WHAT IS EPISTAXIS (NOSEBLEED)
Epistaxis (medical name for nosebleed) refers to blood coming out from the tissue that lines the inside of the nose.
Though more commonly one nostril is affected, it can simultaneously occur from both nostrils. The small blood vessels (capillaries) inside the nose help warm and moisten the air that we breathe, but they can rupture easily due to even mild trauma.
Most nosebleeds are minor and go away with home care. Severe bleeding or the presence of symptoms (like vomiting, breathlessness) would need timely medical consultation. However, epistaxis is almost never fatal.
TYPES
There are two main types of nosebleeds, depending on the site of the bleed – front or back of the nose.
Anterior nosebleed
An anterior nosebleed starts in the front of the nose on the lower part of the wall that separates the two sides of the nose (septum). This bleed is from the fragile capillaries in the front area of the nose and is the most common type of epistaxis. It usually isn’t serious and is managed with home remedies.
Posterior nosebleed
A posterior nosebleed occurs deep inside the nose from a larger blood vessel located near the throat. It can result in heavy bleeding, which may flow down the back of the throat. This may also cause nausea, throat irritation, bad taste, and blood in the cough or vomit. This needs immediate medical attention.
CAUSES
DRY AIR – It is the most common cause of nosebleeds as dry air causes the delicate nasal lining to dry out and become crusty or cracked, and therefore more likely to bleed when rubbed, picked, or during sneezing or blowing the nose. Dry air is seen more commonly in-
- Hot, low-humidity climates
- Areas at high altitudes
- Heated indoor spaces
- Smoking
TRAUMA – Even minor trauma can cause the fragile capillaries of the nasal lining to rupture, such as picking the nose with sharp nails, inserting an object in the nose, injury to the face, or hard blowing of the nose. Nasal trauma can also occur due to the use of recreational drugs as snuffs, and breathing in chemicals, fumes, or other strong odors.
INFECTIONS OR ALLERGIES – Having an upper respiratory infection (cold or cough), or a sinus infection, increases trauma to the fragile blood vessels due to frequent sneezing, blowing the nose, coughing, and use of sprays/inhalers. The infection or allergy itself causes inflammation of the nose lining, which makes the blood vessels more susceptible to rupture. Antihistamine and decongestant medicines, especially as sprays, dry out the nasal lining and increase the risk of capillary rupture and nosebleeds.
ABNORMALITIES IN THE NOSE – Conditions like deviated nasal septum (DNS) and the presence of polyps or tumors in the nose should be ruled out, especially in repeated and frequent nosebleeds.
INCREASED BLEEDING RISK – This is seen in patients who take blood-thinning medications or have bleeding disorders, like haemophilia or von Willebrand disease, thrombocytopenia (platelet deficiency), leukaemia, or hereditary telangiectasia (small, fragile, dilated blood vessels that easily rupture).
OTHER RISK FACTORS: High blood pressure, plaques in blood vessels (atherosclerosis), pregnancy, too much alcohol intake, vitamin C deficiency, and facial or nasal surgery are other risk factors for nosebleeds. Sleeping with the head to one side may rarely put direct pressure on the nose and cause epistaxis at night.
Generally, children and adults >50 years have a higher risk of epistaxis; however, anyone can have a nosebleed anytime, and 60% of the population has epistaxis at some point.
RED FLAG SIGNS
Although seeing blood coming out of the nose can be alarming, most nosebleeds aren’t serious. And can be managed at home. Medical consultation should be sought if:
- Nosebleeds are frequent.
- Bleeding is significant, a lot of fresh blood is coming spontaneously out (like more than a small cup).
- Bleeding not stopping after more than 15 to 20 minutes of pinching the nose.
- Both nostrils are bleeding out simultaneously.
- Nosebleed follows the starting a new medication.
- There are symptoms like vomiting, headache, dizziness, or breathlessness.
- There is accompanying unusual bruising or bleeding in other parts of the body.
- History of severe facial or head injury/trauma.
- There are symptoms suggesting anemia (feeling weak, faint, tired, cold, breathless or having pale skin).
- Family history of bleeding disorders.
CSF rhinorrhoea (cerebrospinal fluid leakage from the nose) refers to a medical condition where the protective fluid surrounding the brain and spinal cord leaks through a defect in the skull and out of the nose. It is a serious condition because it provides a passage for life-threatening infections like meningitis. It usually occurs due to a massive head or face injury, or sometimes after sinus-surgery or neurosurgery. Usually, the fluid is clear, watery, or slightly straw-colored as opposed to the red blood of epistaxis, but sometimes the CSF may contain blood, making the diagnosis challenging.
MANAGEMENT
An ENT expert will determine the source of the bleeding by the use of a small speculum to hold the nostril open and an endoscope (lighted scope) to see inside the nasal passages. Blood tests to check for hemoglobin, complete blood counts including platelets, and other general functions may be recommended. Occasionally, imaging by X-rays or a CT scan may be needed.
Blood pressure should be checked and kept in control. A re-evaluation of blood thinner medication if being taken would be required in some cases.
CSF rhinorrhea with blood can be differentiated from epistaxis as the former leaves no stiffness or crusting when dry on a tissue, while epistaxis blood dries into a stiff, crusty scab. CSF rhinorrhea characteristically increases when leaning forward, coughing, or straining and may be accompanied by headache that changes with posture, hearing changes, and dizziness. Lab tests will reveal high glucose in CSF, which is absent in nosebleeds.
Home
Minor nose bleeds can be managed at home. One should be calm, breathe through the mouth, and sit up straight with the head slightly forward. Keep a damp cloth for the blood, and use the thumb and index finger to pinch the soft sides of the nose till the bleeding stops.
Hard or aggressive blowing of the nose should be avoided. Sneezing with an open mouth covered by the elbow or a handkerchief is less traumatic to the nasal capillaries.
For a dry nose, saline nasal drops or gels, can be useful to prevent nosebleeds.. Humidifiers in a dry climate are also useful. OTC drops for short-term use in epistaxis include decongestant and vasoconstricting drops (oxymetazoline, xylometazoline, phenylephrine).
One should drink plenty of fluids after a nosebleed. Good options include water, natural juices, and other non-caffeinated liquids.
Hospital/Clinic
More severe bleeds presenting in the hospital may be managed by:
- Medicines. A combination of local anaesthetic and vasoconstrictor (lidocaine-epinephrine) or tranexamic acid applied as cotton balls or a nasal sponge may be used in the nose.
- Nasal packing. The doctor inserts gauze, special nasal sponges or foam, or an inflatable latex balloon into the nose to create pressure at the site of the bleed. This is removed after 24 to 48 hours.
- Sealants. The doctor may use a sealing (clotting) agent like thrombin or fibrin.
- Cauterization. This procedure involves applying a chemical substance (silver nitrate) or heat energy (electrocautery) to seal the bleeding blood vessel under a local anaesthetic.
- Ligation. In this procedure, the ENT expert ties off the culprit blood vessel to stop the bleeding.
- Foreign body removal. If the cause of the nosebleed is a foreign object, the doctor will remove it.
- Surgery. This may be needed to repair a broken nose or correct a deviated septum (septoplasty).
Reference: Epistaxis Education
Also read:
Common Cold and Flu- Know the difference, effective care and 10 alert signs