Nosebleeds (Epistaxis)

Diagnosis of Nosebleeds

Identifying the Bleeding Source

A key step in managing epistaxis is to identify the source of bleeding. This involves:

1. History Taking: Inquire about the frequency, duration, and severity of nosebleeds; which side usually bleeds; any known triggers or underlying medical conditions; medications (especially anticoagulants or antiplatelet drugs); and family history of bleeding disorders.
2. Physical Examination:
   • Often, if bleeding is active and from both nostrils, it can be difficult to determine the origin side immediately. To help identify the source, the child's head can be tilted slightly forward (to prevent blood from flowing into the pharynx, which can cause swallowing and gagging), and the child asked to gently blow their nose to clear clots. Wiping the entrance to the nose then allows observation of which nostril the blood is primarily flowing from into a tray or tissue.
   • Anterior Rhinoscopy: After clearing clots, the nasal cavity is examined, preferably with a nasal speculum and good illumination (headlight). Focus is placed on Kiesselbach's plexus on the anterior septum.
   • Nasal Endoscopy: If the bleeding source is not visible anteriorly, or if posterior bleeding is suspected, nasal endoscopy (rigid or flexible) may be necessary after topical anesthesia and vasoconstriction (e.g., with lidocaine and oxymetazoline). This allows for a thorough examination of the entire nasal cavity, including the posterior regions and the area around the tuberculum septi (which contains cavernous tissue). Solutions of cocaine (e.g., 5% solution) with adrenaline (1:1000) were historically used for anesthesia and vasoconstriction, especially in older children with wide nasal passages, to facilitate examination.
3. Laboratory Tests: If recurrent or severe epistaxis, or if a systemic cause is suspected, blood tests may include a complete blood count (CBC) with platelet count, coagulation studies (PT/INR, PTT), and potentially tests for specific bleeding disorders.
4. Imaging: Rarely needed for routine epistaxis. CT or MRI scans may be considered if a tumor, sinus pathology, or CSF leak (often with clear fluid mixed with blood after trauma) is suspected. Angiography may be used to identify and embolize bleeding vessels in severe, intractable posterior epistaxis.

 

Treatment and Management of Nosebleeds (Epistaxis)

The primary goals of epistaxis management are to stop the acute bleeding, prevent recurrence, and identify and treat any underlying cause.

 

First Aid and Conservative Measures

For most common anterior nosebleeds, these steps can be effective:

1. Positioning: Have the patient sit upright and lean slightly forward. This prevents blood from being swallowed and reduces venous pressure in the nose. Unbuttoning the collar can also help.
2. Direct Pressure: Pinch the soft, fleshy part of the nose (alae nasi) firmly against the nasal septum for at least 5-10 minutes continuously, breathing through the mouth.
3. Cold Compress: Apply a cold pack or ice wrapped in a cloth to the bridge of the nose and forehead. A warm heating pad on the legs was a historical ancillary measure.
4. Avoid Irritants: Refrain from picking, rubbing, or blowing the nose forcefully.
5. Humidification: Using a humidifier, especially in dry climates or during winter, can help keep nasal passages moist.
6. Oxygen Therapy (if available and indicated): In some settings, having the patient inhale oxygen through the nose (e.g., from an oxygen pillow) for 3-5 minutes while exhaling through the mouth was suggested.

If bleeding is excessive, pressing the wing of the corresponding half of the nose firmly against the septum can sometimes stop it. Inserting a cotton ball moistened with hydrogen peroxide, ε-aminocaproic acid, adrenaline (epinephrine), or thrombin into the bleeding nostril can also be tried as a first-aid measure.

