Epistaxis: A Merck Manual of Patient Symptoms podcast

Epistaxis is nose bleeding. Bleeding can range from a trickle to a strong flow, and the consequences can range from a minor annoyance to life-threatening hemorrhage. Swallowed blood is a gastric irritant, so patients also may describe vomiting blood.

Pathophysiology

Most nasal bleeding is anterior, originating from a plexus of vessels in the anteroinferior septum (Kiesselbach's area).

Less common but more serious are posterior nosebleeds, which originate in the posterior septum overlying the vomer bone, or laterally on the inferior or middle turbinate. Posterior nosebleeds tend to occur in patients who have preexisting atherosclerotic vessels or bleeding disorders and have undergone nasal or sinus surgery.

Etiology

The most common causes of epistaxis are

• Local trauma (eg, nose blowing and picking)
• Drying of the nasal mucosa

There are a number of less common causes (see Table 1: Approach to the Patient With Nasal and Pharyngeal Symptoms: Some Causes of Epistaxis). Hypertension may contribute to the persistence of a nosebleed that has already begun but is unlikely to be the sole etiology.

Table 1
PrintOpen table in new window
Some Causes of Epistaxis Cause* Suggestive Findings Diagnostic Approach Common Local trauma (eg, nose blowing, picking, blunt impact) Apparent by history Clinical evaluation Drying of the mucosa (eg, in cold weather) Usually visibly dry on examination Clinical evaluation Less common Local infections (eg, vestibulitis, rhinitis) Crusting in the nasal vestibule, often with local pain and dry mucosa Clinical evaluation Systemic disorders (eg, AIDS, liver disease) Presence of known disease Mucosal erosions and hypertrophy Clinical evaluation Foreign bodies (mainly in children) Often recurrent epistaxis with a malodorous discharge Clinical evaluation Arteriosclerosis Usually in older patients Clinical evaluation Rendu-Osler-Weber syndrome Telangiectasias on the face, lips, oral and nasal mucosa, and tips of the fingers and toes Positive family history Clinical evaluation Tumor (benign or malignant) of the nasopharynx or paranasal sinuses Mass seen within the nose or nasopharynx Bulging of the lateral nasal wall CT Septal perforation Visible on examination Clinical examination Coagulopathy History of prior epistaxis or other bleeding sites, such as gingiva CBC with platelet count, PT/PTT *Epistaxis of any cause is more common among patients with bleeding disorders (eg, thrombocytopenia, liver disease, coagulopathies) and with anticoagulant use. In such patients, bleeding is also often more severe and difficult to treat. Some Causes of Epistaxis Cause* Suggestive Findings Diagnostic Approach Common Local trauma (eg, nose blowing, picking, blunt impact) Apparent by history Clinical evaluation Drying of the mucosa (eg, in cold weather) Usually visibly dry on examination Clinical evaluation Less common Local infections (eg, vestibulitis, rhinitis) Crusting in the nasal vestibule, often with local pain and dry mucosa Clinical evaluation Systemic disorders (eg, AIDS, liver disease) Presence of known disease Mucosal erosions and hypertrophy Clinical evaluation Foreign bodies (mainly in children) Often recurrent epistaxis with a malodorous discharge Clinical evaluation Arteriosclerosis Usually in older patients Clinical evaluation Rendu-Osler-Weber syndrome Telangiectasias on the face, lips, oral and nasal mucosa, and tips of the fingers and toes Positive family history Clinical evaluation Tumor (benign or malignant) of the nasopharynx or paranasal sinuses Mass seen within the nose or nasopharynx Bulging of the lateral nasal wall CT Septal perforation Visible on examination Clinical examination Coagulopathy History of prior epistaxis or other bleeding sites, such as gingiva CBC with platelet count, PT/PTT *Epistaxis of any cause is more common among patients with bleeding disorders (eg, thrombocytopenia, liver disease, coagulopathies) and with anticoagulant use. In such patients, bleeding is also often more severe and difficult to treat.

Evaluation

History: History of present illness should try to determine which side began bleeding first; although major epistaxis quickly involves both nares, most patients can localize the initial flow to one side, which focuses the physical examination. Also, the duration of bleeding should be established, as well as any triggers (eg, sneezing, nose blowing, picking) and attempts by the patient to stop the bleeding. Important associated symptoms prior to onset include symptoms of a URI, sensation of nasal obstruction, and nasal or facial pain. The time and number of previous nose-bleeding episodes and their resolution should be identified.

Review of systems should ask about symptoms of excessive bleeding, including easy bruising; bloody or tarry stools; hemoptysis; blood in urine; and excess bleeding with toothbrushing, phlebotomy, or minor trauma.

Past medical history should note presence of known bleeding disorders (including a family history) and conditions associated with defects in platelets or coagulation, particularly cancer, cirrhosis, HIV, and pregnancy. Drug history should specifically query about use of drugs that may promote bleeding, including aspirinSome Trade Names
BUFFERIN
ECOTRIN
GENACOTE
Click for Drug Monograph
and other NSAIDs, other antiplatelet drugs (eg, clopidogrelSome Trade Names
PLAVIX
Click for Drug Monograph
), heparinSome Trade Names
HEPFLUSH-10
Click for Drug Monograph
, and warfarinSome Trade Names
COUMADIN
Click for Drug Monograph
.

Physical examination: Vital signs should be reviewed for indications of intravascular volume depletion (tachycardia, hypotension) and marked hypertension. With active bleeding, treatment takes place simultaneously with evaluation.

During active bleeding, inspection is difficult, so attempts are first made to stop the bleeding as described below. The nose is then examined using a nasal speculum and a bright head lamp or head mirror, which leaves one hand free to manipulate suction or an instrument.

