Immediate Management of Epistaxis: Bloody Nuisance or Ominous Sign?
Terence M. Davidson, MD; Daniel DavidsonTHE PHYSICIAN AND SPORTSMEDICINE - VOL 24 - NO. 8 - AUGUST 96
In Brief: Epistaxis typically originates from the nasal septum when the nasal mucosa overlying a dilated blood vessel is injured. Epistaxis may, however, signal an underlying condition such as a coagulation disorder, so the treating physician must be alert for signs of serious illness. Most nosebleeds stop spontaneously within 5 minutes with or without pressure to the forehead, nose, or upper lip. Some require anterior nasal packing. A few arise from posterior arteries and require anterior-posterior nasal packing and a referral.
Although a bleeding nose may seem merely a bloody nuisance, it can sometimes be a sign of a serious condition such as coagulopathy or cancer. Sports-related trauma and various other causes make epistaxis a common condition in active-and apparently healthy-people. Physicians must not only be adept at pinpointing the site of bleeding and stanching the flow, but also must be alert to potentially serious causes.
Causes of Bleeding
The blood supply to the nose (figure 1: not shown) originates from two sources: the internal and external carotid arteries. It is profuse and diffuse, with many arterial and venous anastomoses.
The vast majority of nosebleeds originate from the nasal septum and erupt when the relatively thin nasal mucosa overlying a dilated septal vessel dries, scabs, and falls (or is picked) off.
Trauma is the second most common cause of nosebleeds. A force sufficient to deform the nasal skeletal structures can cause mucosal disruption and bleeding anteriorly on the septum, laterally along the nasal walls, or, with Le Fort's fracture, posteriorly at the sphenopalatine or superiorly at the ethmoid vessels. Posterior epistaxis, though rare, is the third most common type of nosebleed. Its etiology is still debated.
Nosebleeds may also herald underlying illness (1,2). The astute physician, therefore, must recognize that the presentation of such nosebleeds is in one way or another atypical.
Epistaxis can usually be managed with a step-by-step approach (figure 2: not shown). The vast majority of spontaneous or traumatic nosebleeds in people who have no underlying coagulopathy stop on their own with or without ice to the forehead, pressure to the upper lip, or pinching of the nostrils against the septum. Those that continue to bleed after 3 or 4 minutes can be controlled by one of two approaches.
The easiest is applying pressure to the bleeding site with anterior nasal packing (table 1). To do this, the physician topically vasoconstricts and anesthetizes the nasal mucosa. Bacitracin or a similar ointment is applied to one of the commercial anterior nasal packs (Xomed, Inc, Jacksonville, Florida; Shipert Medical Technology, Englewood, California). The tampon is inserted with a firm grasp, using a hemostat or bayonet forceps. The tampon will swell and compress the bleeding site. Layered, 1/2-in. gauze with petrolatum is a rough but effective alternative to the tampon. A second approach is to stop the bleeding with vasoconstrictors such as topical oxymetazoline hydrochloride, cocaine, or epinephrine 1:100,000, and then to cauterize the bleeding site with silver nitrate or electric cautery.
The rare and more serious posterior nosebleed requires an anterior-posterior (AP) pack and referral to an otolaryngologist (3). Commercial balloons such as the Epistat (Xomed, Inc) and Nasostat (Sparta, Pleasanton, California) are the most commonly used devices. A Foley balloon catheter with anterior gauze packing is also effective. The most secure AP pack is a 4" x 4" gauze sponge pulled against the posterior choana with a transnasal, 0 silk suture, combined with anterior layered gauze packing, though it is the most difficult and messy to insert. Table 2 shows the contents of a complete epistaxis tray.
The following examples are hypothetical composite cases that highlight various underlying causes of epistaxis, along with targeted treatment strategies.
Case 1: Easily Controlled Bleeding
A 5-year-old male soccer player invariably trots over to the bench with blood pouring from his nose as halftime approaches. The bleeding is always controlled within 2 to 3 minutes by applying ice to his forehead and digital pressure to his upper lip and the base of his nose. Further history reveals that the patient frequently develops spontaneous epistaxis at night, and his pillow is often bloodstained in the morning. All of his witnessed nosebleeds have spontaneously ceased in less than 5 minutes. Physical exam shows crusting over the anterior septum.
