Introduction

It is classified as anterior or posterior, depending upon the source of bleeding.

• Anterior haemorrhage - the source of bleeding is visible in about 90% of cases - usually from the nasal septum, particularly Kiesselbach's plexus (also called Little's area), which is an anastomotic network of vessels on the anterior portion of the nasal septum.^[1] These vessels are supplied by the internal and external carotid arteries. Bleeding can also arise from the inferior turbinate.
• Posterior haemorrhage - this emanates from deeper structures of the nose and occurs more commonly in older individuals.^[2] The area is supplied by the sphenopalatine artery and bleeding can arise in the posterior nasal cavity or the nasopharynx.

Epidemiology^[3]

Epistaxis is so common that almost everyone has had a nosebleed on at least several occasions, usually as a result of trauma. It has peaks of incidence at age 2-10 and 50-80 years old. Both sexes are equally affected. American studies calculate the incidence in the general population as being 60%, with less than 10% seeking medical attention.

Aetiology

Most causes are simple trauma, resolving without much ado and not sinister. Occasionally it indicates a more serious underlying disease. Often no cause is found.

• Trauma to the nose (the most common cause) - especially nose picking! Insertion of foreign bodies and excessive nose blowing may also be seen as trauma. The latter is likely to occur with a cold when the nasal mucosa is congested. Sinusitis causes nasal congestion.
• Disorders of platelet function - thrombocytopenia and other causes of abnormal platelets, including splenomegaly and leukaemia. Waldenström's macroglobulinaemia may present with nosebleeds. Idiopathic thrombocytopenic purpura (ITP) can occur in children and young adults.
• Drugs - aspirin and anticoagulants.
• Disorders of platelets are more likely to be a problem than clotting factor deficiency.
• Abnormalities of blood vessels in the elderly arteriosclerotic vessels prolong bleeding. Hereditary haemorrhagic telangiectasia (Osler-Rendu-Weber syndrome) cause recurrent epistaxis from nasal telangiectasiae.
• Malignancy of the nose may present with bleeding - juvenile angiofibroma is a highly vascular benign tumour that typically presents in adolescent males.
• Cocaine use - if the septum looks sloughed or atrophic ask about use of cocaine.^[4] The drug is usually taken by inhalation and it has a very strong vasoconstrictive effect that can lead to complete obliteration of the nasal septum.
• Other conditions - Wegener's granulomatosis and pyogenic granuloma can present as an epistaxis.

The association between hypertension and epistaxis is probably a myth. Although hypertension is common when patients present with acute bleeding,^[5] the incidence of undiagnosed hypertension found on follow-up is no higher than would be expected in the general population.^[6]

Investigation

• These are unnecessary in most (mild) cases but recurrent or severe cases require at least a full blood count, coagulation studies and blood typing.
• Quite marked anaemia can result but a haematological malignancy may also be revealed.
• Any suspicion of malignancy of the nose or other abnormality should require referral to an ENT surgeon. CT scanning and/or nasopharyngoscopy are the investigations of choice.^[3]

Management^[2]

• Initial assessment - First Aid
  • Maintain a calm attitude around the patient - but protect yourself - gloves, gown and goggles (the 3Gs).
  • Resuscitate the patient (if necessary) - remember the ABCD(E) of resuscitation.
  • Take a quick history:
    • Which nostril is bleeding? Is there blood the pharynx?
    • How much blood loss has there been? Are there symptoms of hypovolaemia?
    • Is the bleeding recurrent? What measures have been tried before?
    • Past medical history (eg recent trauma) and current medication (especially aspirin or warfarin).
  • Get the patient to sit upright, leaning slightly forward; and to squeeze the bottom part of the nose (NOT the bridge of the nose) for 10-20 minutes to try to stop the bleeding . The patient should breathe through the mouth and spit out any blood/saliva into a bowl. An ice pack on the bridge of the nose may help.
  • Monitor pulse and blood pressure.
  • If bleeding has stopped after this time (as it does in most cases) proceed to inspect the nose using a nasal speculum and consider cautery.
  • If the history is of severe and prolonged bleeding, get expert help - and watch carefully for signs of hypovolaemia.
• Nasal examination - collect the equipment you will need: lidocaine and phenylephrine spray, headtorch, suction, nasal speculum and silver nitrate cautery sticks.
  • Carefully examine the nasal cavity looking for any bleeding points - which can usually be seen on the anterior septum - either an oozing point or a visible clot. Is there any pus suggesting local bacterial infection?
  • Blowing the nose decreases the effects of local fibrinolysis and removes clots, permitting a clearer examination. Applying a vasoconstrictor before examination may reduce haemorrhage and help locate the bleeding site. A topical local anaesthetic reduces pain from examination and nasal packing. Lidocaine with adrenaline is usual.
  • Apply a silver nitrate cautery stick for 10 seconds or so, working from the edge and moving radially (see separate article Nasal Cautery) - never both sides of the septum at the same session. Cautery and cream (Naseptin®) are equally effective for the treatment of epistaxis. However the application of a cream-based treatment may initially be easier and more practical,^[7] particularly in children.
  • Patients can be discharged if there is no further active bleeding, ideally with an advice leaflet.
• If bleeding continues, consider packing:
  • Anterior packing (for anterior bleed):
    • A special nasal sponge or Merocel® tampon is quite easy to insert and fairly comfortable for the patient. As it absorbs blood it swells and the tight fit reduces flow. Lubricate the tampon with K-Y® Jelly or Naseptin® cream, advance the tampon horizontally all the way into the nose and secure the tampon thread. Pack the other side as well.^[2] Packs are generally left in place for 24 hours.
    • Otherwise use bismuth iodoform paraffin paste (BIPP) gauze or 1 cm ribbon gauze impregnated with petroleum jelly (Vaseline®) placed carefully and systematically along the floor and then up the vault of the nose. Both ends of the gauze should protrude from the nostril. This may be more effective but less simple and comfortable than the sponge.
    • Tape the string or ribbon to the cheek and apply a nasal bolster.
    • Anterior epistaxis is generally easy to control with local cautery.
  • Posterior bleeds (around 5%) require packing and a balloon catheter can be useful here.
    • Opiate analgesics to relieve discomfort and reduce elevated blood pressure due to posterior pack.
    • It may be necessary to ligate the sphenopalatine artery endoscopically,^[8] or occasionally the internal maxillary artery and ethmoid arteries, or perform endovascular embolisation of the internal maxillary artery, when packing fails to control a life-threatening haemorrhage.^[9] Ligation of the external carotid artery is a last resort.
• Complications of packing
  • Anosmia
  • Pack falling out and continued bleeding
  • Breathing difficulties and aspiration of clots
  • Posterior migration of the pack causing airway obstruction and asphyxia
  • Perforation of the nasal septum or pressure necrosis of cartilage

• Nasal packs are usually left for 2 or 3 days and the patient should see an ENT specialist. The blood is an excellent culture medium for bacteria and so broad spectrum antibiotics like amoxicillin are usually given.
  
  
• Suture of bleeding vessels in Little's area is an option in refractory anterior epistaxis.^[10]

Prognosis^[3]

Mortality is rare. It is usually associated with hypovolaemia secondary to severe bleeding or in patients with co-morbidities. Most epistaxis resolves spontaneously, normally without treatment. Morbidity often due to the complications of packing.