Nosebleeds Flashcards
(18 cards)
What is the blood supply of the nose?
The blood supply to the nose is derived from branches of the internal (anterior and posterior ethmoid arteries) and external carotid arteries (sphenopalatine and branches of the internal maxillary arteries).
Bleeding usually occurs when the mucosa is eroded and vessels become exposed and subsequently break.
What is the classification of epistaxis?
Anterior haemorrhage - the source of bleeding is visible in about 95% of cases - usually from the nasal septum, particularly Little’s area which is where Kiesselbach’s plexus forms (an anastomotic network of vessels on the anterior portion of the nasal septum).
Posterior haemorrhage - this emanates from deeper structures of the nose and occurs more commonly in older individuals. Nosebleeds from this area are usually more profuse and have a greater risk of airway compromise.
What is the aetiology of epistaxis?
Trauma
Disorders of platelet function
Rhinosinusitis
Drugs such as aspirin and anticoagulants
Abnormalities of blood vessels in the elderly arteriosclerotic vessels prolong bleeding.
Hereditary haemorrhagic telangiectasia (Osler-Rendu-Weber syndrome) causes recurrent epistaxis from nasal telangiectasias.
Malignancy of the nose may present with bleeding
juvenile angiofibroma is a highly vascular benign tumour that typically presents in adolescent males.
GPA
Cocaine
What is the most common cause of epistaxis.
Epistaxis is usually benign, self-limiting and spontaneous. The majority of nosebleeds are caused by simple trauma.
What type of trauma to the nose can cause epistaxis?
Trauma to the nose (the most common cause) - especially nose picking! Insertion of foreign bodies and excessive nose blowing may also be seen as trauma. The latter is likely to occur with a cold when the nasal mucosa is congested. Sinusitis causes nasal congestion.
Examples of platelet dysfunction causing epistaxis?
Thrombocytopenia and other causes of abnormal platelets, including splenomegaly and leukaemia. Waldenström’s macroglobulinaemia may present with nosebleeds.
Idiopathic thrombocytopenic purpura (ITP) can occur in children and young adults.
Why does cocaine cause epistaxis?
If the septum looks sloughed or atrophic ask about use of cocaine.
The drug is usually taken by inhalation and it has a very strong vasoconstrictive effect that can lead to complete obliteration of the nasal septum.
What should you ask in the hx of a patient presenting with a nosebleed?
Determine if blood is running out of the nose and one nostril (usually anterior) or if blood is running into the throat or from both nostrils (usually posterior).
Ask about trauma (including nose picking).
Note family or past history of clotting disorders or hypertension.
Note whether there has been previous nasal surgery.
Discuss medication - especially clopidogrel, warfarin, aspirin.
Enquire about any facial pain or otalgia - these may be presenting signs of a nasopharyngeal tumour
In young male patients ask about nasal obstruction, headache, rhinorrhoea and anosmia - signs of juvenile nasopharyngeal angiofibroma.
What are the investigations for nosebleeds?
These are unnecessary in most (mild) cases but recurrent or severe cases require at least FBC, coagulation studies and blood typing.
Quite marked anaemia can result but a haematological malignancy may also be revealed.
Any suspicion of malignancy of the nose or other abnormality should require referral to an ENT surgeon. CT scanning and/or nasopharyngoscopy are the investigations of choice.
In order to perform anterior rhinoscopy you need a Thuddicum’s speculum. It gives a good view of the nasal vestibule, the anterior nasal septum and the front end of the inferior and middle turbinates. It is very important to carry out this examination. If a Thuddicum’s speculum is not available an otoscope can be used to carry out the anterior rhinoscopy.
What is the initial management of epistaxis?
Resuscitate the patient (if necessary) - remember the ABCD(E) of resuscitation.
Ask the patient to sit upright, leaning slightly forward, and to squeeze the bottom part of the nose (NOT the bridge of the nose) for 10-20 minutes to try to stop the bleeding. The patient should breathe through the mouth and spit out any blood/saliva into a bowl. An ice pack on the bridge of the nose may help.