The diagnosis--a common one--is nose picking. This little boy constantly picks his nose, which leads to scab formation and bleeding from the underlying dilated vessels.
Treatment is twofold. First, petrolatum or a bacitracin ointment should be applied to the anterior naris twice a day. Antibiotic ointments are discouraged because of the risk of inducing allergic reaction.
The second part of treatment is to discourage the nose picking. It is easy enough to tell the child not to pick his nose during the day. The problem is that many children pick their noses unconsciously at night, hence the bloodstained pillow. The easiest way to stop this practice is to place a glove on the child's hand for sleeping. Baseball batting gloves, gardening gloves, and socks all work well. They simply add enough bulk to the child's fingers so they no longer fit inside the nostril.
All nosebleeds must be looked on as a possible sign of underlying coagulopathy. This could be the first symptom of hemophilia or leukemia. Had the bleeding persisted for more than 5 minutes or not responded to treatment, a coagulation workup would have been required (2).
Case 2: Profuse Nosebleed
A 12-year-old football player jogs to the sidelines with an absolutely horrendous nosebleed after a particularly jarring tackle. Blood pours out anteriorly, and he spits more out of his mouth. The bleeding stops as suddenly as it began. His jersey is soaked, and an estimated 200 mL of blood is lost.
This is a classic juvenile angiofibroma. These highly vascular tumors arise in the nasal pharynx, typically in pubescent males. They commonly present with a sentinel nosebleed that is typically voluminous, rapid, and very different from that seen in anterior septal bleeding.
Had the bleeding not stopped spontaneously, an anterior nasal pack would not have tamponaded the bleeding site in the nasal pharynx. The only means of stopping the bleeding would have been an AP pack.
AP tamponade is best performed in the field by establishing the posterior tamponade with a Foley balloon. The Foley is passed through the nose and into the nasopharynx. The balloon is filled with water and then pulled anteriorly, and thus is held in place against the posterior choana by anterior traction. The anterior naris is then obstructed, either with layered gauze packing or with an anterior balloon. Holding the Foley anteriorly is no small feat. If available, an umbilical cord clip or safety pin may work as well as any other device. Immediate referral for angiography and resection is then made.
Case 3: Trauma-Induced Epistaxis
A 14-year-old basketball player is struck in the nose by an opponent's elbow while grabbing a rebound. She runs to the bench holding her nose, which is now pouring blood.
The recommended treatment is to have the player sit down and lean forward. This is particularly necessary with basketball players because most of them are so tall that the average physician can barely reach the player's nose without standing on a stool or having the player sit. Pressure applied externally to the nose, if tolerated, will generally tamponade the bleeding, which stops either because of the pressure or of its own accord. (External pressure is unlikely to compound the injury.) Fractured noses will bleed from a mucosal tear inside the nose. While this bleeding is impressive and generally anterior, it is not overwhelming and usually stops spontaneously.
If the nose is crooked or flattened, it is safe to say it has been fractured and reduction is required. If the nose is cosmetically unchanged, it does not matter whether it is broken or not; no reduction will be required. Nasal x-rays are never requested. They are right only half the time and never contribute to diagnosis or treatment.
Once the bleeding has stopped, the nose should be inspected to rule out a septal hematoma. Typically, a septal hematoma is uncomfortable, will cause nasal obstruction, and is not easy to diagnose. It is seen as a smooth bulging of the septum, typically obstructing the airway. Gentle palpation reveals it is soft and compressible, very unlike a normal septum. If a hematoma is suspected, the patient should be referred to a head and neck surgeon for needle aspiration or cruciate incision and drainage. Both of these procedures are followed by a firm anterior layered gauze pack to tamponade the bleeding and keep the septal mucosa pressed firmly against the cartilage.
