This article is on Epistaxis, a condition frequently experienced by patients and seen by General Practitioners/Emergency physicians and Otolaryngologists. It is intended to help inform patients, relatives of patients and health professionals. The information in the grey boxes is more technical and intended more for Health professionals that are reading this article.

 

What is Epistaxis?

Epistaxis is the medical term for nosebleeds.

 

Who gets Epistaxis/Nosebleeds?

Nosebleeds are very common and most people will have experienced them at some stage in their life. Children under the age of 10 and adults in their 40s to 60s have the highest rate.

Anterior Bleed – Most Common (90%)
– Usually self limiting
– Kiesselbach’s plexus/Littles Area
– Anastamosis of branches from anterior ethmoid artery, sphenopalatine artery, greater palatine artery and superior labial artery

Posterior Bleed (10%)
– Significant haemorrhage
– Sphenopalatine Artery
– If suspected, for urgent ED/ENT Surgeon review

 

What are the causes?

The most common causes are dry air and irritation to the nose. This includes nose picking, sneezing and direct injuries.

Several medications and medical conditions can increase the risk of having nose bleeds. A recent study at Waikato Hospital demonstrated that 43.9% of epistaxis patients presenting to hospital were on blood thinning medications (anticoagulants).(reference Duignan et al. 2018).

Causes and Risk Factors:
– Anticoagulants: Patients should receive review of medication and INR
– Coagulopathy
– Platelet function disorders
– Hemophilia
– Von Willebrand disease
– Hereditary hemorrhagic telangiectasia
– Aneurysms
– Malignancy
– Hypertension
– Winter/Dry conditions

 

What are the symptoms?

Most nosebleeds are not associated with any other symptoms. In severe cases with significant blood loss you may experience blurry vision and feel light headed.

If the bleeding occurs regularly or unusual bruises appear on the body, please seek further medical attention. A reduction in blood iron levels from regular nose bleeds can lead to symptoms of tiredness.

 

What are the treatment options?

Most cases of epistaxis are brief and self resolving. The following should be attempted in the first instance:
1. Pinch the tip/soft part of the nose
2. Lean forward tilt your head down slightly. (Do not lie down or tilt your head backwards)
3. If available, place an ice pack/frozen peas on the bridge of the nose and/or back of the neck.
4. Keep pressure on for 15 minutes
5. If bleeding continues after 15 minutes, repeat steps 1-5.
6. If bleeding continues while pressure is applied or bleeding continues after 30 minutes of pressure, please seek medical attention.

An antibiotic ointment or vaseline can be used to the nostrils to moisturise the nose. In some cases, a packing may be placed in the nostrils to stop the bleeding. On rare occasions, surgery may be required to stop the bleeding.

Rapid Rhino
In primary care, if uncontrolled epistaxis is encountered, Rapid Rhino packing provides a simple method to achieve tamponade.

– Submerge the Rapid Rhino in Sterile Water for 30 seconds
– Insert the Rapid Rhino perpendicular to the nostril (Along the floor of nose)
– Inflate the balloon with air until rounded and firm
– Refer to ED/ENT for review

 

What are the potential complications?

While the majority of nosebleeds are safe and easily controlled, some require more medical attention.

Urgent medical review is required if you have ongoing bleeding despite applying pressure on the nose or you are swallowing large amounts of blood and have difficulty breathing. Significant blood loss can be life-threatening.

 

Can you prevent it?

The ability to prevent nosebleeds depends on whether the risk factors can be effectively reduced. In general, avoiding trauma to the nose (nose picking) and keeping the nose moist will reduce the risk. A dry nose with crusting is more likely to be picked.

In children, crusting around the nostrils called ‘vestibulitis’ can lead to nose picking and bleeds. This is easily prevented by a short course of antibiotic ointment to the nostrils. For adults, regular review of your medication is important, in particular those who take blood thinning or blood pressure medication.

 

What are the day to day impacts?

Most nosebleeds are one off and should not have long term effects. The same area can bleed many times over a week or more if the area fails to heal, minimising trauma and resting reduces the chance of this. If there are recurrent episodes, please seek medical attention for review.

 

Further reading:

1. Cleveland Clinic – Nosebleed (Epistaxis): Management and Treatment

 

References:
1. Alter H. Approach to the adult with epistaxis. 2020. UpToDate
2. Messner A. Management of epistaxis in children. 2020. UpToDate
3. Womack J, Kropa J, Stabile M. Epistaxis: Outpatient Management. 2018. Am Fam Physician. 98(4):240-245.
4. Yau S. An update on epistaxis. 2015. AFP. 44(9):653-656.

 

Author + Affiliation:
Dr Johnny Wu, Department of Otolaryngology, Waikato Hospital.
Reviewed by Dr James Sanders, Otolaryngologist, Waikato Hospital

Date of Publication +/- Review:
Date of Publication:
Date of Review: 11/06/2021

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