Nosebleeds (Epistaxis)

Sheila M. Nolan, MD

Nosebleeds - BASICS

Nosebleeds - description

• Epistaxis: Bleeding from the nose
• Bleeding may be evident anteriorly through the nares or posteriorly through the nasopharynx.

Nosebleeds - general prevention

• Vaporizers, humidifiers, or saline sprays prevent desiccation of the nasal mucosa.
• Petroleum jelly applied to the anterior nasal septum aids healing of inflamed nasal mucosa.
• Antigen avoidance and medical therapy should be used to reduce allergic symptoms.
• Fingernails should be cut short, and nose-picking behavior should be discouraged.
• Protective athletic equipment should be worn.

Nosebleeds - epidemiology

• Nosebleeds occur in all ages throughout the year.
• Children aged 2–10 years are most commonly affected.
• Nosebleeds are more common in the winter.

Nosebleeds - pathophysiology

• The nasal mucosa has a rich blood supply originating from both the internal and external carotid arteries.
• Blood vessels of the nasal septum and lateral nasal walls have little anatomic support or protection. The thin mucosal surface is prone to drying.
• Blood vessels of the nose form many plexiform networks. Especially important is Kiesselbach plexus in the anterior nasal septum, the most common site of nosebleeds in children.
• The nose is subject, by position, to traumatic injury.

Nosebleeds - etiology

• Inflammation of, or trauma to, the nasal passages accounts for most nosebleeds:
  • Viral upper respiratory infections, allergic rhinitis, bacterial rhinitis
  • Nose picking, external trauma, foreign bodies, postsurgical bleeding, chemical or caustic agents/inhalants
• Local structural abnormalities may predispose to epistaxis:
  • Rhinitis sicca, or environmental drying of the nasal mucosa, commonly promotes epistaxis.
  • Nasal polyps, telangiectasias, meningoceles, angiofibromas, vascular malformations, septal deviations or spurs
• Less commonly, nosebleeds may herald, or accompany, systemic illnesses:
  • Hematologic diseases such as leukemias, thrombocytopenias, hemophilias (and von Willebrand disease), and hemoglobinopathies
  • Clotting disorders owing to infection, hepatic failure, or poisoning/envenomation
  • Hypertension (usually not the cause, but can make hemostasis difficult)
• Pseudoepistaxes from pulmonary hemoptysis, bleeding esophageal varices, or pharyngeal/laryngeal tumors that bleed can be mistaken for epistaxis.

Nosebleeds - associated conditions

Hemoptysis, hematemesis, or melena may be the presenting concerns in individuals with bleeding from the nasopharynx.

Nosebleeds - DIAGNOSIS

Nosebleeds - signs & symptoms

Bleeding

Nosebleeds - history

• Frequency of occurrence
• Persistence of bleeding
• Nose-picking behavior/traumatic injury
• Nasal congestion, discharge, obstruction
• Allergies
• Medications or drugs of abuse (especially cocaine)
• Previous or concurrent bruising or bleeding
• Menstrual history
• Family history of systemic disease or hemorrhagic disorder

Nosebleeds - physical exam

• Vital signs with BP determination
• Inspection of nose, nasopharynx, and oropharynx
• General examination with attention to lymph nodes, liver and spleen size, rashes, icterus, pallor
• Procedure:
  • Examination of the nose may be facilitated by application of a topical vasoconstricting agent and/or anesthetic agent.
  • Anxiety may interfere with examination and treatment of children. Sedation and analgesia may be beneficial in some circumstances.

Nosebleeds - tests

Nosebleeds - lab

• Laboratory evaluation is not indicated in healthy children with readily controlled epistaxis from an anterior site.
• Recurrent or refractory nosebleeds or suspicious findings from the history and physical examination may warrant a directed laboratory evaluation (such as platelet count, PT and PTT, CBC, and/or bleeding time) and/or consultation.

Nosebleeds - differencial diagnosis

Epistaxis is a common event in normal children. A careful history and physical examination should identify those children with unusual predisposing causes for nosebleeds.