Generally speaking, if a person is hit in the nose forcefully enough to cause bleeding, a fracture has occurred. If the nose is straight, return to play is a judgment call. If the nose has been broken, any repeat trauma before the fracture has fully healed will more easily fracture and displace the nose. Hence, the most conservative approach would be to remove the player from the field for 6 weeks.
But given our ability to reduce nasal fractures and given the importance of continuing play, a strong argument can be made to resume play the next day, assuming the patient feels well and his or her nose is not grossly swollen and obstructing vision. Early return to play with or without nose protection carries risk of refracture and impaired nasal function. The risk, however, is small. Most fractures (including refractures) can be repaired, so if play is important, the risk-benefit ratio is reasonable.
Case 4: Continual Hemorrhage
A 16-year-old female softball player is forcefully tagged while sliding into second base. She pops up with her nose streaming blood anteriorly and walks to the dugout. Ice is applied to her forehead, pressure is applied to her upper lip, and her nostrils are squeezed shut, but the bleeding persists.
With her nostrils squeezed shut, the blood runs down the back of her throat. The nostril pinching is therefore discontinued and the nose allowed to bleed anteriorly. The bleeding is unilateral. A nasal balloon is inserted and inflated. The patient is brought to the emergency room for further evaluation.
The patient had no previous bleeding and denies taking aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs), birth control pills, or any other medication. Family history reveals a maternal aunt with some unknown recurrent nosebleed disorder. The nasal tampon is removed and the bleeding immediately resumes. The nasal tampon is reinserted and the bleeding is controlled.
A complete blood count and coagulation profile are ordered. The hematocrit returns at 36% with a hemoglobin of 12 g/dL, and the prothrombin time, partial thromboplastin time, quantitative platelet count, and bleeding time (Ivy method) are all normal. The patient is discharged with instructions to return the next day.
The nasal tampon is again removed the following day, and this time the bleeding does not resume. The patient's nose is filled with bacitracin ointment, and a cotton pledget saturated in bacitracin ointment is placed in the anterior naris. The patient is instructed to change the pledget two to three times a day for the next 5 days. This moist anterior nasal plug is the key to preventing rebleeding and should be used for 3 to 7 days after all significant anterior nose bleeds.
The patient returns after 5 days. She has no recurrent bleeding and her nose is clean, but on close inspection multiple telangiectasia lesions are noted on the nasal mucosa. Further examination reveals telangiectasia also on the lips and dorsal tongue. Diagnosis is made of hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease)--an autosomal dominant illness. The patient is referred to a head and neck surgeon. Her case highlights the fact that the single best predictor of coagulopathy is family history.
Case 5: Prolonged Bleeding Time
A 24-year-old high school baseball coach has recurrent epistaxis. Bleeding can occur anytime, but is most annoying during baseball games. It is always controlled by pinching the nostrils--but it typically takes 10 to 15 minutes to fully control. The coach denies aspirin intake but uses an NSAID on a regular basis for the pains of an old football injury. The patient has no other underlying illnesses, and a recent physical examination was normal.
This case is unusual for the time it takes the bleeding to stop. The patient is taken off the NSAID. At first he has fewer nosebleeds, but during a playoff game his nose again bleeds, and again takes 10 to 15 minutes of direct pressure to control. After the game, his nose is examined and no lesions are seen. He has one or two visible vessels on his nasal septum, but no crusting and no obvious bleeding site.
A complete blood count and coagulation profiles are obtained. The hematocrit is 45% with a hemoglobin of 15 g/dL. Prothrombin time, partial thromboplastin time, and platelet count are all normal. Bleeding time with the Ivy method is prolonged. This test is repeated and is again prolonged. The patient is referred to a hematologist, and a diagnosis of von Willebrand's disease, one of the more commonly inherited coagulation disorders, is made. The key to this diagnosis was the prolonged nasal bleeding time, even when the patient was taken off the NSAID.
