Background

Epistaxis is commonly referred to as nosebleed which is the result of nasal tube bleeding. This condition can vary in severity from a mild irritation to a more critical medical concern.  

Nosebleeds are frequently caused by trauma to the nasal cavity, such as a blow to the nose. specifically in the winter, and hot. The dry indoor air can cause dry nasal membranes and is responsible in increasing chances of bleeding. 

Nasal bleeds may result from irritations such as smoking, harsh smells, or chemical fumes. Bleeding can occur from an infection, such as sinusitis. 

Nasal sprays that contain decongestants should not be used for an extended period as they may cause nosebleeds. 

Epidemiology

Many people with the disorder will at some point in their life experience nose bleeding. This incidence is seen more in children and older individuals. 

The hormonal changes and imbalance that occur throughout puberty may contribute to gender variations in nosebleeds. 

It is expected that epistaxis will increase with age in specific area because of dry nasal mucosa and the existence of underlying medical disorders. 

Anatomy

Pathophysiology

The nasal mucosa is more prone to bleeding when it is dry and inflamed. This happens when there is low humidity like in winters, or when someone use decongestant nasal sprays. 

The nasal tissues may undergo structural changes because of persistent inflammation, enhancing the possibility of epistaxis. 

Bleeding may result from disrupted crust formation due to dry mucosa. Nasal mucosal inflammation may show inflammatory diseases like sinusitis or rhinitis. 

Etiology

Exposure to allergens such as chemical fumes, tobacco smoke, or strong smell that can irritate the nasal mucosa hence causing inflammation and making nosebleeds more likely. 

The nasal mucosa may become inflamed because of nasal infections. Vascular tissue may settle of this inflammation. 

Irritation and damage can result from foreign items in the nasal passages. This is mostly seen in children who may insert small objects into their noses. 

Genetics

Prognostic Factors

Uncontrolled hypertension is a potential prognostic factor. High blood pressure can contribute to the rupture of small blood vessels in the nasal mucosa. 

Age can be a prognostic factor, with older individuals potentially experiencing more severe or recurrent epistaxis. Aging is responsible for change in the fragility of blood vessels in the nasal mucosa. 

Structural abnormalities, including a deviated septum, nasal polyps, or other anatomical variations can impact the presence of nosebleeds. 

Individuals with bleeding disorders, impaired clotting mechanisms, or taking anticoagulant medications may have a higher risk of persistent or recurrent epistaxis. 

Clinical History

Age Group:  

Nosebleeds are relatively common in children. Epistaxis can occur in adults of all ages.  

Adolescents may also experience nosebleeds, and the risk may be influenced by factors such as hormonal changes during puberty, environmental factors, and the presence of underlying conditions. 

Associated Comorbidity or Activity:   

Structural abnormalities in the blood vessels of the nasal cavity, such as arteriovenous malformations, may contribute to recurrent or severe epistaxis. 

Liver diseases that impact the synthesis of clotting factors can contribute to bleeding disorders and an increased risk of nosebleeds. Chronic inflammation of the sinuses can lead to nasal congestion, irritation, and an increased likelihood of nosebleeds. 

Infections of the nasal passages, such as bacterial or viral sinusitis, can cause inflammation and make the nasal mucosa more susceptible to bleeding. 

The use of anticoagulant medications, antiplatelet agents, or other drugs that affect blood clotting can increase the risk of nosebleeds. 

Acuity of Presentation:  

Acute nosebleeds can be characterized by a rapid and significant flow of blood from one or both nostrils. 

Acute epistaxis refers to a sudden and immediate onset of nose bleeding. It can occur spontaneously or may be triggered by trauma, such as a blow to the nose. 

Chronic epistaxis involves recurrent or persistent nosebleeds over an extended period. The bleeding may be less severe than in acute cases but can be a persistent issue. 

Physical Examination

• Focused Nasal Examination: Determine whether the bleeding is anterior or posterior. Posterior bleeding, from deeper vessels, may require more advanced interventions. 
• Anatomical Abnormalities: Assess for any structural abnormalities, such as a deviated septum, nasal polyps, or tumors, which may contribute to recurrent nosebleeds. 
• Vital Signs: Measure vital signs, including blood pressure, heart rate, and respiratory rate, especially in cases of significant bleeding to assess the patient’s overall condition. 
• Blood Coagulation Studies: Consider ordering blood coagulation studies, especially if the patient has a history of bleeding disorders or is taking anticoagulant medications. 
• Allergy Assessment: Evaluate for allergies, as individuals with allergic rhinitis may be more prone to nosebleeds due to nasal congestion and frequent rubbing or blowing of the nose. 
• Assessment of Bleeding Severity: Determine the severity of bleeding, considering factors such as the duration, amount of blood loss, and impact on the patient’s overall well-being. 