Monitor the patient’s pulse and blood pressure.
If bleeding has stopped after this time (as it does in most cases) proceed to inspect the nose, using a nasal speculum; consider cautery.
If the history is of severe and prolonged bleeding, obtain expert help - and watch carefully for signs of hypovolaemia.
What is the general advice given to patient presenting with nosebleeds?
Do not blow your nose for a week
Do not clean the nose
Avoid hot baths and showers
Let food cool down and do not drink hot tea and coffee for the first 72 hours
No strenuous exercise for a week
Typically patients are told to avoid the above for 2 weeks. You must always warn them that the epistaxis may recur, if it does, then they should apply firm pressure for 15 minutes as shown below. If this fails to work then they should attend A&E.
What is nasal cautery?
Nasal cautery is a common treatment of epistaxis. A caustic agent such as silver nitrate (chemical cautery) or an electrically charged wire such as platinum (electrocautery) is used to stop bleeding in the nasal mucous membrane.
Chemical cautery of the visible blood vessels on the anterior part of the nasal septum is the most popular treatment method for idiopathic recurrent nosebleeds.
How do you perform nasal cautery?
Carefully examine the nasal cavity, looking for any bleeding points, which can usually be seen on the anterior septum - either an oozing point or a visible clot. Note whether there is any pus, suggesting local bacterial infection.
Blowing the nose decreases the effects of local fibrinolysis and removes clots, permitting a clearer examination.
Applying a vasoconstrictor before examination may reduce haemorrhage and help locate the bleeding site. A topical local anaesthetic reduces pain from examination and nasal packing.
Apply a silver nitrate cautery stick for ten seconds or so, working from the edge and moving radially - never both sides of the septum at the same session.
What is the management of epistaxis in children?
In children, the bleeding usually comes from Little’s area and is often precipitated by digital trauma.
In most cases, it is possible to prevent further bleeding by using a cream such as naspetin or bactroban.
These have anti-bacterial properties and treat any staphylococcal colonization that may be causing inflammation of the nasal vestibule but also have a protective effect.
The cream should be gently applied by squirting a small amount in to the nostril followed by careful posterior massage of the nasal alar so that the cream is worked backwards in to the nasal cavity.
It is also important to strongly discourage digital trauma.
What is the next line management of epistaxis after nasal cautery?
If bleeding continues, packing may be considered.
A topical application of injectable form of tranexamic acid has been shown to be better than anterior nasal packing in the initial treatment of idiopathic anterior epistaxis.
It may be necessary to ligate the sphenopalatine artery endoscopically, or occasionally the internal maxillary artery and ethmoid arteries, or perform endovascular embolisation of the internal maxillary artery, when packing fails to control a life-threatening haemorrhage.
Ligation of the external carotid artery is a last resort.
What is anterior nasal packing?
Anterior nasal packing is the next step in your systematic management after cautery. Remember, the floor of the nose is horizontal & goes straight back, not up, so that’s the direction your packs should go.
Patients who bleed through anterior packs and spit out clots may be having a posterior bleed. This requires a posterior pack to be inserted.
What is posterior nasal packing?
Most often this is simply a foley catheter passed into the nose so that the balloon is in the postnasal space.
The balloon can then be blown up, pulled forward to apply pressure to the back of the nose and then clipped at the front to stop it from falling backwards.
The anterior nose can then be repacked. It is also a good idea to call your SpR at this point too.
Posterior packs normally stay in for 48 hours. If the patient continued to bleed despite this then the next step would be to ligate the artery that is supplying the bleeding point.
The two vessels that are commonly ligated are the sphenopalatine artery and the anterior ethmoidal artery.
What are the complications of packing?
Anosmia.
Pack falling out and continued bleeding.
Breathing difficulties and aspiration of clots.
Posterior migration of the pack, causing airway obstruction and asphyxia.
Perforation of the nasal septum or pressure necrosis of cartilage.
Nasal packs are usually left for two or three days and the patient should see an ENT specialist. The blood is an excellent culture medium for bacteria and so broad-spectrum antibiotics like amoxicillin are usually given.
