Nosebleed

Introduction
Nosebleed, medically termed epistaxis, is bleeding from the nasal cavity due to rupture of blood vessels within the nasal mucosa. It is a common condition that can range from mild and self-limiting to severe and life-threatening. Most cases are anterior in origin and benign, but posterior bleeds may require urgent medical intervention.

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Epidemiology

• Common in all age groups, with peaks in children (2–10 years) and older adults (>60 years).

• Anterior bleeds account for ~90% of cases (Kiesselbach’s plexus).

• Posterior bleeds are less common but often more severe and associated with comorbidities such as hypertension and atherosclerosis.

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Etiology

Local causes

• Trauma (nose picking, facial injury, nasal surgery).

• Dry air or low humidity leading to mucosal crusting and vessel fragility.

• Nasal inflammation (rhinitis, sinusitis).

• Nasal tumors or polyps.

• Foreign bodies in the nose.

Systemic causes

• Hypertension.

• Coagulopathies (e.g., hemophilia, thrombocytopenia).

• Liver disease.

• Medications (anticoagulants such as warfarin, direct oral anticoagulants, antiplatelets like aspirin or clopidogrel, intranasal corticosteroids).

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Pathophysiology
Nasal mucosa has a rich vascular supply from both internal and external carotid arteries.

• Anterior epistaxis: Most commonly arises from Kiesselbach’s plexus (Little’s area) – a confluence of vessels in the anterior nasal septum.

• Posterior epistaxis: Originates from branches of the sphenopalatine artery, deeper and harder to control.

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Clinical Presentation

• Unilateral or bilateral bleeding from nostrils.

• May present with blood in the throat (posterior bleed).

• Associated symptoms: dizziness, lightheadedness, syncope in severe cases.

• Signs of hypovolemia may be present in massive bleeding.

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Diagnosis

History

• Onset, duration, frequency of episodes.

• Precipitating factors (trauma, sneezing, medications).

• Past history of nasal or systemic disease.

• Drug history (especially anticoagulants).

Examination

• Vital signs (to assess stability).

• Inspection of nasal cavity with nasal speculum.

• Identify bleeding site if possible.

• Examine for signs of systemic disease (bruising, petechiae).

Investigations

• Usually not required for single mild episodes.

• CBC, coagulation profile, renal and liver function tests for recurrent/severe bleeds.

• Nasal endoscopy if bleeding source is not identified.

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Management

First aid measures (for mild anterior epistaxis)

• Sit upright, lean forward to avoid aspiration.

• Pinch soft part of nose (below nasal bone) for 10–15 minutes continuously.

• Apply cold compress to bridge of nose to promote vasoconstriction.

• Avoid lying flat or tilting head back.

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Medical and procedural treatment

1. Topical Vasoconstrictors (for active anterior bleeds)

• Oxymetazoline 0.05% nasal spray: 2–3 sprays in affected nostril, may repeat after 10 minutes if needed.

• Phenylephrine 0.25–0.5% nasal drops: 2–3 drops, up to every 4 hours.

2. Chemical or Electrical Cautery

• Silver nitrate sticks applied to bleeding point after topical anesthesia (lidocaine 4%).

• Avoid bilateral septal cautery at same session to prevent perforation.

3. Nasal Packing

• Anterior nasal packing: Ribbon gauze soaked in petroleum jelly or antibiotic ointment; or use prefabricated nasal tampons.

• Posterior nasal packing: Balloon catheters (e.g., Foley catheter) or commercial posterior packs; requires monitoring for hypoxia.

4. Systemic Medications (adjunctive)

• Tranexamic acid: 500–1000 mg orally every 8 hours for short-term use, or topical tranexamic acid solution applied to nasal mucosa.

• Antibiotics (e.g., amoxicillin–clavulanate 625 mg orally every 8 hours) may be given with nasal packing to prevent sinusitis or toxic shock syndrome.

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Surgical interventions (for refractory bleeding)

• Endoscopic ligation of sphenopalatine artery.

• Arterial embolization (interventional radiology).

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Prevention of recurrence

• Keep nasal mucosa moist with saline sprays or petroleum jelly.

• Use humidifiers in dry environments.

• Avoid nasal trauma and vigorous nose blowing.

• Manage underlying conditions (hypertension, coagulopathy).

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Complications

• Aspiration of blood leading to airway compromise.

• Anemia from chronic/recurrent bleeding.

• Septal perforation (if cautery or packing is excessive).

• Infection following nasal packing.