Epistaxis (Nosebleeds)

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• Epistaxis (Nosebleeds) What is it?
• Causes
• Types
• Epistaxis First Aid
• When should I go to the hospital?
• Diagnosis
• Treatment
• Prevention

Epistaxis (Nosebleeds)

Epistaxis or nosebleeds is a common condition in which there is bleeding from one or both sides of the nasal septum due to tearing of the small blood vessels that feed the septum caused by hard nasal picking, a severe impact on the nasal septum, dry nasal mucosa, or a condition in which the body's temperature rises. In addition, abnormalities such as clotting disorders or hemophilia, nasal polyps, or nasopharyngeal cancer can all cause epistaxis, as can some medications, such as anticoagulants in patients with heart disease, which can cause epistaxis as well.

What causes epistaxis/nosebleeds?

Epistaxis or nosebleeds occurs when small blood vessels or capillaries in the nasal septum rupture or tear, leading to bleeding from one or both nostrils. Most epistaxis is not severe and will stop with home remedies. We can classify the causes of epistaxis into common and abnormal conditions as follow:

Common conditions:

• Dry air due to high temperature and low relative humidity inside the living facility causes blood vessels in the nasal septum to dry out, clot, and burst when impacted.
• Nose-picking
• Excessive sneezing or nose blowing
• An accident with severe impact to the nose, head, or face
• Certain medications, such as intranasal steroids for allergies, vasoconstrictor decongestants, and antihistamines, cause the nasal septum to dry out and bleed.
• The use of anticoagulant medications such as warfarin or heparin in patients with heart disease
• The use of a CPAP machine (Continuous positive airway pressure) to treat snoring or sleep apnea
• After nose surgery, nasal septal surgery, and sinus surgery
• Acute sinusitis or upper respiratory infections
• Upper respiratory infections caused by viruses, bacteria, or fungi
• Nasal cannula insertion, nasogastric tube insertion
• The use of ammonia, a volatile substance that can irritate the respiratory system.
• Overdosage on aspirin
• Introducing foreign objects into the nasal cavity or there is a foreign object struck in the nose.

Abnormal conditions or diseases including:

• Septal deviation
• Septal perforation
• Inflammation of the sinuses
• Clotting disorders such as hemophilia
• Bleeding disorders
• Immune thrombocytopenia (ITP)
• Hereditary hemorrhagic telangiectasia
• Leukemia
• Nasal polyps
• Nasal cancer
• Nasopharyngeal carcinoma (NPC)
• Nasal tumors

How many different types of epistaxis/nosebleeds are there?

There are two types based on the location of the epistaxis:

1. An anterior nosebleed is bleeding from the front of the nose at the lower part of the nasal septum on both sides. The capillaries and blood vessels in the area are small, fragile, and easily broken. Anterior nosebleeds are the most common types of epistaxis/nosebleeds and are usually not serious. This type of epistaxis is most common in children, and first aid at home can stop the bleeding.
2. A posterior nosebleed is bleeding from deep inside the nose caused by a tear or rupture of a large blood vessel. A posterior nosebleed is more severe than an anterior nosebleed due to the volume of bleeding that may run down the throat, causing dangerous choking. Hence, if there is severe epistaxis, the patient should see a medical doctor as soon as possible to stop the bleeding. This type of epistaxis is more common in adults.

Epistaxis First Aid: How to stop nosebleeds at home?

At-home basic first aid for epistaxis or nosebleeds includes the following procedures:

1. Sit upright, leaning slightly forward to prevent blood from flowing into the throat and lungs, which can block the airway.
2. Use a damp cloth to help catch the blood.
3. Pinch both sides of the nostrils firmly and constantly press on the front of the nasal septum for 5 minutes until the bleeding stops while breathing through the mouth.
4. Spit the blood out to avoid swallowing and vomiting.
5. Apply a cold compress to the forehead, bridge of the nose, and back of the neck with ice-wrapped clothes.
6. Avoid blowing your nose vigorously, including picking your nose, lifting heavy objects, overexerting yourself, or participating in sports, as this may slow blood clotting.
7. Monitor for shock.

Epistaxis/nosebleeds—When should I go to the hospital?

