Epistaxis

'Nose bleed'

Aetiology

Local causes

• Idiopathic

• Trauma

• Foreign bodies

• Inflammation

• Tumour

Systemic causes

• Drugs - e.g. Warfain, aspirin

• Clotting abnormalities

• Liver disease

• Haemophilia

• Leukaemia

• Thrombocytopaenia

• Arteriosclerosis

• Hereditary haemorrhagic telangectasia

• Systemic inflammatory conditions

• Wegner's granulomatosis

• Hypertension - causes prolonged bleeding but not primary cause of epistaxis

Pathophysiology

• The nose is a vascular organ secondary to heating/humidification requirements

• The nose gains a blood supply from a number of vessels, originating from both the internal and external carotid artery

• One of the commonest sites of bleeding is Little's area on the anterior septum, where a number of vessels anastamose (anterior ethmoid, posterior ethmoid, sphenopalatine, great palatine, superior labial)

Management

1. First aid measures - pinching the fleshy anterior part of the nose, leaning forward, spitting out into a bowl, ice pack compression

2. On arrival to secondary care: resuscitation if necessary, arrest/slow flow (e.g. ice, topical vasoconstrictor), anterior rhinoscopy/nasal endoscopy to investigate source of bleeding

3. Direct therapy - silver nitrate cautery if there is an identifiable anterior bleeding point

4. Indirect therapy - this includes nasal packs (e.g. rapid rhino) or Foley catheters to compress difficult to identify bleeding points (likely posterior) or heavy bleeding points

5. Surgery - sphenopalatine artery ligation (endoscopic)