Epistaxis

Epistaxis is bleeding from the nose. Most cases are anterior, from Little area (Kiesselbach plexus) on the anterior septum, and stop with simple measures. Posterior bleeding from the sphenopalatine artery territory is less common, bleeds heavily, and needs admission.

Anatomy. The anterior septum receives anastomosing branches from the anterior and posterior ethmoidal, sphenopalatine, greater palatine and superior labial arteries (Little area). The posterior nose is supplied by the sphenopalatine artery (Woodruff plexus).

Classification. Anterior or posterior; spontaneous or traumatic; acute or recurrent; primary (idiopathic) or secondary (local, systemic, drug related).

Severity. Minor (under 10 minutes, stops with pressure), moderate (over 10 minutes despite pressure), and severe (haemodynamic compromise, posterior, or needing transfusion).

History. Duration, side, volume, frequency, first aid used, trauma, nose picking, recent upper respiratory infection, nasal surgery, intranasal drug use (cocaine, steroids, decongestants), oxygen therapy, dryness. Family history of bleeding (hereditary haemorrhagic telangiectasia, von Willebrand disease). Bruising, gum bleeding, menorrhagia, melaena, haematuria, anticoagulant and antiplatelet use, alcohol, liver and kidney disease, and cancer or weight loss.

Drug history. Warfarin, direct oral anticoagulants, aspirin, clopidogrel, NSAIDs, selective serotonin reuptake inhibitors, ginkgo and fish oil, intranasal corticosteroids, and chemotherapy.

Examination. Airway, breathing, circulation; pulse, blood pressure, orthostatic change, oxygen saturation. Anterior rhinoscopy with a headlight after clearing clots (suction), identifying the bleeding point or telangiectasia (lips, tongue, fingertips), septal deviation, perforation, ulcer, mass or foreign body. Oropharynx for blood trickling in the posterior pharynx. Skin for bruising, purpura and telangiectasia, and abdomen for hepatosplenomegaly.

Red flags

• Haemodynamic instability or bleeding over 30 minutes despite pressure
• Posterior bleeding or bilateral heavy bleeding
• Anticoagulant use with major bleeding, or bleeding disorder
• Unilateral recurrent bleeding with obstruction, mass or facial pain
• Head or facial trauma, or CSF leak
• Young male with unilateral obstruction (juvenile nasopharyngeal angiofibroma)
• Hereditary haemorrhagic telangiectasia
• Pregnancy with hypertension
• Bruising, petechiae or other bleeding sites (haematological disease)

Special groups. Children: nose picking, dryness, foreign body, bleeding disorder; consider non-accidental causes only when other features. Older adults: hypertension, anticoagulants. Pregnancy: hormonal rhinitis. Region specific: schistosomiasis, brucellosis, leishmaniasis, typhoid, dengue and other viral haemorrhagic fevers in some regions.

Local

• Digital trauma (nose picking), dry mucosa, rhinitis, upper respiratory infection
• Facial and nasal trauma, fracture, foreign body, septal deviation and perforation
• Intranasal drug use (cocaine, corticosteroids), oxygen therapy, continuous positive airway pressure
• Hereditary haemorrhagic telangiectasia
• Nasal polyps, papilloma, nasal and sinus carcinoma, nasopharyngeal carcinoma, juvenile nasopharyngeal angiofibroma, haemangioma
• Granulomatosis with polyangiitis, sarcoidosis, tuberculosis, syphilis
• Post-surgical bleeding
• Skull base trauma, carotid artery aneurysm (traumatic or internal carotid, rare)

Systemic and drug related

• Hypertension (usually a coincident finding, rarely a cause)
• Anticoagulants and antiplatelets, liver disease and coagulopathy
• Thrombocytopenia and platelet dysfunction (immune thrombocytopenia, leukaemia, uraemia, myelodysplasia, marrow failure)
• Von Willebrand disease, haemophilia and other inherited bleeding disorders
• Vitamin K deficiency, disseminated intravascular coagulation
• Viral haemorrhagic fevers, dengue, typhoid, leptospirosis
• Alcohol excess

Reasoning. Resuscitate and stop the bleeding first. Then decide on investigation by severity, recurrence, anticoagulant use and findings.

First line. Pulse, blood pressure, oxygen saturation, and blood tests for moderate to severe bleeding or anticoagulant use: full blood count, group and save, urea, creatinine, liver function, prothrombin time or INR, activated partial thromboplastin time, and fibrinogen. Minor self-limited bleeding in a well patient needs no blood tests.

Targeted tests. Platelet function and von Willebrand screen (von Willebrand factor antigen, activity and factor VIII) for recurrent bleeding with a bleeding history. Blood film and bone marrow assessment for cytopenias. Nasal endoscopy for recurrent unilateral bleeding. CT or MRI with angiography for suspected tumour or vascular lesion.

Genetic testing and screening for visceral involvement (pulmonary, hepatic, cerebral arteriovenous malformations) in suspected hereditary haemorrhagic telangiectasia (Curacao criteria: recurrent epistaxis, telangiectasia, visceral lesions, and first degree relative; three criteria definite). ANCA and angiotensin converting enzyme for granulomatous disease. Dengue, typhoid or other infection tests in febrile patients in endemic areas.

Limitations. Blood tests do not predict nasal bleeding. Blood pressure measured during acute bleeding is unreliable.

