MANAGEMENT
OF NOSE BLEEDS
(EPISTAXIS)
Nosebleeds are a fairly common occurrence in day to day living. They tend to be frightening to a non-medical professional because they can be profuse and dramatic, however, are they rarely life-threatening. They can occur at any age but are most common under age 10 and over age 50.
Nosebleeds can
be divided into two types:
1.
Anterior (front of
the nose) and
2.
Posterior (back of
the nose)
Anterior
epistaxis represents about 90% of nosebleeds and
tend to be easier to manage. With an anterior nosebleed, the blood will tend to
come out the front of the nose. Bleeding that is more profuse and going
down the back of the throat is a more likely indicator of posterior
epistaxis. The nasal mucous membranes warm and humidify air as it passes
through the nose. To accomplish this, the nose has a very rich vascular supply.
There is a collection of blood vessels on the anterior septum,
where the vast majority of nosebleeds occur.
Often, there is no obvious cause for the bleeding and it may seem very random.
Some factors that may cause bleeding include dry air, trauma either from an
injury or from picking the nose, chemical irritants, nasal septal deformities,
allergies, upper respiratory infections, medications such as aspirin and other
anti-coagulants, and medical illnesses such as hypertension and vascular
disease. At times, nosebleed could be the first clinical manifestation of an
underlying systemic disease like malignancy of the lymphoid system blood
vessels and coagulation disorders. Sometimes, unprovoked spontaneous bleeding
from nose occurs in teenaged boys harboring rare vascular tumors like juvenile
nasopharyngeal angiofibroma.
Most nosebleeds can
be managed conservatively. Humidifying the air and applying nasal saline sprays
may help as the first line of treatment.
1.
Avoid hard nose blowing
and nose picking, especially in children.
2. Avoid hot and spicy foods and hot showers and avoid aspirin and other
anti-coagulants unless prescribed medically. If bleeding occurs, sit down and
lean forward and relax.
3. Pinch the nose firmly on the soft part of the nose so that pressure is
applied against the septum. Apply an ice pack to the external nose.
4. Pinch the nose for a few minutes. If it is still bleeding then pinch
the nose for another 10-15 minutes. If bleeding continues then medical
attention may be necessary. Topical over-the-counter nasal sprays containing
oxymetazoline or phenylephrine may help to decrease bleeding as a temporary
measure.
If bleeding
persists or recurs or is severe then a consultation with an ENT surgeon is
recommended. A diagnostic nasal endoscopy would help in clinching the site and
the probable cause of bleeding. A surgical procedure may or may not be
needed. Anterior bleeding can sometimes be managed with chemical
cauterization using silver nitrate. Occasionally, persistent bleeding will
require nasal packing and, if there is a recurrence or intractable bleeding,
surgical management or embolization may be required. The surgical approach is
very straightforward with an endoscopic approach to visualize
the bleeding site and ligate or clip the offending vessel and prevent further
episodes.
Glossary
:
Epistaxis: Bleeding from the nose
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