Nosebleeds - TREATMENT

Nosebleeds - general measures

• Elevate the head of the bed.
• Direct pressure, applied by gently squeezing the nostrils, is usually sufficient to stop most nosebleeds.
• Ice or cold packs to the neck or nasal dorsum appear not to have a significant benefit, but may be combined with application of pressure.
• A cotton pledget beneath the upper lip may aid hemostasis by compressing the labial artery.
• Vasoconstricting agents (0.25% phenylephrine, 0.05% oxymetazoline, 1:1,000 epinephrine, or 1–5% cocaine) will help reduce bleeding as well as improve visualization.
• Application of topical thrombin or fibrin glue may be used when direct visualization of the bleeding site is achieved.
• Once identified, an offending vessel may be cauterized with a silver nitrate stick or a swab dipped in trichloroacetic acid:
  • Antiseptic creams combining chlorhexidine and neomycin applied topically are more effective than no treatment and just as effective as cautery with silver nitrate.
• Anterior nasal packing with oxycellulose or petroleum jelly gauze may be required to control refractory epistaxis when the site of bleeding cannot be precisely identified.
• Otorhinolaryngologic consultation may be needed for severe nosebleeds or when posterior nasal packing, fracture reduction, surgery, or embolization is required. Nasal endoscopy is now routinely used.
• Parental reassurance is an important, but often neglected, aspect of therapy.

Nosebleeds - FOLLOW UP

• Nosebleeds are easily controlled and self-limited in most instances.
• Postsurgical nosebleeds can be particularly problematic.
• Referral to an otorhinolaryngologist is indicated for patients with specific local abnormalities, such as polyps, tumors, or vascular malformations, or severe nosebleeds, recurrent nosebleeds, and/or posteriorly located nosebleeds.
• Identification of systemic illness may require referral to the appropriate specialist.

Nosebleeds - prognosis

• Uncomplicated epistaxis is most often self-limited or resolves with simple first-aid techniques.
• Refractory or recurrent epistaxis may require more specialized techniques, surgical intervention, and/or otorhinolaryngologic intervention.

Nosebleeds - complications

• Usually uncomplicated
• Rare complications: Significant blood loss, airway obstruction, aspiration, and vomiting

Nosebleeds - patient monitoring

• Blood clots in the nasopharynx should be removed because they may obscure engorged, bleeding vessels.
• Failure to detect a posterior location within the nasal cavity as the source of bleeding may interfere with measures to control bleeding.
• After nasal packing, it is essential to examine the oropharynx to confirm adequate hemostasis.
• Absorbable-type packings should be used, if required, in patients with bleeding disorders. Standard packings are prone to rebleeding on removal.
• Impregnation of nasal packings with antibiotic ointment reduces the risk of toxic shock syndrome.

Nosebleeds - bibliography

1. Kubba H, MacAndie C. A prospective, single-blind, randomized controlled trial of antiseptic cream for recurrent epistaxis in childhood. Clin Otolaryngol. 2001;26:465–468.
2. Mahmood S, Lowe T. Management of epistaxis in the oral and maxillofacial surgery setting: An update on current practice. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;95:23–29.
3. Tan LS, Calhoun KH. Epistaxis. Med Clin North Am. 1999;83:43–56.
4. Viehweg TL, Roberson JB, Hudson JW. Epistaxis: Diagnosis and treatment. J Oral Maxillofac Surg. 2006;64(3):511–518

Nosebleeds - CODES

Nosebleeds - icd9

784.7 Epistaxis

Nosebleeds - PATIENT TEACHING-MED

Families should be given instructions in basic first aid for nosebleeds, because minor insults, such as sneezing or excessive manipulation, may cause nosebleeds to recur.

Nosebleeds - FAQ

• Q: How should the patient with nosebleeds be positioned?
• A: When possible, patients with nosebleeds should be kept erect. The upright position decreases vascular congestion. Recumbent patients may appear to have less bleeding, but this is owing to redirection of blood flow through the posterior pharynx.
• Q: How does rhinitis sicca contribute to epistaxis, and why does it occur?
• A: The nose warms, humidifies, and filters inspired air. Many modern heating systems and air-conditioning units reduce household humidity to unnaturally low levels. Rhinitis sicca is the direct result of inhaling dry air and results in friable nasal mucosa. Turbulent airflow from a septal deformity also promotes drying.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

Other Book Chapters Related to Nosebleeds

Read excerpts from these other book chapters related to Nosebleeds:

Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Williams & Wilkins.

More About Causes of Nosebleeds

• Back to symptom: Nosebleeds: Introduction (review 260 causes)
• Next Book Extract About Nosebleeds: Medications causing Nosebleeds
• All Book Extracts: All Online Book Extracts for Nosebleeds

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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