Epitaxis (Nosebleed): Causes, Types, Risk Factors And What Should You Do To Stop A Nosebleed.

What is Epitaxis?

Epitaxis is a medical condition which referred to as nosebleeds and mainly characterized by bleeding from the nose.

The nasal mucosa contains a rich blood supply that can be easily ruptured and cause bleeding. This could be spontaneous or start as a trauma. 

Nosebleeds are mainly occur in males than females and been reported in up to 60% of the population with peak incidences in those under the age of ten and over the age of 50. An increase in blood pressure (e.g. due to general hypertension) tends to increase the duration of spontaneous epistaxis.

Anticoagulant medication and disorders of blood clotting can promote and prolong bleeding. Spontaneous epistaxis is more common in the elderly as the nasal mucosa (lining) becomes dry and thin and blood pressure tends to be higher. The elderly are also more prone to prolonged nosebleeds as their blood vessels are less able to constrict and control the bleeding.

The vast majority of nosebleeds occur in the anterior (front) part of the nose from the nasal septum. This area is richly endowed with blood vessels (Kiesselbach's plexus). This region is also known as Little's area. Bleeding extended back in the nose is known as a posterior bleed and is usually due to bleeding from Woodruff's plexus, a venous plexus situated in the posterior part of inferior meatus. Posterior bleeds are often prolonged and difficult to control. They can be associated with bleeding from both nostrils and with a greater flow of blood into the mouth.

Sometimes blood flowing from other sources of bleeding passes through the nasal cavity and exits the nostrils. It is thus blood coming from the nose but is not a true nosebleed, that is, not truly originating from the nasal cavity. Such bleeding is called "pseudoepistaxis" (pseudo + epistaxis). Examples include blood coughed up through the airway and ending up in the nasal cavity, then dripping out.

What are the types of Epitaxis?

Epitaxis (nosebleeds) are described by the site of the bleed. There are two main types and one is more serious than the other.

1. An anterior nosebleed starts in the front of the nose on the lower part of the wall that separates the two sides of the nose (called the septum). Capillaries and small blood vessels in this front area of the nose are fragile and can easily break and bleed. This is the most common type of nosebleed and is usually not serious. These nosebleeds are more common in children and are usually able to be treated at home.

2. A posterior type of nosebleed is more common in adults and nosebleed occurs deep inside the nose. This nosebleed is caused by a bleed in larger blood vessels in the back part of the nose near the throat. This can be a more serious nosebleed than an anterior nosebleed. It can result in heavy bleeding, which may flow down the back of the throat. You may need medical attention right away for this type of nosebleed.

Who gets nosebleeds?

Anyone can get a nosebleed. Most people will have at least one in their lifetime. However, there are people who are more likely to have a nosebleed. They include:

People who have blood clotting disorders, such as hemophilia or von Willebrand disease.

Children between ages two and 10. Allergies, colds, dry air and sticking fingers and objects into their nose make children more prone to nosebleeds.

Adults between ages 45 and 65. Blood may take longer to clot in mid-life and older adults. They are also more likely to be taking blood thinning drugs (such as daily aspirin use), have high blood pressure, hardening of the walls of arteries (atherosclerosis) or a bleeding disorder.

Pregnant women: Blood vessels in the nose expand while pregnant, which puts more pressure on the weak blood vessels in the lining of the nose.

People who take blood-thinning drugs, such as aspirin or warfarin.

What causes epitaxis?

Nosebleeds have many causes. Fortunately, most are not serious.

The most common cause of nosebleeds is dry air. Dry air can be caused by hot, low-humidity climates or heated indoor air. Both environments cause the nasal membrane (the delicate tissue inside your nose) to dry out and become crusty or cracked and more likely to bleed when rubbed or picked or when blowing your nose.

Other common causes of nosebleeds include:

Colds (upper respiratory infections) and sinusitis, especially episodes that cause repeated sneezing, coughing and nose blowing.

Blowing your nose with force.

Nose picking.

Inserting an object into your nose.

Injury to the nose and/or face.

Allergic and non-allergic rhinitis (inflammation of the nasal lining).

Excessive use of Blood-thinning drugs like aspirin, non-steroidal anti-inflammatory drugs, warfarin, and others.

Cocaine and other drugs inhaled through the nose.

Chemical irritants (chemicals in cleaning supplies, chemical fumes at the workplace, other strong odors).

High altitudes. The air is thinner (lack of oxygen) and drier as the altitude increases.

Deviated septum (an abnormal shape of the wall that separates the two sides of the nose).

Frequent use of nasal sprays and medications to treat itchy, runny or stuffy nose. Medication like antihistamines and decongestants can dry out the nasal membranes.

Other, less common causes of nosebleeds include:

Alcohol use.

Bleeding disorders, such as hemophilia or von Willebrand disease.

High blood pressure.

Atherosclerosis.

Facial and nasal surgery.

Nasal tumors.

Nasal polyps.

Immune thrombocytopenia.

Leukamia

Hereditary hemorrhagic telangiectasia.

Pregnancy.

What should you do to stop a nosebleed?

Follow these steps to stop a nosebleed:

Relax.