Most epistaxis or nosebleed is not severe, and the patient can initiate at-home first aid. However, epistaxis with lots of bleeding could be dangerous. Therefore, if you notice any of the following symptoms, you should see a medical doctor as soon as possible for a thorough diagnosis:

• Nosebleeds that last for more than 5 minutes
• Been in an accident or received an impact to the head, face, or nose
• Nosebleeds come out as blood clots.
• Pale skin, pale lips, feeling lightheaded, dizzy, or fainting.
• Blood choking, vomiting blood, and difficulty breathing.
• Rapid heartbeat
• Nosebleeds with a palpable neck mass or a lump in the nasal septum could be due to a nasal polyp, nasopharyngeal tuberculosis, or nasopharyngeal cancer that needs further investigation by a physician

How to diagnose epistaxis/nosebleeds?

At the hospital, the otolaryngologist will prioritize stopping nose bleeding to prevent hypotension from blood loss. In some cases, epistaxis can be a sign of a more serious issue or complicated disease, such as nasopharyngeal cancer, which is usually detected while receiving treatment for epistaxis at a hospital. A thorough evaluation of epistaxis from an ear, nose, and throat specialist can promptly pinpoint underlying diseases causing the epistaxis.

Epistaxis: Hospitalization is the treatment to stop nosebleeds at the hospital?

If the epistaxis or nosebleed persists, the patient should seek treatment at a hospital as soon as possible to avoid shock and unconsciousness from blood loss. Upon arriving at the hospital, an otolaryngologist will arrange for the patient to sit in an appropriate position, assess the overall condition and determine the treatment method based on the symptom severity and the location of the bleeding. The otolaryngologist can choose among the following treatments:

• Topical decongestants apply to the nasal septum. A topical vasoconstrictor constricts only the blood vessels in the nasal mucosa, reducing swelling and allowing the doctor to see the condition inside the nasal septum to determine the source of the nosebleeds or if there are foreign bodies, including abnormalities of the nasal septum.
• Cauterization with chemicals such as silver nitrate or thermal energy, such as electrocautery, to seal the bleeding blood vessel. The otolaryngologist will administer local anesthetics on the nasal septum to numb the nose before treatment.
• Anterior nasal packing: The otolaryngologist will insert special nasal sponges into the nostrils and press on them to stop the bleeding. The absorbent material will remain for 48–72 hours before removal. In some cases, the otolaryngologist may consider using a self-dissolving material without the need to remove it.
• Internal artery ligation: In some cases, the doctor may decide on internal artery ligation or artery occlusion to stop bleeding by using an occlusive tube with nasal endoscopy to tie off a blood vessel to stop bleeding. Endoscopic technology harnesses advanced medical technology to help the doctor to locate the source of bleeding, particularly in the posterior nasal septum, and allow the bleeding to stop quickly.
• Medication adjustments or new prescriptions: Some medications contain anticoagulants. Therefore, in patients with congenital diseases, the otolaryngologist may consider adjusting the existing medications or using a new drug to help control blood pressure, or prescribing an anticoagulant, such as Tranexamic, to help with the blood clot.
• Surgical repair of a broken nose or correction of a deviated nasal septum: In patients with a broken nose or a deviated septum, the doctor may consider surgery to stop nosebleeds, repair the broken nose, or reposition a deviated nasal septum. The anesthesiologist will administer anesthesia before surgery.
• Foreign body removal: Many epistaxes are caused by children accidentally putting toys or foreign objects into their noses, resulting in nosebleeds. The doctor will examine the nose to see if there are foreign bodies, and their removal will help stop the bleeding for good.

How to prevent epistaxis and nosebleeds?

• Do not pick or blow your nose forcefully.
• Wear a helmet and seat belt while driving to prevent accidents or injuries to the nose, head, or face.
• Do not smoke, breathe in secondhand smoke, and avoid inhaling chemicals, dust, and PM2.5 pollutants.
• Refrain from spending too much time in dry, hot, or cold environments.
• Apply Vaseline to the nose or use nasal saline drops to prevent the nasal septum from drying out.
• Eat fruits and vegetables that are high in vitamin C to nourish and strengthen the capillaries in the nose.
• Drink enough water and get enough rest.

Epistaxis/nosebleed diagnoses by an ear, nose, or throat specialist at the hospital

Epistaxis or nosebleeds can happen to anyone, regardless of gender or age. Epistaxis frequently occurs with no apparent reason but should be systematically examined. Even though most nosebleeds are not dangerous and are manageable with first aid at home, those who experience heavy nosebleeds should not disregard the condition and should go to the hospital for proper management. Persistent heavy bleeding can be life-threatening, especially in young children, seniors, patients with anemia or dehydration, or those taking anticoagulants. Ultimately, those with nasal bleeding caused by malignant disease benefit from an accurate diagnosis, prompt hemostasis, and appropriate care that effectively halts the disease's progression.