Nosebleeds (Epistaxis)

Epistaxis is the medical term for a nosebleed, which occurs when the lining of the nasal passage is irritated or lacerated and bleeds abnormally. Epistaxis can range from an occasional minor nosebleed that resolves itself with simple first aid measures (comprising the wide majority of cases) to sustained or excessive bleeding that requires medical assistance. Nosebleeds are divided into two types:

• Anterior, in which the bleeding occurs in the front half of the nasal passage
• Posterior, in which the blood moves out the back of the nasal passage. Posterior epistaxis is rarer and can be harder to identify and treat.

Left untreated, recurrent or chronic epistaxis can lead to significant blood loss.

Causes

Epistaxis can have a wide range of causes. Mechanical disturbances, such as nose-picking, forceful nose-blowing, or an injury to the face or head, usually are the immediate cause. Epistaxis can be facilitated and exacerbated by a wide range of underlying conditions, including drying of the nasal passages, high blood pressure, cancer, an infection, cocaine use, or a bleeding disorder such as hemophilia. All of these conditions can inflame the nasal passages, making them more susceptible to hemorrhage or problems with clotting.

Diagnosis

Beyond a physical examination, patients with recurrent or severe epistaxis may be assessed with an endoscopic camera inserted in the nose. Performed under general anesthesia, this procedure may be followed directly by some of the treatments listed below. In addition, an angiogram, which provides a view of the blood flow in the area, may be done.

Treatment

Usually, epistaxis and other hemorrhages of the head and neck are treated with first aid, cautery, packing, surgical procedures, and embolization.

• First aid treatment includes pinching the nose, leaning forward, and using a nasal sprays or ointments that keep the area moist.
• Cautery is the use of a caustic substance (silver nitrate) or an electrical instrument to seal the site of the hemorrhage and induce clotting.
• Packing is the insertion of gauze or an inflatable balloon into the sinuses to keep the area moist and apply pressure to the site of hemorrhage, but this treatment can be uncomfortable and may lead to infection.
• Surgical procedures, such as surgical reconstruction of the dividing wall in the middle of the nose (the nasal septum) and arterial ligation, in which an artery, such as the external carotid artery, the internal maxillary artery, or the ethmoid artery, is constricted with either cautery or a small metal clip.
• Embolization for posterior epistaxis and other hemorrhages of the head and neck, like other interventional neuroradiological procedures, involves the insertion of a catheter, or tube, through an artery in the groin. The tube is guided up through the blood vessels to the site of the epistaxis, where it delivers small particles of a spongy material that embolize, or clog up, the artery that feeds the epistaxis to allow the hemorrhage to heal. This material eventually will break down. Alternatively, small pieces of soft flexible platinum wire that induce clotting may be used to embolize the artery.