 

Medical Interventions: Cauterization and Packing

If conservative measures fail or bleeding is significant, medical intervention is required:

• Topical Vasoconstrictors and Anesthetics: Applied to visualize the bleeding site and prepare for further intervention (e.g., oxymetazoline, phenylephrine, lidocaine).
• Chemical Cauterization: If a specific bleeding point is identified (commonly in Kiesselbach's plexus), it can be cauterized using silver nitrate sticks or trichloroacetic acid. The area is first anesthetized. Superficial cauterizing agents like alum or tannin form a superficial scab. Stronger agents like chromic acid (historically used, excess neutralized with 2% sodium bicarbonate), electrocautery, or surgical diathermy cause deeper eschar formation. Cauterization should be performed carefully to avoid excessive damage or septal perforation (avoiding cauterizing directly opposite sites on the septum simultaneously). It's often done after bleeding has stopped to prevent the eschar from being washed away. A "halo" cauterization around the bleeding site, rather than directly on it, has been suggested to obliterate feeding vessels and potentially reduce recurrence.
• Anterior Nasal Packing: If cauterization is not possible or fails, anterior nasal packing is performed. A lubricated gauze strip (plain or impregnated with antibiotic ointment or hemostatic agent) or an expansile nasal sponge (e.g., Merocel) is inserted into the bleeding nostril to apply pressure. Tampons are typically left for 24-72 hours. If bleeding continues, the nasal cavity may need to be repacked.
• Posterior Nasal Packing: For bleeding originating from the posterior nasal cavity that is not controlled by anterior packing. This involves placing a pack (e.g., Foley catheter, specialized balloon catheter like Epistat or Rapid Rhino, or a traditional gauze pack passed through the nasopharynx) to occlude the choana. Posterior packing is uncomfortable and often requires hospitalization and analgesia. Complications like sinusitis, otitis media, or even pressure necrosis can occur.

To facilitate tampon removal and improve hemostasis, tampons can be pre-impregnated with lubricating or hemostatic substances (e.g., antibiotic ointment, petroleum jelly, 3% hydrogen peroxide, plasma, blood serum, thrombin, or a hemostatic sponge). Pneumatic tampons (inflatable balloons) of various designs are also available; a rubber cannula is inserted into the nasal cavity and inflated with air, pressing against the nasal mucosa to compress bleeding vessels.

 

Advanced Hemostatic Measures and Systemic Treatments

• Systemic Hemostatic Agents: Oral or intravenous administration of agents like tranexamic acid or ε-aminocaproic acid (5-10% calcium chloride solution, 1% Vicasol solution were historical mentions).
• Blood Transfusion: For severe nosebleeds with significant blood loss and hemodynamic instability. Direct blood transfusion was particularly emphasized for conditions like hemophilia or Werlhof's disease.
• Management of Underlying Conditions:
  • For hemophilia, antihemophilic globulin and plasma are prescribed.
  • Correction of coagulopathies or hypertension.
• Fluid Resuscitation: Intravenous physiological saline or blood-substituting solutions are indicated for exsanguination.

When managing nosebleeds, it is crucial to ensure that blood is not flowing down the back of the pharynx, as this indicates ongoing bleeding and failure of the applied methods.

 

Cryotherapy for Recurrent Epistaxis

Cryoexposure (application of extreme cold) can be used for epistaxis of various etiologies, especially for recurrent nosebleeds of unclear origin. It can be performed both during active bleeding and in an interval free from bleeding (for habitual epistaxis). The bleeding source is identified after topical anesthesia and vasoconstriction. A cryoapplicator (e.g., with vapor-liquid nitrogen circulation) or "snow" from carbonic acid (-79°C) applied with a polymer spoon (e.g., 4x6 mm) can be used. Exposure is often performed using a two-cycle method, typically freezing the area around the bleeding site ("halo" technique) rather than the site itself. Freezing should not be done on directly opposite septal sites simultaneously. Exposure time averages 30-120 seconds with a cryoapplicator, and 15-30 seconds with a cryoprobe or carbonic acid "snow." Sometimes, nasal tamponade is performed immediately after freezing, without waiting for thawing, which is considered a more effective combined technique. Post-cryotherapy, blanching occurs, followed by edema and hyperemia within a day. A yellowish necrotic area forms, which later sloughs off.

