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epistaxis (nose bleed)

Generally a benign condition related to disruption of Kiesselbach's plexus. Etiology: 1) trauma a) self-inflicted - digital manipulation - vigorous blowing - vigorous wiping b) septal perforation c) external nasal trauma 2) inflammation a) rhinitis b) sinusitis 3) infection a) bacterial infection - Salmonella typhi - Corynebacterium diphtheriae - Bordetella pertussis b) parasitic infection 4) vascular disorders a) Osler-Weber-Rendu syndrome (hereditary hemorrhagic telangiectasia) b) ANCA-associated vasculitis - Wegener's granulomatosis - Churg-Strauss syndrome 5) coagulation disorders a) iatrogenic - coumadin - aspirin - heparin - non-steroidal anti-inflammatory drugs b) coagulation factor deficiency - hemophilia - hepatic failure - vitamin K deficiency c) blood dyscrasia - immune thrombocytopenic purpura (ITP) - leukemia - polycythemia d) disseminated intravascular coagulation (DIC) 6) tumors a) benign tumors - hemangioma - juvenile nasopharyngeal angiofibroma - meningioma b) cancer - squamous cell carcinoma - adenocarcinoma - lymphoma - olfactory neuroblastoma 7) miscellaneous disorders a) decreased environmental humidity b) atrophic rhinitis b) vicarious menstruation d) chemical irritation e) septal deformity f) hypertension is a risk factor [6] Pathology: - 90% arise in the anterior nasal septum - posterior epistaxis more likely to result in serious hemorrage Clinical manifestations: - visible blood in the oropharynx does not confirm posterior epistaxis Laboratory: 1) minor & not recurrent problem - no laboratory testing indicated 2) refractory or recurrent epistaxis a) complete blood count (CBC) b) bleeding time c) prothrombin time (PT) & partial thromboplastin time (PTT) Special laboratory: - nasal endoscopy for recurrent epistaxis [3] Management: 1) general considerations/strategy a) most episodes are self limited - anterior nasal packing for severe acute epistaxis in anticoagulated patient [9] b) clear nose of blood & clot with suction c) compress with direct pressure to the nasal septal area for at least 5 minutes [5] (15-20 minutes) d) apply topical vasoconstricting agent & anesthetic for 5-10 minutes if direct pressure is unsuccessful - 4% cocaine (vasoconstriction & anesthesia) - oxymetazoline - cotton ball soaked in phenylephrine 1%/lidocaine 4% e) NosebleedQR applied to bleeding nasal mucosa f) nasal packing for persistent epistaxis despite compression [5] - use resorbable packing if anticoagulant or antiplatelet agent - anterior nasal packing for severe acute epistaxis in anticoagulated patient [9] g) anterior rhinoscopy to identify the source of the bleeding after removing blood clots h) nasal endoscopy for recurrent bleeding i) topical vasoconstrictors, nasal cautery, or moisturizing or lubricating agents after bleeding site identified [5] 2) anterior epistaxis a) anterior nasal packing for severe acute epistaxis in anticoagulated patient [9] b) cauterize with diathermy if general strategy unsuccessful - do not cauterize both sides of the nasal septum, this may lead to septal perforation c) pack nose unilaterally if unsuccessful d) pack nose bilaterally with gauze if unsuccessful e) topical application of tranexamic acid (for injection) more effective than anterior nasal packing [4] f) surgical intervention if unsuccessful 3) posterior epistaxis a) admit patient to hospital if compression & vasoconstriction unsuccessful b) pack nose unilaterally if unsuccessful c) consider diathermy with endoscopic guidance d) pack nose unilaterally with balloon catheter - foley catheter # 12 or 13 french with 30 mL balloon e) intervene surgically - cauterize, arterial ligation, endovascular embolization 4) premarin vaginal cream may be useful [2] 5) discharge instructions a) vasoconstricting sprays for 2-3 days - phenylephrine spray - oxymetazoline b) do not blow wipe or pick nose c) no heavy lifting, straining, or exertion d) saline nasal sprays PRN e) humidified environment

General

mucosal bleeding

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 46-48
  2. Prescriber's Letter 13(10): 2006 Alternative or 'Off-label' Routes of Drug Administration Detail-Document#: 221012 (subscription needed) http://www.prescribersletter.com
  3. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 18. American College of Physicians, Philadelphia 2009, 2012, 2018. - Schlosser RJ. Clinical practice. Epistaxis. N Engl J Med. 2009 Feb 19;360(8):784-9 PMID: 19228621
  4. Zahed R, Mousavi Jazayeri MH et al Topical Tranexamic Acid Compared With Anterior Nasal Packing for Treatment of Epistaxis in Patients Taking Antiplatelet Drugs: Randomized Controlled Trial. Acad Emerg Med. 2017 Nov 10. PMID: 29125679
  5. Tunkel DE, Anne S, Payne SC et al Clinical Practice Guideline: Nosebleed (Epistaxis) Executive Summary Otolaryngology. Hea & Neck Surgery, Jan 7, 2020 PMID: 31910122 https://journals.sagepub.com/doi/full/10.1177/0194599819889955 - Tunkel DE, Anne S, Payne SC Clinical Practice Guideline: Nosebleed (Epistaxis). Otolaryngol Head Neck Surg. 2020 Jan;162(1_suppl):S1-S38. PMID: 31910111 - Tunkel DE, Holdsworth SM, Alikhaani JD, Monjur TM, Satterfield L. Plain Language Summary: Nosebleed (Epistaxis). Otolaryngol Head Neck Surg. 2020 Jan;162(1):26-32. PMID: 31910124
  6. Byun H, Chung JH, Lee SH et al Association of Hypertension With the Risk and Severity of Epistaxis. JAMA Otolaryngol Head Neck Surg. Sept 10, 2020 PMID: 32910190 https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2770570
  7. Rothaus C Epistaxis. NEJM Resident 360. Mar 10, 2021 https://resident360.nejm.org/clinical-pearls/epistaxis
  8. Kasle DA, Fujita K, Manes RP Review of Clinical Practice Guideline: Nosebleed (Epistaxis). JAMA Surg. Published online July 7, 2021 PMID: 34232284 https://jamanetwork.com/journals/jamasurgery/fullarticle/2781752
  9. NEJM Knowledge+ Otolaryngology - Seikaly H. Epistaxis. N Engl J Med. 2021 Mar 11;384(10):944-951. PMID: 33704939 Review. https://www.nejm.org/doi/pdf/10.1056/NEJMcp2019344