WiYaMi

Epistaxis (Nose bleed):

Epistaxis comes from the Greek word “epistazein” which means "bleed from the nose" and is a combination of the two words: “epi” meaning "upon, in addition" and “stazein” meaning "to drip". It is the loss of blood from the tissue that lines the inside of your nose.The location of the nose in the middle of the face and the large number of blood vessels close to the surface in the lining of nose make it an easy target for injury and nosebleeds. Epistaxis more commonly occurs in children (ages 2–10) and older adults (ages 50–80). Most nosebleeds are benign, self-limiting, and spontaneous, but some can be recurrent.

 

Causes:

1. Local causes- local trauma caused by nose-picking, incorrect or excessive use of topical nasal sprays, a foreign body in the nose, anatomic irregularities such as a deviated septum, facial trauma, inflammatory reactions, and rarely intranasal tumours.
2. Systemic causes- It includes hypertension, cardiovascular diseases, vascular malformations or telangiectasia, and bleeding disorders like Von Willebrand disease  and haemophilia A and B. 
3. Environmental factors- It include changes in humidity or temperature as nasal vessels are more prone to rupture in cold weather and dry environments. Additionally, environmental factors can trigger allergies which can increase the risk of epistaxis for multiple reasons. As excessive nose blowing and the use of allergy medications that dry the nasal mucosa—for instance, decongestants and antihistamines— can further compound the risk of developing a  nose bleed.
4. Medications- Drugs as anticoagulants as warfarin, platelet aggregation inhibitors, NSAIDs, blood thinners as well as homeopathic medications that prolong bleeding (like ginseng and Vitamin E), can all increase the risk of epistaxis.

Types of epistaxis- on the basis of the site where the bleeding originates

1. Anterior epistaxis- It is the most common type of nosebleed, and usually involves one nostril that originates from the anterior (frontal) part of the nose. Most of the time, cases of anterior epistaxis originate from the Kiesselbach plexus, which is a vascular network found on the nasal septum, as these arteries can be easily traumatized.
2. Posterior epistaxis-  It is the bleeding from the posterior or superior nasal cavity and involves both nostrils. Usually, it originates from the Woodruff plexus, which is a vascular network found in the lateral wall of the nasal cavity. For these types of nosebleeds, the blood may also flow backwards and uncomfortably get swallowed  or coughed up (hemoptysis).

 

Management-

1. Anterior epistaxis - It can usually be controlled by pinching the nasal alae together for 10 minutes while the patient sits upright. If this manoeuver fails, a cotton pledget impregnated with a vasoconstrictor (eg, phenylephrine 0.25%) and a topical anaesthetic (eg, lidocaine 2%) is inserted and the nose pinched for another 10 minutes.Initial management includes compression of the nostrils (application of direct pressure to the septal area  for at least five minutes, and for up to 20 minutes) and plugging of the affected nostril with gauze or cotton that has been soaked in a topical decongestant.
2. 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.
   
   Credit - Dr Mukta Meel, Dr Shivraj Singh