Makindo Medical Notes

Related Subjects: |Assessing Hearing Loss |Benign Paroxysmal Positional Vertigo (BPPV) |Cholesteatoma |Epistaxis (Nosebleeds) |Acute Mastoiditis |Nasal polyps |Acute Sinusitis |Sudden Sensorineural Hearing loss (SNHL) |Causes of Vertigo

The blood supply of the nose is vulnerable to bleeding and damage as it lies very superficial. The role of the nose and its vasculature is to both humidify and warm the incoming air, which it does remarkably well...at a price that is a vulnerability to excessive bleeding. Do not underestimate the blood loss from epistaxis.

About

• Epistaxis is bleeding from the nose, caused by damage to the blood vessels of the nasal mucosa.
• Usually mild and inconsequential but in rare cases potentially life-threatening.
• Patients can have significant bleeding which is occult as the patient swallows the blood.
• Treat epistaxis seriously and keep a watch for signs of haemodynamic compromise - tachycardia, postural hypotension, etc.

Anatomy

Aetiology

• 90% of nosebleeds originate from Kiesselbach's plexus (Little's area), which lies quite anterior.
• Posterior bleeds are rarer but more difficult to treat and arise from Woodruff's plexus.
• Severe bleeding may be arterial from the sphenopalatine artery.
• Management is more difficult as it is not directly compressible, more common in the elderly, and tends to be more severe.

Risk Factors

• Hypertension, Bleeding disorders, anticoagulants.
• Previous epistaxis/cautery, recent nose trauma.
• Recent upper respiratory tract infection, Nasal foreign body.
• Cocaine use, Nose picking.
• Atherosclerosis, increased venous pressure from mitral stenosis.
• Haem disorders (thrombocytopenia, leukaemia, and haemophilia).
• Excessive alcohol consumption.

Clinical

• Enquire about a personal or family history of bleeding disorders - haemophilia, Von Willebrand's disease, Osler Weber Rendu syndrome, Thrombocytopenia.
• Ask about the use of Warfarin, Aspirin, Clopidogrel, NSAIDs.

Investigations

• Check FBC, U&E, and Coagulation screen if coagulopathy is suspected or the patient is on warfarin or heparin.
• Consider Group and Save and Cross-matching if severe bleeding.

Complications of Epistaxis

• Rare complications include hypovolaemia, anaemia, and even shock.
• Also complications from nasal packing treatment.

Management

• ABC: Significant blood loss, which may be occult, should warrant urgent IV access and blood taken for group and save. Monitor Clinical Signs.
• Most Epistaxis settles with direct pressure such as pinching the tip of the nose for 10-15 minutes with the patient sitting forward. If the person is haemodynamically compromised, manage as an emergency and arrange immediate transfer to Accident and Emergency.
• If a posterior bleed is suspected (bleeding is profuse, from both nostrils, and the bleeding site cannot be identified on examination), hospital admission is recommended.
• If bleeding stops with first-aid measures, a topical antiseptic such as Naseptin® (chlorhexidine and neomycin) cream may be applied to prevent re-bleeding.
• If bleeding persists after 10–15 minutes of adequate pressure, nasal cautery or packing may be necessary if expertise is available in primary care; otherwise, transfer to A&E.
• Remove any clot and apply adrenaline (1:1000) soaked pledget with lidocaine as a topical anaesthetic.
• Attempt cautery with silver nitrate sticks; use nasal packing for anterior bleeds and saline-filled Foley catheter with antibiotics for posterior bleeds. Avoid nose blowing/picking for a week.
• Avoid Aspirin/NSAIDs/Anticoagulants—seek expert advice if uncertain.

General

• If first-aid or nasal cautery in primary care stops the bleeding, advise self-care measures. Avoid activities for 24 hours that could risk re-bleeding, like blowing/picking the nose, heavy lifting, strenuous exercise, lying flat, or drinking alcohol or hot drinks.
• Advise that if bleeding restarts and does not respond to first-aid measures, they should seek urgent medical advice.

Notes on Nasal Cautery

• Consider nasal cautery if first aid fails, and the expertise and facilities (good lighting, topical anaesthetic spray, and nasal speculum) are available.
• Before cautery: Clear clots and apply a topical anaesthetic with a vasoconstrictor (such as lidocaine with phenylephrine). Wait 3–4 minutes for effect.
• To cauterize: Identify the bleeding point — usually a small red dot. Lightly apply the silver nitrate stick to this point for 3–10 seconds until a grey-white color develops.
• Only cauterize one side of the septum to avoid nasal septal perforation.
• After cautery, apply Naseptin® cream to prevent infection.

Notes on Nasal Packing

• Consider if cautery is ineffective or the bleeding point is not visible. Use a local anaesthetic with a vasoconstrictor before packing.
• Use nasal tampons (Merocel®) or inflatable packs (Rapid-Rhino®) according to instructions. Have the patient sit with head forward while packing.
• Ensure the pack is secure and not pressing on the nasal cartilage to prevent cosmetic defects. If there’s bleeding in the oropharynx, consider packing the other nostril.
• Admit to hospital, ideally in an ENT department, for observation.

Algorithms

References

• Epistaxis management