Patricia A. Reidy, Emily Karwacki Sheff, Catherine M. Franklin, Daniel E. Kane, Elissa Ladd, Margaret Ann Mahoney, Patrice K. Nicholas Epistaxis (nosebleed) is a common problem experienced by most individuals at some time in their lives. Epistaxis occurs in 60% of the population and is the second most common reason for emergency admission to otolaryngology services.1 The incidence is highest in individuals younger than 10 years and in individuals 70 to 79 years.2 Most nosebleeds are idiopathic. Some individuals are more prone to nosebleeds because of fragile mucous membranes. Local predisposing factors include nasal trauma, rhinitis, drying of the nasal mucosa from low humidity, nasal septum deviation, alcohol use, and chemical irritants (e.g., cocaine). Systemic conditions from either genetic or acquired coagulation disorders, hematologic cancers, and anticoagulation medication can cause epistaxis.2 Herbal supplements can inhibit platelet aggregation, causing adverse effects with other prescribed medications.3 Bleeding can occur from the anterior or posterior nares. Ninety percent to 95% of nosebleeds occur within the Kiesselbach plexus, a vascular plexus on the anterior nasal septum, and are associated with irritated mucous membranes or trauma.2,4 This plexus is particularly vulnerable and easily injured. Posterior nosebleeds occur within the posterior branches of the sphenopalatine artery and account for 5% of cases. In general, these nosebleeds are idiopathic or associated with vascular disease and can be difficult to control.3 Studies have not found an association between hypertension and epistaxis, although there may be an elevated risk caused by vascular changes.3 Patients with epistaxis initially are seen with scant to copious amounts of blood emerging from the nares. Anterior nosebleeds are usually unilateral with continuous moderate bleeding. Depending on the amount of bleeding, small clots may also emerge. Patients may report that the bleeding began spontaneously or that nasal trauma preceded the bleeding. Posterior nosebleeds can occur bilaterally, are associated with severe bleeding, and are difficult to treat. Bleeding into the pharynx is indicative of a posterior epistaxis. If the patient’s condition is stable, the provider should obtain a thorough health history regarding frequency, duration, trauma, nasal obstruction, and prior treatments. It is important to inquire about other systemic conditions, prescribed and complementary alternative medications, intranasal substances, and clotting disorders to establish the causative factors and initiate care.1,3 Vital signs and airway safety should first be determined, and the patient should be instructed to sit up straight, tilt the head forward, and apply firm, continuous pressure for 15 minutes to the anterior aspect of the affected nostril.2 The provider should assess for blood loss and risk for hemodynamic instability. If the epistaxis is the result of trauma, the nose should be checked for fractures. An internal examination may be deferred until the blood flow has subsided; but if the bleeding does not readily subside or nasal compression causes postnasal bleeding, the nose should be examined with a nasal speculum. The blood is cleared with suction or nose blowing to identify the site of bleeding. Topical vasoconstrictive agents such as 1:1000 epinephrine or 4% cocaine, applied either as a spray or on a cotton pledget, serves as both an anesthetic and a vasoconstricting agent. If this preparation is not available, a topical decongestant (e.g., oxymetazoline) can be used in conjunction with a topical anesthetic (e.g., lidocaine) to examine the nose.2,3 The nose should be inspected to identify the bleeding site before further treatment is initiated. If the site cannot be identified, the posterior pharynx is inspected for any bleeding. Rinsing the oropharynx first with water will clear the area to permit identification of any new bleeding.2 It is important to consider any underlying condition that may have caused the epistaxis. Laboratory assessment of bleeding parameters may be necessary to exclude underlying disease, especially if the bleeding recurs without a clinical explanation. A complete blood count (CBC) with a type and screen/crossmatch should be obtained if severe bleeding has occurred. A prothrombin time (PT) and international normalized ratio (INR) should be obtained if the patient is taking an anticoagulant. Additional laboratory studies should be performed if the patient is hemodynamically unstable.2,3
Epistaxis
Definition and Epidemiology
Pathophysiology
Clinical Presentation
Physical Examination
Diagnostics
Epistaxis
Chapter 89
