What Is Epistaxis?

What is epistaxis?

Epistaxis or commonly called a nosebleed is defined as a type of bleeding that occurs from the nostrils, the nasal cavity, or the nasopharynx. Nosebleeds are mostly caused by the rupture of blood vessels inside the nose. Bleeding may be spontaneous or caused by injuries or trauma. Nosebleeds usually go away on their own and are rarely a cause for concern. 

Epistaxis is categorized according to the site of bleeding:

• Anterior (front of the nose)
• Posterior (back of the nose)

At some point in time, around 60 percent of the population will experience epistaxis and approximately 6 percent may need immediate medical attention.  

Causes of Epistaxis

Most cases of epistaxis have unknown causes. However, its other common causes include trauma, the use of certain medications, nasal or sinus surgeries, or tumors.

Nosebleeds often occur in the front part of the nose, usually on the wall that divides the two sides of the nose or the nasal septum. The blood vessels in the nasal septum can be easily damaged. When there is a tear in these blood vessels, a nosebleed occurs. Nose picking with sharp fingernails and nasal irritation caused by blowing too much can cause a tear in the blood vessels, leading to a nosebleed. 

Heated indoor air can dehydrate the nasal membranes and make the blood vessels more prone to rupture. For this reason, nosebleeds are more likely experienced during the winter season and dry climates. 

Frequent or recurring nosebleeds may be due to any of the following conditions:

• Allergies
• Upper respiratory infections
• Dry nose and nose picking
• Vigorous nose blowing and nose picking
• Bleeding disorders (e.g., von Willebrand disease or hemophilia)
• High blood pressure
• The use of anticoagulant or blood-thinning medications such as coumadin/warfarin
• The use of anti-inflammatory medications such as aspirin or ibuprofen
• The use of decongestants or antihistamines for colds and allergies
• Nasal fracture
• Basal skull fracture 
• Hereditary hemorrhagic telangiectasia (HHT)
• Malignant and nonmalignant tumors, especially in smokers and older adults

Most nosebleeds are not considered as a medical emergency. However, if a nosebleed lasts for more than 20 minutes or occurs after an accident or injury, seek immediate medical attention. It may be something more serious, such as a posterior nosebleed. 

Injuries due to a vehicular accident, a punch in the face, or a fall may cause a nosebleed. If a nosebleed occurs after an injury, it may be a sign of an internal bleeding, skull fracture, or a broken nose. 

Diagnosis

To determine the cause of the nosebleed, the doctor will first perform a physical examination. The doctor will check for any foreign objects in your nose and ask questions regarding your other symptoms, current medications, medical history, and if you have had any recent injuries. 

There is no specific test that can identify the exact cause of nosebleeds. However, doctors may use certain diagnostic tests to help determine the cause. They include:

• Complete blood count (CBC)
• Partial thromboplastin time (PTT)
• Facial X-ray 
• CT scan of the nose
• Nasal endoscopy

Treatment

When it comes to treating nosebleeds, it is important to try to determine the site of the bleeding, whether it is in the front (anterior) or back of the nose (posterior). Medical attention is required in posterior nosebleeds. 

Anterior Nosebleeds

Anterior nosebleeds are often due to dry air. This can be prevented by gently applying petroleum jelly, saline gel, or topical antibiotic inside the nose, particularly the septum, through the use of a Q-tip. 

The following steps can help stop an anterior nosebleed:

1. Remain calm. Agitation tends to cause more bleeding. 
2. Sit up. Do not lie down to avoid swallowing blood.
3. Squeeze the soft part of the nose and ensure that your nostrils are entirely closed.
4. Slightly lean forward, keep your nostrils closed for 5-10 minutes, and breathe through your mouth. 
5. After 5-10 minutes, release your nostrils and check if the bleeding has stopped. 
6. If bleeding still continues, repeat these steps. 

A cold compress can also be applied over the bridge of the nose to help close off small, ruptured blood vessels. 

Posterior Nosebleeds

Posterior nosebleeds require immediate medical attention to stop the bleeding and prevent heavy blood loss. Although posterior nosebleeds are less commonly experienced, they are more serious than anterior nosebleeds. 

Older adults, individuals with hypertension (high blood pressure), facial or nasal injury, and a history of sinus or nasal surgery are more prone to experiencing posterior nosebleeds.  

Treatment of posterior nosebleeds generally includes nasal packing and/or cautery, which involves the burning and sealing of blood vessels to stop and prevent further bleeding. 

Frequent Nosebleeds

It is important to see an otolaryngologist or an ENT (ear, nose, and throat) specialist if you frequently experience nosebleeds. These specialists will thoroughly examine your nose using an endoscope before recommending treatment.

Prevention

Although you cannot always prevent a nosebleed from happening, there are ways to reduce your risk of getting it:

• Avoid picking your nose and keep your fingernails short and clean.
• Avoid rubbing or blowing your nose too hard.
• Keep your nostrils moist by applying a thin layer of petroleum jelly three times a day and before bedtime. 
• Topical antibiotics like Polysporin and Bacitracin can also be applied. 
• Use a humidifier and saline nasal products to keep your nostrils moist. 
• Avoid using medications for cold and allergies too often because they can also dry out your nose. 
• Stop smoking since it can dry out and irritate the inside of your nose. 
• Always wear a seatbelt to protect you from any facial trauma in case of an accident. 
• When playing sports, such as hockey, lacrosse, or karate, make sure to wear proper headgear to protect your face and reduce your risk of facial injuries. 
• Avoid breathing in irritating chemicals by wearing proper protective gears or equipment. 

Certain medications can make nosebleeds worse. Consult your doctor if you have any concerns regarding its side effects, particularly nosebleeds. Do not stop taking your medications unless your healthcare provider tells you otherwise. 

References

Epistaxis (Nosebleeds). (February 2015). http://care.american-rhinologic.org/epistaxis

Nosebleeds. (August 2018). https://www.enthealth.org/conditions/nosebleeds/

Severe Nosebleed (Epistaxis). https://www.mountsinai.org/locations/cerebrovascular-center/conditions/vascular-malformations/severe-nosebleed

How Can I Stop a Nosebleed? (January 2017). https://www.webmd.com/first-aid/nosebleeds-causes-and-treatments

Pope LER, Hobbs CGL. Epistaxis: an update on current management. Postgraduate Medical Journal. 2005;81:309-314. Tabassom, A. and Cho, J.J. Epistaxis (Nose Bleed). [Updated 2018 Sep 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-.Fatakia, A., et al. Epistaxis: a common problem. Ochsner journal vol. 10,3 (2010): 176-8.