What is EPISTAXIS?

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  • April 3, 2021
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Epistaxis is known as bleeding from inside the nose. It is fairly common and seen in all age groups- children, adults and older people. It is often presented as an emergency. Epistaxis is a sign, not a disease.

CAUSES OF EPISTAXIS

It can occur due to various causes which are listed below:

  1. Local causes

  • Nose

  • Trauma : finger nail trauma, injuries of nose, intra-nasal surgery, hard blowing of nose

  • Infections :

  • Acute infection such as: Nasal diphtheria, Acute sinusitis, Viral rhinitis

  • Chronic infection such as: Rhinitis sicca, Atrophic rhinitis, Tuberculosis, Syphilis, Septal perforation

  • Foreign bodies : Rhinolith, neglected foreign bodies

  • Neoplasm of nose and paranasal sinuses : Carcinoma, Papilloma, Sarcoma

  • Atmospheric changes : High altitude, sudden decompression (Caisson’s disease)

  • Deviated Nasal Septum

  • Nasopharynx

  • Adenoids

  • Malignant tumors

  1. General causes

  • Cardiovascular system : Hypertension, Atherosclerosis, Mitral Stenosis

  • Disorder of blood and blood vessels : Aplastic Anemia, Leukemia, Hemophilia, vitamin K deficiency

  • Liver diseases : Hepatic Cirrhosis

  • Kidney diseases : Chronic Nephritis

  • Drugs : Uncontrolled use of salicylates and other analgesics, anticoagulant therapy

  • Mediastinal compression : Tumors of mediastinum

  • Acute general infection : Influenza ,Measles, Chickenpox, Whooping cough, Rheumatic Fever, Pneumonia

  • Vicarious menstruation : Epistaxis occurring at the time of menstruation

  1. Idiopathic

SITES OF EPISTAXIS

  1. Little’s area : 90%

  2. Above the level of middle turbinate

  3. Below the level of middle turbinate

  4. Posterior part of nasal cavity

  5. Diffuse : Both from septum and lateral nasal wall

  6. Nasopharynx

WHAT IS ITS CLASSIFICATION?

  1. Anterior epistaxis

  • When blood flows out from the front of the nose of the patient in sitting posture.

  • It is more common.

  • The site of epistaxis is from little’s area or anterior part of lateral wall.

  • It commonly affects children and young adults.

  • Its main cause is trauma.

  • Bleeding is usually mild, can be controlled by local pressure and anterior pack.

  1. Posterior epistaxis

  • In posterior epistaxis, blood flows back into the throat. The Person may consume it and later have a coffee colored vomits.

  • It is less common.

  • The site of posterior epistaxis is mostly from the posterior superior part of the nasal cavity, often difficult to localize the bleeding point.

  • It occurs after the age of 40.

  • The cause is spontaneous, often due to hypertension or atherosclerosis.

  • In this case, bleeding is severe requiring hospitalization.

WHAT ARE ITS CLINICAL FEATURES?

  • Bleeding through the nose and blood trickling into oropharynx

  • Bleeding usually starts from one nostril.

  • A sensation of flowing liquid at the back of the throat

  • The urge to swallow frequently

  • Excessive nose bleeding may cause dizziness, fainting, confusion, loss of alertness and lightheadedness.

HOW CAN EPISTAXIS BE DIAGNOSED?

It can be diagnosed through:

  • History taking

  • Assessment of nose

  • Blood tests for hemoglobin

  • Complete blood count (CBC), Platelet count

  • CT-Scan or X-ray of sinuses and nasal area to search for neoplasm of the Nasopharynx and sinuses

WHAT CAN BE DONE FOR ITS MANAGEMENT?

Epistaxis can be managed through different ways, they are:

  • Medical management

         Initial first aid management

  • Tilt the head forward to prevent posterior blood drainage.

  • Apply constant pressure by pinching nares together for 5 to 10 minutes.

  • If there is no sign of improvement, pack the nose with vasoconstriction soaked gauze and heavy coat of petroleum jelly for 10 minutes.

  • In severe case, Nasostat is inserted, a Foley’s catheter device which provide direct compression to the site via balloon.

  • Resuscitation with IV fluid or possibly blood transfusion may be necessary for severe blood loss to prevent hypokalemic shock.

  • Cold compress should be applied to the nose to cause reflex vasoconstriction.

  • Other management includes:

  • In benign case of epistaxis, the local application of Vasoconstriction agents has been shown to reduce the bleeding time. E.g.: Oxymetazoline, Ephedrine

  • Cauterization: This procedure is useful in anterior epistaxis when the bleeding point has been located. Firstly, the area is anesthetized and the bleeding point is cauterized with a head of silver nitrate or coagulated with electrocautery.

  • Anterior nasal packing: If bleeding point is profuse or the site of bleeding is difficult to localize, anterior packing should be done. In this procedure, ribbon gauze soaked with liquid paraffin is used and about 1 m gauze is required for each nasal cavity. The whole nasal cavity is filled tightly by layering the gauze from floor to roof and from before backwards. Pack can be removed after 24 hours if bleeding has stopped, and sometimes it has to be kept for 2-3 days.

  • Posterior nasal packing: A post nasal pack is first prepared by tying three silk ties to a piece of gauze rolled into the shape of the cone. A rubber catheter is passed through the nose. Patient requiring post nasal pack required hospitalization.

  • Ligation of bleeding point: Three blood vessels including sphenopalatine, anterior and posterior ethmoid arteries are ligated. When the bleeding is from the external carotid system and the conservative measures have failed, ligation of the external carotid artery above the origin of the superior thyroid artery should be done.

WHAT ARE SOME WAYS TO PREVENT EPISTAXIS?

  • Forceful nose blowing, straining, high altitudes and nasal trauma should be avoided.

  • Instruct the person to have adequate humidification to prevent drying of nasal passage.

  • Instruct the person to contact the health care provider immediately if bleeding is not controlled by first aid management.

Article Credit :

Richa Bhattarai 

The author is currently pursuing B.Sc. Nursing at OM Health Campus in Chabahil, Kathmandu.

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