Epistaxis overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amir Behzad Bagheri, M.D., Liudvikas Jagminas, M.D., FACEP [2] José Eduardo Riceto Loyola Junior, M.D.[3]
Overview
Epistaxis is the relatively common occurrence of hemorrhage (bleeding) from the nose, usually noticed when it drains out through the nostrils. There are two types: anterior (the most common), and posterior (less common, and more severe). Sometimes in more severe cases, the blood can come up the nasolacrimal duct and out from the eye. Fresh blood and clotted blood can also flow down into the stomach and cause nausea and vomiting.
Historical Perspective
In past centuries, people thought epistaxis happened due to internal diseases. As the medical knowledge advanced, people found out that nasal compression can stop bleeding. Hippocrates was the first one who used some instruments to stop nasal bleeding. The term epistaxis was originally derived from the Greek word epistazein (epi – above, over; stazein – to drip).
Classification
Epistaxis may be classified according to the anatomical origin of the bleeding into 2 groups: anterior and posterior. It can also be further classified into primary (if idiopathic) or secondary (if there is a known cause) and acute or chronic.
Pathophysiology
Nosebleeding happen due to tears in the mucosal lining and the many small blood vessels it contains. Fragility or injury may cause tears, while inflammation, coagulation problems, and other disorders may make the injury harder to repair. In some patients rupture of nasal blood vessels is spontaneous.
Causes
The causes of epistaxis can be divided into idiopathic and non-idiopathic ones. There are many diseases can cause epistaxis, it can start spontaneous either. Usually epistaxis is not dangerous but in some cases it can become life threatening. Trauma is the most common cause of epistaxis. besides it, medications and idiopathic epistaxis are other common causes of epistaxis.
Differentiating Epistaxis from other Diseases
Many diseases can cause epistaxis. Based on patient history and physical examination we can diagnose cause of epistaxis. The challenging part is differentiate anterior epistaxis from posterior epistaxis. Rhinoscopy is the best way to distinguish between anterior and posterior epistaxis. In selected cases, endoscopy may be required.
Epidemiology and demographics
Epistaxis is a prevalent symptom worldwide. About 60 percent of people experience epistaxis at least once, and about 6 percent of these people look for medical action at least once. It is more common in children and elderly patients
Risk Factors
The most common risk factor of epistaxis in trauma. Other risk factors include coagulopathies, infections and vascular abnormalities. It can occur spontaneously. Childhood and senility are unchangeable risk factors.
Screening
No screening is indicated for epistaxis in asymptomatic patients.
Natural History, Complications, and Prognosis
Although epistaxis often ceases easily, it can become challenging to stop especially in posterior epistaxis which can cause aspiration. Most of the time bleeding stops without any intervention.Prognosis is generally good, and mortality is very rare.
Diagnostic study of choice
The diagnostic study of choice to find the source of epistaxis is rhinoscopy. In patients which rhinoscopy is not able to find the source vessel of bleeding, internal carotid artery (ICA) angiography is the preferred diagnostic study to find the bleeding site.
History and Symptoms
History of trauma, especially nose picking for anterior epistaxis, previous epistaxis and coagulopathies are in top list. Dizziness and fainting can be symptoms of epistaxis in case of heavy bleeding.
Physical Examination
Patients with epistaxis are usually well-appearing. Physical examination of patients with epistaxis is usually remarkable for bleeding from nostrils and posterior nose bleeding.
Laboratory Findings
Laboratory findings is usually normal among patients with epistaxis, but when bleeding is heavy or physician is suspicious to coagulopathy, The following tests should be performed: CBC, PT, PTT, BT.
ECG
There are no ECG findings associated with epistaxis.
X-ray
There are no X-ray findings associated with epistaxis.
Echocardiography and Ultrasound
There are no echocardiographic or ultrasonographic findings associated with epistaxis.
CT Scan
Paranasal sinuses CT scan is helpful in diagnosis causes of epistaxis, when the cause is unknown, also when epistaxis is heavy and/or recurrent.
Other Imaging Findings
Rhinoscopy and nasal endoscopy may be helpful in the diagnosis of epistaxis. It can help assessing the source of bleeding, distinguishing between anterior and posterior epistaxis, and also help in the treatment.
Other Diagnostic Studies
Bone marrow biopsy is another diagnostic study to find cause of epistaxis a cause like leukemia is suspected.
Medical Therapy
The majority of cases of epistaxis] are self-limited and require only supportive care. If there is active bleeding, compression of the nostrils is the first measure to stop bleeding. If bleeding continues despite this, ice application and nasal packing are possible measures to control bleeding. There are other options like cautery and some vasoconstrictive agents like oxymetazoline or phenylephrine to control bleeding.
Surgery
Surgery is not the first-line treatment option for patients with epistaxis. Surgery is usually reserved for patients with either heavy active bleeding, recurrent epistaxis and non-compliant medical therapy.
Primary Prevention
Effective measures for the primary prevention of epistaxis include cooler house and a vaporizer, nasal saline spray, and water soluble jelly can be helpful, especially during winter months.
Secondary Prevention
The primary and secondary prevention strategies for epistaxis are the same.
Cost-effectiveness of Therapy
Most of the patients with epistaxis don't need any medical procedure. Nasal compression is the best first option to stop bleeding. 95.5% of patients with epistaxis who attend emergency departments were discharged, patients were charged on average $1146.21 per visit.