Sit upright and lean your body and your head slightly forward. This will keep the blood from running down your throat, which can cause nausea, vomiting, and diarrhea. (Do NOT lay flat or put your head between your legs.)

Breathe through your mouth.

Use a tissue or damp washcloth to catch the blood.

Use your thumb and index finger to pinch together the soft part of your nose. Make sure to pinch the soft part of the nose against the hard bony ridge that forms the bridge of the nose. Squeezing at or above the bony part of the nose will not put pressure where it can help stop the bleeding.

Keep pinching your nose continuously for at least 5 minutes (timed by clock) before checking if the bleeding has stopped. If your nose is still bleeding, continue squeezing the nose for another 10 minutes.

If you’d like, apply an ice pack to the bridge of your nose to further help constrict blood vessels (which will slow the bleeding) and provide comfort. This is not a necessary step, but you can try this if you want.

After the bleeding stops, DO NOT bend over, strain and/or lift anything heavy. DO NOT blow or rub your nose for several days

What are the medical treatment for epitaxis?

Cauterization 

This method involves applying a chemical such as silver nitrate to the nasal mucosa, which burns and seals off the bleeding. Eventually the nasal tissue to which the chemical is applied will undergo necrosis. This form of treatment is best for mild bleeds, especially in children, that are clearly visible. A topical anesthetic (such as lidocaine) is usually applied prior to cauterization. Silver nitrate can cause blackening of the skin due to silver sulfide deposit, though this will fade with time.

You can spray an over-the-counter decongestant spray, such as oxymetazoline (Afrin, Dristan, Neo-Synephrine, Vicks Sinex, others) into the bleeding side of the nose and then apply pressure to the nose as described above. 

WARNING: These topical decongestant sprays should not be used over a long period of time. Doing so can actually cause an increase in the chance of a nosebleed.

Nasal packing 

If pressure and chemical cauterization cannot stop bleeding, nasal packing is the mainstay of treatment. There are several forms of nasal packing that can be contrasted by anterior nasal packing and posterior nasal packing.Traditionally, nasal packing was accomplished by packing gauze into the nose, thereby placing pressure on the vessels in the nose and stopping the bleeding. Traditional gauze packing has been replaced with products such as Merocel and the Rapid Rhino. The Merocel nasal tampon is similar to gauze packing except it is a synthetic foam polymer (made of polyvinyl alcohol and expands in the nose after application of water) that provides a less hospitable medium for bacteria. The Rapid Rhino stops nosebleeds using a balloon catheter, made of carboxymethylcellulose, which has a cuff that is inflated by air to stop bleeding through extra pressure in the nasal cavity. Systematic review articles have demonstrated that the efficacy in stopping nosebleeds is similar between the Rapid Rhino and Merocel packs; however, the Rapid Rhino has been shown to have greater ease of insertion and reduced discomfort. People who receive nasal packing need to return to a medical professional in 24–72 hours in order to have packing removed.There are also several dissolvable packing materials that stop bleeding through use of thrombotic agents that promote blood clots, such as surgicel. The thrombogenic foams and gels do not require removal and dissolve after a few days. Posterior nasal packing can be achieved by using a Foley catheter, blowing up the balloon when it is in the back of the throat, and applying traction. 

Complications of nasal packing include abscesses, septal hematomas, sinusitis, and pressure necrosis. In rare cases toxic shock syndrome can occur with prolonged nasal packing. As a result, many forms of nasal packing involve use of topical antistaphylococcal antibiotic ointment.

Tranexamic acid 

Tranexamic acid helps promote blood clotting. For nosebleeds it can be applied to the site of bleeding, taken by mouth, or injected into a vein.

Surgery 

Ongoing bleeding despite good nasal packing is a surgical emergency and can be treated by endoscopic evaluation of the nasal cavity under general anesthesia to identify an elusive bleeding point or to directly ligate (tie off) the blood vessels supplying the nose. These blood vessels include the sphenopalatine, anterior and posterior ethmoidal arteries. More rarely the maxillary or a branch of the external carotid artery can be ligated. The bleeding can also be stopped by intra-arterial embolization using a catheter placed in the groin and threaded up the aorta to the bleeding vessel by an interventional radiologist.There is no difference in outcomes between embolization and ligation as treatment options, but embolization is considerably more expensive. Continued bleeding may be an indication of more serious underlying conditions.

Other treatment options

The utility of local cooling of the head and neck is controversial. Some state that applying ice to the nose or forehead is not useful. Others feel that it may promote vasoconstriction of the nasal blood vessels and thus be useful.

How to prevent epitaxis?

Things you can do to prevent nosebleeds include:

Keep your fingernails short and avoid picking your nose.

Blow your nose as little as possible and only very gently.

Live in a humidified place.

Wear a head guard during activities in which your nose or head could get injured.

Always follow the instructions that come with nasal decongestants, overusing these can cause nosebleeds.

Talk to your Parents/Guardians if you experience nosebleeds frequently and aren't able to prevent them. They may refer you to an ENT specialist for an assessment.

Sources:

www.nhsinform.scot

www.clevelandclinic.org

Wikipedia