective nasal anesthesia and vasoconstriction. Dose is 2-3 sprays each nostril q12h. Not recommended below 6 years of age.
2. Lidocaine 4% (Xylocaine): When used with vasoconstrictors, their effect is prolonged and the pain threshold increased.
3. Mupirocin ointment 2% (Bactroban nasal): It helps to prevent local infection and provide local moisturization. Usage is 0.5 g each nostril twice daily for 5 days.
4. Silver nitrate: Coagulates cellular protein and removes granulation tissue. It also has antibacterial effects. It cauterizes supplying blood vessels.
Prevention of Epistaxis:1. Put petroleum jelly inside of the nose to keep it moist.
2. Avoid vigorous nose blowing or sneezing.
3. Sneeze with open mouth to reduce the force of the sneeze.
4. Do not use digital manipulation in nose.
5. Avoid smoking and drinking.
6. Avoid hot and spicy foods and drink plenty of fluids.
7. Avoid strenuous activities.
8. Avoid taking hot showers.
9. Avoid sporting activities which have the risk of being hit on the nose.
10.Limit blood thinners like aspirin & other NSAIDs, vitamin E, heparin, garlic, ginger and ginseng.
11. Avoid oral contraceptives (OCP).
12. Do not strain at bowel movements. Take laxative, if necessary.
13. Avoid allergic triggers such as wheat or dairy products if you are susceptible.
14. Maintain humidity of house by keeping humidifier in bedroom, especially if house is very dry.
Home remedies to prevent recurrence of nose bleed (Epistaxis)1. Consume citrus fruit to prevent recurrence of nosebleed.
2. Use a few drops of castor oil, vitamin E or zinc oxide in nose daily to prevent recurrence of nosebleed.
3. Crush an onion and smell it repeatedly.
4. Use the juice of Durva (Dhub) grass as nasal drop.
5. Use 3-4 drops of freshly prepared Indian Gooseberry (Amla) juice into the nostrils.
6. Use the juice of fresh pomegranate (Anar) flowers or leaves as nasal drop.
7. A small piece of camphor (Kapur) mixed with the juice of green coriander leaves may be used as nasal drop.
8. Powder of alum mixed with ghee can also be used as nasal drops.
9. A tsp of Chawanaprasa with milk twice daily may also provide relief.
10. Lemon is a very good antiseptic and also helps in fast coagulation of the blood. Use a drop or two of lemon juice in the affected nose to stop bleeding.
11. Apple cider vinegar is useful to stop nosebleed. Soak a small cotton ball in the vinegar and pack it lightly into the nostril.
Warning: The reader of this article should exercise all precautions before following any of the method mentioned in this article and the site. To avoid any problems, it is advised that you consult a Doctor. The responsibility lies solely with the reader and not with the site or the writer.
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