Epistaxis
10-MINUTE CONSULTATIONBMJ 23 February 2012
د. حسين محمد جمعه
اختصاصي الامراض الباطنة
البورد العربي
كلية طب الموصل
2012
A 52 year old man presents with recurrent epistaxis. It usually settles after 10 minutes.
What you should coverAsk about
• Initial onset, frequency, duration, and triggers (such as
weather)
• How are the nose bleeds controlled?
• Distinguish between anterior (blood running out of the
nose, usually one nostril) and posterior (blood running into
the throat or from both nostrils) bleeds
• Trauma, including nose picking
• Previous nasal surgery
• Medical history, specifically checking for hypertension and clotting disorders in the patient or their family
• Medication—check for aspirin, clopidogrel, warfarin, and any potential drug interactions that might have precipitated bleeding. If appropriate, test blood clotting. Also inquire about any homeopathic medicines.
• Assess for symptoms and signs of anaemia if bleeding has been heavy or prolonged. If appropriate, carry out a full blood count
• Facial pain or deep otalgia with epistaxis may be the first sign of a nasopharyngeal tumour
• In young male patients consider juvenile nasopharyngeal angiofibroma and ask about nasal obstruction, headache, rhinorrhea, and anosmia. These are rare benign tumours that tend to bleed. They occur in the nasopharynx prepubertal and adolescent males.
Ninety five per cent of nose bleeds arise from Little’s area, aregion of the anteroinferior nasal septum. This area is extremely vascular, as terminal branches of the internal and external carotid arteries anastamose here.
What you should do
First aidWhether the patient is bleeding or not, assess their
cardiovascular state—pulse, blood pressure, and capillary refill.
If the patient is actively bleeding, seat them and ask them to lean forward (to minimise the swallowing of blood) and apply pressure on to the soft cartilaginous part of the nose for 10 minutes. If bleeding does not stop, refer them to an ear, nose,
and throat department and sent them to hospital.
The urgency and mode of transfer will depend on the clinical condition of the patient, but do not underestimate the amount of blood that
can be lost during epistaxis.
Patients should not drive themselves to hospital because they may be not covered by their motor insurance in this situation.
Treatment
If the patient has stopped bleeding, use an otoscope or a torch and nasal speculum to look at the anterior nose and septum for evidence of a bleeding vessel, which will often appear as a red dot on pale mucosa. If a vessel is seen, chemical cautery may be attempted using a topical local anaesthetic such as lidocaine or co-phenylocaine (5% lignocaine with 0.5% phenylephrine) to help vasoconstriction, if bleeding is active, and a silver nitrate stick. If no facility for cautery is available refer to ear, nose, and throat; most departments have rapid access casualty clinics designed for this purpose.If the patient’s history suggests anterior epistaxis and no vessel is seen, it is reasonable to discharge with a two week course of 0.1% chlorhexidine, 0.5% neomycin cream or petroleum jelly—these help with drying of the nasal mucosa and can prevent further bleeding. Advise patients to return if bleeding persists.
Simple pressure will not stop epistaxis from posteriorly placed vessels, so recurrent or heavy bleeds that appear posterior in origin need endoscopic assessment in an ear, nose, and throat clinic to help identify a bleeding point.
Follow-up
Always give patients advice about how to stop further bleeding:(1) Pinch the soft part of the nose and lean forward
(2) Avoid hot foods and drinks (preventing vasodilatation)
(3) Place ice packs on the nose (to promote vasoconstriction).
If epistaxis is refractory or if you suspect any problem other than a simple bleed—for example, a septal perforation or tumour—seek an opinion from an ear, nose, and throat clinician.
