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]
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
All nosebleeds are 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 rapture 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 in general populations worldwide. About 60 percent of people experience epistaxis at least once, and about 6 percent of these people looking 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 spontaneous either. 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 stops easily, it can become challenging to stop specially in posterior epistaxis which can cause aspiration. Most of the time bleeding stops without any action .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 efficient to find the source vessel of bleeding, internal carotid artery (ICA) angiography is the most efficient action 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.
Diagnosis
Epistaxis has different causes and based on medical history, family history, and physical examination we can find the cause Rhinoscopy is the first option to find the location of bleeding..[1] [2] [3]
- Trauma is the most cause of epistaxis.
Treatment
- Nasal compression for more than 5 minutes is the first action to stop active nose bleeding.[1] [2] [3] [4] [5]
- Rhinoscopy should be performed to find the bleeding site. Lubricants, Topical vasoconstrictors, Nasal cautery are options after finding the bleeding site.
- Nasal packing is used when we couldn't find the bleeding site or when we couldn't stop bleeding with other actions:
- Absorbale packing is preferred in patients with HTT or on anticoagulants and in children.
- Non-absorbable packing is the other option that can be used for other patients.
- In patients on anticoagulant medications, we should evaluate the need for or risk of discontinuation Anti-Coag/Anti-Platelet medications.
Surgery
Embolization and surgical arterial ligation are the last options to stop epistaxis in patients which other actions didn't work.[1] [3]
Primary Prevention
Avoid Nose-picking and using lubricants and nasal saline spray can decrease possibility of epistaxis.[1] [4]
References
- ↑ 1.0 1.1 1.2 1.3 Krulewitz, Neil Alexander; Fix, Megan Leigh (2019). "Epistaxis". Emergency Medicine Clinics of North America. 37 (1): 29–39. doi:10.1016/j.emc.2018.09.005. ISSN 0733-8627.
- ↑ 2.0 2.1 Tunkel, David E.; Anne, Samantha; Payne, Spencer C.; Ishman, Stacey L.; Rosenfeld, Richard M.; Abramson, Peter J.; Alikhaani, Jacqueline D.; Benoit, Margo McKenna; Bercovitz, Rachel S.; Brown, Michael D.; Chernobilsky, Boris; Feldstein, David A.; Hackell, Jesse M.; Holbrook, Eric H.; Holdsworth, Sarah M.; Lin, Kenneth W.; Lind, Meredith Merz; Poetker, David M.; Riley, Charles A.; Schneider, John S.; Seidman, Michael D.; Vadlamudi, Venu; Valdez, Tulio A.; Nnacheta, Lorraine C.; Monjur, Taskin M. (2020). "Clinical Practice Guideline: Nosebleed (Epistaxis)". Otolaryngology–Head and Neck Surgery. 162 (1_suppl): S1–S38. doi:10.1177/0194599819890327. ISSN 0194-5998.
- ↑ 3.0 3.1 3.2 Thornton, M A.; Mahesh, B N.; Lang, J (2005). "Posterior Epistaxis: Identification of Common Bleeding Sites". The Laryngoscope. 115 (4): 588–590. doi:10.1097/01.mlg.0000161365.96685.6c. ISSN 0023-852X.
- ↑ 4.0 4.1 Chaaban, Mohamad R.; Zhang, Dong; Resto, Vicente; Goodwin, James S. (2016). "Demographic, Seasonal, and Geographic Differences in Emergency Department Visits for Epistaxis". Otolaryngology–Head and Neck Surgery. 156 (1): 81–86. doi:10.1177/0194599816667295. ISSN 0194-5998.
- ↑ Viehweg, Tate L.; Roberson, John B.; Hudson, J.W. (2006). "Epistaxis: Diagnosis and Treatment". Journal of Oral and Maxillofacial Surgery. 64 (3): 511–518. doi:10.1016/j.joms.2005.11.031. ISSN 0278-2391.