Anterior bleeding sites are usually apparent on direct examination. If no site is apparent and there have been only 1 or 2 minor nosebleeds, further examination is not needed. If bleeding is severe or recurrent and no site is seen, fiberoptic endoscopy may be necessary.

The general examination should look for signs of bleeding disorders, including petechiae, purpura, and perioral and oral mucosal telangiectasias as well as any intranasal masses.

Red flags: The following findings are of particular concern:

• Signs of hypovolemia or hemorrhagic shock
• Anticoagulant drug use
• Cutaneous signs of a bleeding disorder
• Bleeding not stopped by direct pressure or vasoconstrictor-soaked pledgets
• Multiple recurrences, particularly with no clear cause

Interpretation of findings: Many cases have a clear-cut trigger (particularly nose blowing or picking) as suggested by findings (see Table 1: Approach to the Patient With Nasal and Pharyngeal Symptoms: Some Causes of Epistaxis).

Testing: Routine laboratory testing is not required. Patients with symptoms or signs of a bleeding disorder and those with severe or recurrent epistaxis should have CBC, PT, and PTT.

CT may be done if a foreign body, a tumor, or sinusitis is suspected.

Treatment

Presumptive treatment for actively bleeding patients is that for anterior bleeding. The need for blood replacement is determined by the Hb level, symptoms of anemia, and vital signs. Any identified bleeding disorders are treated.

Anterior epistaxis: Bleeding can usually be controlled by pinching the nasal alae together for 10 min while the patient sits upright (if possible). If this maneuver fails, a cotton pledget impregnated with a vasoconstrictor (eg, phenylephrineSome Trade Names
NEO-SYNEPHRINE
Click for Drug Monograph
0.25%) and a topical anesthetic (eg, lidocaineSome Trade Names
XYLOCAINE
Click for Drug Monograph
2%) is inserted and the nose pinched for another 10 min. The bleeding point may then be cauterized with electrocautery or silver nitrate on an applicator stick. Cauterizing 4 quadrants immediately adjacent to the bleeding vessel is most effective. Care must be taken to avoid burning the mucous membrane too deeply; therefore, silver nitrate is the preferred method. Alternatively, a nasal tampon of expandable foam may be inserted. Coating the tampon with a topical ointment, such as bacitracinSome Trade Names
AK-TRACIN
BACIGUENT
BACIIM
Click for Drug Monograph
or mupirocinSome Trade Names
BACTROBAN
Click for Drug Monograph
, may help. If these methods are ineffective, various commercial nasal balloons can be used to compress bleeding sites. Alternatively, an anterior nasal pack consisting of ½-in petrolatum gauze may be inserted; up to 72 in of gauze may be required. This procedure is painful, and analgesics usually are needed; it should be used only when other methods fail or are not available.

Posterior epistaxis: Posterior bleeding may be difficult to control. Commercial nasal balloons are quick and convenient; a gauze posterior pack is effective but more difficult to position. Both are very uncomfortable; IV sedation and analgesia may be needed, and hospitalization is required.

Commercial balloons are inserted according to the instructions accompanying the product.

The posterior gauze pack consists of 4-in gauze squares folded, rolled, tied into a tight bundle with 2 strands of heavy silk suture, and coated with antibiotic ointment. The ends of one suture are tied to a catheter that has been introduced through the nasal cavity on the side of the bleeding and brought out through the mouth. As the catheter is withdrawn from the nose, the postnasal pack is pulled into place above the soft palate in the nasopharynx. The 2nd suture hangs down the back of the throat and is trimmed below the level of the soft palate so that it can be used to remove the pack. The nasal cavity anterior to this pack is firmly packed with ½-in petrolatum gauze, and the 1st suture is tied over a roll of gauze at the anterior nares to secure the postnasal pack. The packing remains in place for 4 to 5 days. An antibiotic (eg, amoxicillin/clavulanateSome Trade Names
AUGMENTIN

875 mg po bid for 7 to 10 days) is given to prevent sinusitis and otitis media. Posterior nasal packing lowers the arterial Po₂, and supplementary O₂ is given while the packing is in place.

Rarely, the internal maxillary artery and its branches must be ligated to control the bleeding. The arteries may be ligated with clips using endoscopic or microscopic guidance and a surgical approach through the maxillary sinus. Alternatively, angiographic embolization may be done by a skilled radiologist.

Bleeding disorders: In Rendu-Osler-Weber syndrome, a split-thickness skin graft (septal dermatoplasty) reduces the number of nosebleeds and allows the anemia to be corrected. Laser (Nd:YAG) photocoagulation can be done in the operating room. Selective embolization also is very effective, particularly in patients who cannot tolerate general anesthesia or for whom surgical intervention has not been successful. New endoscopic sinus devices have made transnasal surgery more effective.

Blood may be swallowed in large amounts and, in patients with liver disease, should be eliminated promptly with enemas and cathartics to prevent hepatic encephalopathy. The GI tract should be sterilized with nonabsorbable antibiotics (eg, neomycinSome Trade Names
NEO-FRADIN
NEO-RX
Click for Drug Monograph
1 g po qid) to prevent the breakdown of blood and the absorption of ammonia.

Key Points

• Most nosebleeds are anterior and stop with direct pressure.
• Screening (by history and physical examination) for bleeding disorders is important.
• Patients should always be asked about aspirinSome Trade Names
  BUFFERIN
  ECOTRIN
  GENACOTE
  Click for Drug Monograph
  or ibuprofenSome Trade Names
  ADVIL
  MOTRIN
  NUPRIN
  Click for Drug Monograph
  use.

Last full review/revision July 2012 by Marvin P. Fried, MD

Content last modified November 2012