 

Surgical Management for Intractable Epistaxis

If conservative measures and packing fail to control severe or recurrent epistaxis, surgical interventions may be necessary:

• Endoscopic Sphenopalatine Artery Ligation (ESPAL): The most common surgical procedure for intractable posterior epistaxis. The sphenopalatine artery is identified and ligated or cauterized endoscopically.
• Anterior and/or Posterior Ethmoidal Artery Ligation: For bleeding from the superior or posterior-superior nasal cavity. This may require an external or endoscopic approach.
• Internal Maxillary Artery Ligation: A more invasive procedure, less commonly performed now due to the effectiveness of ESPAL.
• External Carotid Artery Ligation: Rarely performed, only as a last resort for life-threatening hemorrhage unresponsive to other measures. Ligation of both external carotid arteries is an extreme measure.
• Septoplasty: May be required to correct a severe septal deviation that contributes to recurrent bleeding or to gain access to a posterior bleeding site. Mucosal exfoliation along with the perichondrium has also been described.
• Embolization: Interventional radiologists can perform selective arterial embolization to occlude bleeding vessels, particularly useful for posterior epistaxis.

An operating microscope can improve visibility during procedures like internal maxillary artery ligation. Pulsating bleeding on the eve of surgery might sometimes be addressed by ligating the vessel from the side of the hard palate in the area of the incisive foramen; if this fails, ligation on the other side may be attempted.

 

Nutritional Considerations and General Advice

For patients prone to frequent nosebleeds: with significant active bleeding, it's advisable to temporarily refrain from eating. Avoid hot food and stimulating drinks like strong tea, coffee, or cocoa, as these can increase blood pressure and dilate blood vessels. A diet rich in proteins (e.g., cottage cheese, lightly fried liver, concentrated chicken broth – considering individual sensitivities) may be recommended. Adequate intake of fresh vegetables, fruits, juices, and vitamins is also important.

Patients can sometimes overcome the urge to sneeze by firmly pressing their thumb against the hard palate just behind the upper incisors, or by energetically pressing the tip of the index finger in the corner between the upper lip and the nasal bridge. If the urge persists, anesthetics might be needed (historically).

 

Special Considerations: CSF Leak and Tamponade Techniques

In cases of epistaxis following trauma, especially head injury, the possibility of a cerebrospinal fluid (CSF) leak must be considered if the discharge is clear and watery, or if blood is mixed with clear fluid. This requires urgent neurosurgical evaluation.

Regarding tamponade, a well-executed anterior pack often stops most bleeding. Deep packing, if not done correctly by an experienced physician, can be traumatic. Some historical notes on tamponade techniques include:

• Bellocq's Tamponade (Posterior Pack): Considered burdensome and potentially dangerous, especially if the tampon size is inappropriate. A too-small tampon can be pushed further, causing pain; a too-large one can obstruct the other nostril and Eustachian tube, leading to complications like otitis media. It's typically reserved for posterior bleeding unresponsive to anterior packing, often after local surgery. Modern practice favors balloon catheters or specialized posterior packs over traditional Bellocq's tampons. If used, an elastic catheter or soft rubber tube is passed through the bleeding nasal cavity into the pharynx, grasped with forceps, and a prepared gauze tampon tied to it is pulled into the nasopharynx. Helping guide the tampon with a finger from the mouth and ensuring it's snug against the choana is advised. One thread from the tampon is brought out through the mouth and taped to the face to facilitate removal and relieve pressure on the soft palate. A protein-based tampon should not be left for more than 1-2 days due to decomposition and infection risk. Temperature monitoring can guide removal timing.
• Anterior Tamponade Technique: A conically rolled cotton wool or antiseptic gauze tampon is introduced into the bleeding zone, and the patient pinches the nostril. A nasal mirror and reflector can aid in placing a short tampon between the inferior concha and septum using nasal forceps. The infusion of even indifferent fluids into the nose during active bleeding is generally inappropriate as it can dislodge clots. Hemostatic dressings impregnated with special drugs (especially concentrated silver) can be harmful, causing necrosis and potential for pyemic embolism. Moistening swabs with hydrogen peroxide offers a good but short-term effect.
• Simple Tamponade for Nosebleeds: A gauze strip folded in several layers (preferably with a hemostatic agent) is inserted as deeply as possible without force along the nasal floor using forceps that grasp the tampon at its outer end, not along its entire length.