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

• Nasal Infections: Infections, including viral or bacterial sinusitis, can cause inflammation and lead to nosebleeds. 
• Nasal Allergies: Allergic rhinitis can result in nasal congestion and frequent rubbing or blowing of the nose, increasing the risk of epistaxis. 
• Vascular Abnormalities: Arteriovenous malformations or other vascular abnormalities in the nasal region can lead to recurrent or severe nosebleeds. 
• Systemic Diseases: Systemic conditions such as lupus or granulomatosis with polyangiitis can affect blood vessels and contribute to nosebleeds. 
• Bleeding Disorders: Conditions such as hemophilia or von Willebrand disease may lead to easy bruising and recurrent nosebleeds. 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

• Local Measures: Apply direct pressure to the nostrils by pinching them together for at least 10 to 15 minutes. This is often effective in stopping anterior nosebleeds. 
• Ice Packs: Applying an ice pack to the nose or the back of the neck may help constrict blood vessels and reduce bleeding. 
• Nasal Packing: If bleeding persists or is recurrent, nasal packing may be necessary. This involves inserting gauze or sponge into the nasal cavity to apply pressure to the bleeding vessels. 
• Cauterization: Cauterization involves the application of heat or chemicals to seal the bleeding blood vessels. This can be done using silver nitrate or electrocautery. 
• Nasal Endoscopy: In cases of persistent or recurrent epistaxis, nasal endoscopy may be performed to visualize the nasal cavity more thoroughly.  

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

use-of-non-pharmacological-approach-for-epistaxis

• Use Humidifiers: Install humidifiers in living spaces, especially during the winter months when indoor heating systems can lead to dry air. 
• Maintain Adequate Humidity: Aim to keep indoor humidity levels between 30% and 50%. This helps prevent the air from becoming excessively dry, reducing the risk of nasal dryness and bleeding. 
• Stay Hydrated: Ensure proper hydration by drinking an adequate amount of water throughout the day. Hydration helps maintain the moisture levels in the body, including the nasal mucosa. 
• Apply Nasal Ointments or Gels: Use nasal ointments or gels containing petroleum jelly or other moisturizing agents. These products can help retain moisture in the nasal mucosa. 
• Avoid Irritants: Identify and minimize exposure to environmental irritants such as tobacco smoke, strong odors, and chemical fumes.  
• Protect the Nose in Harsh Weather: During cold or windy weather, consider using a scarf or other protective clothing to shield the nose from harsh environmental conditions. 

Role of Topical Ointments

• Bacitracin: It has antibiotic properties and is effective against certain bacteria.  

If a nosebleed is associated with an open wound or an irritated nasal mucosa that is at risk of infection, applying bacitracin may help prevent or treat bacterial infections.

Role of Antibiotics

Amoxicillin: It is an antibiotic used to treat bacterial infections. Epistaxis is typically associated with factors such as nasal irritation, dryness, trauma, or underlying medical conditions, and bacterial infections are not the primary cause of most cases of nosebleeds. 

Role of Topical vasoconstrictors

• Oxymetazoline: It is a vasoconstrictor which causes blood vessels to narrow. By constricting blood vessels in the nasal mucosa, it reduces blood flow and help control bleeding.
• When applied directly to the nasal passages, it acts locally to reduce congestion and may contribute to the cessation of bleeding in cases of anterior epistaxis. 

use-of-intervention-with-a-procedure-in-treating-epistaxis

• Nasal Packing: Anterior Packing: Involves placing absorbent material in the anterior part of the nasal cavity to apply direct pressure to the bleeding vessels.  
• Balloon Catheter: Inflatable balloon catheters can be used to apply pressure to the bleeding vessels and control the bleeding. These are often used in cases of posterior epistaxis. 
• Nasal Endoscopy: It helps identify the source of bleeding, structural abnormalities, or lesions that may require intervention. 
• Ligation of Blood Vessels: In cases where bleeding is localized to specific blood vessels, ligation of those vessels may be considered.  

• Angiographic Embolization: In more severe cases or when other interventions are ineffective, angiographic embolization may be recommended.  

use-of-phases-in-managing-epistaxis

• Immediate Home Care: When a nosebleed occurs, the initial phase involves immediate home care. The individual should lean forward to prevent blood from flowing down the throat, pinch the nostrils together, and apply direct pressure to the soft part of the nose for at least 10 to 15 minutes. 
• Medical Evaluation and Treatment: If the nosebleed is severe, recurrent, or not controlled by initial measures, seeking medical evaluation is essential.  
• Ligation of Blood Vessels: Surgical ligation may be considered for localized bleeding from specific blood vessels. 
• Angiographic Embolization: In severe cases, angiographic embolization may be performed to block blood vessels and control bleeding. 
• Management of Underlying Conditions: Addressing and managing underlying conditions, such as hypertension, bleeding disorders, or nasal abnormalities, is crucial for preventing recurrent nosebleeds. 

Medication

Future Trends

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References

Epistaxis – StatPearls – NCBI Bookshelf (nih.gov) 

Epistaxis: What Is It, Types, Causes, Prevention, Treatment, and More | Osmosis