Case 6: Recurrent Trickle
A 36-year-old physician for the local college football team reports to his primary care physician requesting a referral to a hematologist for recurrent epistaxis. The primary care physician, however, insists on seeing him first. The patient gives no family history of bleeding and has undergone surgery in the past with no difficulties. He denies taking any medications.
The bleeding occurs once or twice a day, and although it tends to be only a trickle, it has recently become a repeatedly annoying occurrence. On physical examination, crusting is evident on the septum, and on closer inspection a septal perforation is noted. The patient denies nasal trauma.
When questioned directly, the patient admits to a long history of cocaine use. Septal perforation is a common problem with repeated cocaine application to the nose. The typical symptoms are crusting, whistling, and bleeding. Most cocaine users know this to be a complication, and few will seek medical help unless they have stopped their cocaine habit and are looking to have their perforation repaired.
Perforations do occur from other causes such as repeated nose picking, nasal surgery, and repeated septal cauterizations for nosebleeds. Septal perforations, particularly the smaller ones, can be repaired. There is no sense in repairing them, though, unless the patient has clearly discontinued cocaine use. The crusting and bleeding from septal perforations is best controlled by anterior nasal application of ointments, as in case 1. The crusting is further alleviated by irrigating the nose with hypotonic pulsatile saline. The saline is delivered with a special nasal adapter using an adjustable Waterpik (Teledyne Waterpik, Fort Collins, Colorado). Two commercially available nasal adapters are the Ethicare (Ethicare Products, Fort Lauderdale, Florida) and the Grossan Nasal Irrigator (HydroMed, Inc, Los Angeles).
Case 7: New-Onset Epistaxis
A 45-year-old runner seeks care first thing Monday morning. While running a half marathon the day before, he developed a nosebleed that he could not control and that forced him out of the race. He has no family history of nasal bleeding and has not had problems with bleeding or epistaxis in the past.
During a physical examination 6 months ago, the patient had elevated cholesterol and mildly elevated blood pressure. He was given appropriate instructions for diet and began serious running in an effort to lose weight and further reduce the cholesterol. The running caused the usual lower-extremity discomfort. In part as a precautionary measure against arteriosclerotic heart disease and in part as an analgesic, the patient self medicated with one adult aspirin daily. On physical exam the patient has crusting over an obvious bleeding site within the nose.
The patient's nose is filled with bacitracin ointment and then occluded with a small piece of cotton. He is advised to replace the ointment-saturated cotton pledget two to three times a day for 5 days and is advised to discontinue the aspirin for this period. Based on personal experience, the most common cause of epistaxis in a 40-year-old healthy person is pharmacologic coagulopathy, and the most common offender is aspirin.
The patient returns the following Monday, and his nose exam is normal. He is counseled to use 80 mg of aspirin daily and advised that this is adequate cardiac protection and far less likely to cause recurrent nosebleeds.
Case 8: Serosanguineous Discharge
A 75-year-old tennis player, during her annual physical exam, says that for the past 3 months she has been experiencing a daily serosanguineous nasal discharge.
No other history is necessary. The diagnosis is a nasal or paranasal sinus cancer until ruled out. The recommended workup is a nasal endoscopy. If no tumor is seen, a sinus computed tomography scan with contrast is required.
Keeping Alert for the Unusual
Most nosebleeds are controlled with direct pressure to the glabella, nasal alae, or upper lip and columella. More persistent anterior nosebleeds are controlled with commercially available balloons and tampons. The occasional severe nosebleed requires anterior-posterior tamponade and referral to a specialist. The sports medicine physician must remain vigilant for the uncommon underlying coagulopathies and tumors.
Dr Terence Davidson is a professor of surgery in the Division of Otolaryngology-Head and Neck Surgery at the University of California, San Diego, and an associate dean for continuing medical education at the Veterans Administration Medical Center in San Diego. He is an editorial board member of The Physician and Sportsmedicine. Daniel Davidson is a premedical student at the University of Chicago. Address correspondence to Terence M. Davidson, MD, Division of Otolaryngology-Head and Neck Surgery, University of California, San Diego, 200 West Arbor Dr (8895), San Diego, CA 92103-8895.
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