It's crucial to avoid inserting and pushing a long gauze strip forward until the nasal passage is filled, as the nose is open posteriorly, and the blood-soaked tampon can move into the pharynx, causing nausea and potentially re-bleeding.

Cauterization is performed only after bleeding has stopped; otherwise, the formed crust will be washed off. A loose cotton swab inserted after cauterization can protect the scab.

These measures can also be applied for bleeding due to bruising or blunt blows to the nose where the mucous membrane might rupture. Bleeding from neoplasms in the nasal cavity is rare; polyps, contrary to some beliefs, do not typically tend to bleed profusely unless traumatized.

 

Differential Diagnosis of Epistaxis

While often due to simple local causes, recurrent or severe epistaxis requires a thorough differential diagnosis:

Cause Category	Specific Examples	Key Differentiating Features
Local Factors (Nasal/Nasopharyngeal)	Digital trauma, dry mucosa, rhinitis/sinusitis, deviated septum, foreign body, nasal tumors (benign/malignant), hereditary hemorrhagic telangiectasia (HHT), septal perforation.	Often anterior bleeding (Kiesselbach's plexus), visible lesion on rhinoscopy/endoscopy. HHT shows characteristic telangiectasias. Tumors may cause unilateral obstruction, pain, or cranial nerve signs.
Systemic Factors	Hypertension, coagulopathies (hemophilia, von Willebrand disease, liver disease), platelet disorders (thrombocytopenia, ITP), leukemia, medications (anticoagulants, antiplatelets, NSAIDs), vitamin K or C deficiency, systemic infections (influenza, measles, scarlet fever).	May have bleeding from other sites, bruising, petechiae. Lab tests for coagulation and blood count are crucial. Blood pressure measurement.
Traumatic Factors	Facial fractures, nasal bone fractures, septal fractures, barotrauma.	Clear history of injury. Associated facial bruising, swelling, deformity. Possible CSF rhinorrhea with skull base fractures.
Environmental/Other Factors	Low humidity, high altitude, irritant exposure, vigorous nose blowing, vicarious menstruation.	History of exposure or specific circumstances.

 

Complications of Epistaxis and its Treatment

Potential complications include:

• Anemia: From chronic or severe blood loss.
• Hypovolemic Shock: In cases of massive, uncontrolled hemorrhage (rare).
• Aspiration of Blood: Can lead to respiratory issues.
• Complications of Nasal Packing:
  • Sinusitis or otitis media due to obstruction of drainage pathways.
  • Pressure necrosis of nasal mucosa or septum.
  • Toxic shock syndrome (rare, with prolonged packing).
  • Discomfort, pain, difficulty breathing.
  • Dislodgement of pack into the pharynx.
• Complications of Cauterization: Septal perforation, mucosal damage, crusting.
• Complications of Surgical Intervention or Embolization: Risks associated with anesthesia, infection, bleeding, stroke (rare with embolization), or specific procedural risks.

 

Prevention of Nosebleeds

Measures to prevent epistaxis include:

• Keeping nasal passages moist (humidifier, saline spray, petroleum jelly at nasal entrance).
• Avoiding vigorous nose picking or blowing.
• Treating underlying allergies or chronic rhinitis.
• Managing systemic conditions like hypertension or bleeding disorders.
• Using protective gear during contact sports to prevent nasal trauma.
• Caution with medications that can increase bleeding risk.

 

When to Seek Urgent Medical Attention

Seek immediate medical care if:

• Bleeding is heavy and does not stop after 15-20 minutes of direct pressure.
• Nosebleeds are recurrent and frequent.
• Bleeding is associated with symptoms like dizziness, weakness, fainting, or difficulty breathing.
• The nosebleed occurred after a significant head injury (possibility of skull fracture and CSF leak).
• The patient is on blood-thinning medication.
• There is suspicion of a foreign body in the nose.
• Blood is consistently flowing down the back of the throat despite anterior pressure (suggesting posterior bleed).

An ENT specialist should be consulted for recurrent or severe epistaxis to determine the underlying cause and provide appropriate management, which may include identifying and treating the specific bleeding point or addressing systemic factors.