Epistaxis

Overview

Epistaxis describes bleeding from the nose. In most cases, it originates from Little’s area on the anterior nasal septum, where the Kiesselbach plexus is found. Posterior nosebleeds can arise from the sphenopalatine artery in the posterior nasal cavity. Posterior nosebleeds tend to be more profuse and common in older people.

Epidemiology

• Epistaxis is very common, around 60% of the UK population has had an episode
• Common in children >2 years
• Epistaxis in a child <2 years is likely to be secondary to an underlying cause
• Posterior epistaxis is more common in older people than younger people

Causes

Local causes

• Trauma e.g. nose-picking/nasal fractures/blunt trauma/foreign bodies
• Inflammation e.g. infection/nasal polyps
• Drugs e.g. cocaine
• Granulomatosis with polyangiitis (Wegener’s granulomatosis)
• Post-operative
• Tumours

General causes

• Atherosclerosis
• Coagulopathy
• Anticoagulant use
• Environmental factors e.g. temperature/humidity/altitude etc.
• Excessive alcohol

Presentation

If the bleeding is profuse, from both nostrils, or difficult to visualise, suspect a posterior bleed.

Management

Haemodynamically stable patients

• 1st-line: first aid measures:
  • Pinch nose firmly + sit leaning forward with mouth open + spit out any blood for 20 minutes
  • Avoid lying down if possible – to reduce the risk of aspiration
• If first-aid successful:
  • Offer Naseptin (chlorhexidine + neomycin) to reduce crusting and vestibulitis
    • Avoid if allergic to neomycin, peanut, or soya, use mupirocin instead
  • Consider admission/referral if:
    • Child <2 years of age – epistaxis is likely to be due to an underlying cause
  • Any patient with a predisposition to bleeding e.g. coagulopathy/malignancy
  • Patients with comorbidities such as coronary artery disease/severe hypertension
• If bleeding does not stop after 10-15 minutes:
  • If bleeding site visible: cautery
  • If bleeding site not visible: packing + admit to hospital
• If bleed location unknown/posterior: admit to hospital
• If all options fail: consider sphenopalatine ligation in theatre

Haemodynamically unstable patients

• 1st-line: first aid + admit to emergency department
• If all options fail: consider sphenopalatine ligation in theatre

Monitoring

• Patients are not usually followed up unless they have a potential underlying condition

Patient Advice

• Patients should avoid picking or excess picking of the nose, heavy lifting, strenuous exercise, lying flat, and drinking alcohol or hot drinks 
• Patients should be educated on first aid measures should epistaxis occur again
• Patients should seek urgent medical help if the first-aid measures above do not help

Complications

• Hypovolaemia
• Aspiration
• Death

Prognosis

• Most episodes of epistaxis are self-limiting
• Mortality is rare and associated with complications secondary to treatment and in people with comorbidities e.g. coronary artery disease/coagulopathy/hypertension