Resuscitation. For haemodynamic compromise: oxygen, two large bore IV cannulae, crystalloid 500 mL boluses (0.9 percent sodium chloride) reassessed after each. Blood transfusion for hypovolaemia or haemoglobin under 70 g/L (or under 80 g/L with cardiovascular disease). Urgent senior and ENT help.

First aid (all patients). Sit upright leaning forward, firm continuous pinch of the soft part of the nose (not the bridge) for 15 minutes without releasing, spitting out blood, and ice or a cold compress. Repeat for a further 15 minutes if bleeding continues.

Topical vasoconstriction and cautery.

• Oxymetazoline 0.05 percent nasal spray, 2 sprays to the bleeding nostril, or a cotton pledget soaked in oxymetazoline or in 1 mL of adrenaline 1 in 1,000 (1 mg/mL) placed in the nose for 5 to 10 minutes. Avoid in uncontrolled hypertension and severe cardiac disease.
• If the bleeding point is visible: silver nitrate cautery applied to a single side of the septum for 5 to 10 seconds after topical anaesthesia (lidocaine 4 percent with phenylephrine or lidocaine 5 percent with phenylephrine 0.5 percent, by pledget for 5 to 10 minutes).
• Do not cauterise both sides of the septum at the same visit, because of perforation.

Anterior packing when bleeding persists. Absorbable packing (haemostatic gauze or gelatin foam) or non-absorbable packing (nasal tampon such as expandable polyvinyl alcohol sponge, lubricated and inserted along the floor, hydrated with 10 mL of saline). Review at 24 to 48 hours (remove non-absorbable packs by 48 to 72 hours; maximum 5 days).

Antibiotic prophylaxis for packs is not routine. Give amoxicillin with clavulanic acid 625 mg orally three times daily for the duration of the pack only when there is a prosthetic heart valve or other high risk, or for packs left over 48 hours (evidence is limited).

Posterior bleeding. Posterior balloon catheter or double balloon device, with admission, oxygen monitoring (hypoxia can occur), analgesia and ENT review. Persistent bleeding: endoscopic sphenopalatine artery ligation or interventional radiology embolisation.

Tranexamic acid. Topical tranexamic acid 500 mg (5 mL of 100 mg/mL injection solution) applied on a pledget to the bleeding site, or 1 g orally three times daily for 5 days, may reduce rebleeding in recurrent epistaxis (evidence is limited). Intravenous 1 g over 10 minutes for severe bleeding. Reduce the dose in renal impairment (creatinine 120 to 249 micromol/L: 1 g twice daily; 250 to 500: 1 g daily; over 500: 500 mg daily). Avoid in thromboembolic disease and haematuria.

Anticoagulated patients. Minor bleeding: local measures, do not stop therapy.

Major or life threatening bleeding: stop the drug, and reverse:

• warfarin with vitamin K 5 to 10 mg IV and prothrombin complex concentrate 25 to 50 IU/kg adjusted to INR and product label
• dabigatran with idarucizumab 5 g IV
• apixaban or rivaroxaban with andexanet alfa or prothrombin complex concentrate dosed as the product label states
• heparin with protamine 1 mg for each 100 units given in the last 2 to 3 hours (maximum 50 mg)

Withhold antiplatelets only after discussion with the prescriber.

Coagulopathy and thrombocytopenia. Treat the cause: fresh frozen plasma 15 mL/kg for coagulopathy; platelet transfusion for platelets under 50 x 10^9/L with active bleeding; desmopressin 0.3 micrograms/kg IV over 30 minutes for mild von Willebrand disease or haemophilia A (check sodium; restrict fluids); haematology referral.

Hereditary haemorrhagic telangiectasia. Gentle packing with atraumatic non-adherent dressings, saline gel and humidification, topical tranexamic acid, laser or other ablation by ENT, and systemic therapy (bevacizumab by specialists for severe disease). Iron replacement for anaemia (ferrous sulphate 200 mg orally once or twice daily, or IV iron when oral therapy fails).

Prevention of recurrence. Humidification, saline spray 2 to 3 times daily, petroleum jelly or antiseptic nasal cream (chlorhexidine 0.1 percent with neomycin 0.5 percent cream applied to the anterior nostril 2 to 3 times daily for 10 days, avoiding neomycin allergy). Avoid nose picking and blowing. Avoid hot drinks and straining for 24 hours after bleeding. Review of antiplatelet and NSAID use with the prescriber. In children, trim fingernails.

Neoplastic and granulomatous disease. Urgent ENT referral with biopsy. Angiofibroma: do not biopsy; MRI and angiography, embolisation and surgery.

Monitoring. Haemoglobin after significant bleeding, pulse and blood pressure, oxygen saturation with balloon devices, and nasal pack removal at 24 to 48 hours.

Referral and escalation. Immediate ENT for posterior bleeding, failure of anterior packing, haemodynamic instability or suspected tumour. Haematology for suspected bleeding disorder. Interventional radiology for refractory bleeding. Genetics and specialist centre for hereditary haemorrhagic telangiectasia.

Admission criteria. Posterior packing, haemodynamic compromise, uncontrolled bleeding, anticoagulation with major bleeding, severe anaemia, significant comorbidity, or inability to manage at home.

Discharge and safety netting. Advise on first aid and prevention. Return for bleeding over 15 minutes despite pressure, dizziness, faintness, black stools, recurrent heavy bleeding, bruising, or new facial swelling.