Epistaxis is often a straightforward and easily-treatable illness. Given the possible repercussions of a major bleed, however, general practitioners should be familiar with the causes, potential hazards and emergency care.

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What is epistaxis?

One of the most frequent ENT (ear, nose, and throat) emergencies seen by family doctors is epistaxis (GPs). In recent years, epistaxis treatment has developed dramatically. Effective therapy requires an understanding of nasal anatomy as well as possible risks and problems.

Epistaxis is a difficult and frequent ailment. It is difficult to quantify the lifetime incidence of epistaxis, however, it has been reported to be as high as 60%. However, only a tiny fraction of cases need specialised care. As it is often spontaneous and self-limiting, many patients self-manage this illness. They only see their general practitioner (GP) when their health worsens or changes. The application of competent first aid is often sufficient. Patients are infrequently moved to a hospital in order to get care from an ear, nose, and throat (ENT) specialist. Because most episodes are small, the GP's involvement in recognising signs and symptoms indicative of more serious medical issues is crucial.

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History

What questions to ask?

1. Questions should concentrate on the history of the acute episode and prior occurrences, including length, intensity, frequency, and bleed location.
2. Patients with posterior epistaxis often bleed from both nostrils and may have the sensation of blood flowing down their throats rather than their noses. The strategies they used to suppress prior outbreaks have educational significance. Regrettably, pinching over the nasal bones, as opposed to the cartilaginous tip, remains widespread.
3. It is essential to inquire about haematemesis and melaena. In individuals with epistaxis, upper gastrointestinal haemorrhage is often missed. Additionally, it is essential to search for signs and symptoms of anaemia, which might indicate the severity of bleeding.
4. To further characterise the origin of bleeding, physicians might inquire about local trauma, such as picking the nose, a suspected foreign body, or an active upper respiratory infection. The presence of foreign things in the nose is critical, since materials such as batteries may cause severe harm and lead to a medical emergency.
5. A comprehensive medical history might provide insight into the source of bleeding. Epistaxis requires a significant medical history, including a history of hepatic impairment, hypertension, easy bruising or bleeding, or a family history of coagulation abnormalities.
6. The social history of alcohol, tobacco, and recreational drug usage is equally important. Specific questions should be asked concerning cocaine usage.
7. Anticoagulant usage is an essential element of collecting a medical history. Not only will it raise the danger of bleeding, but it may also affect patient treatment.

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Major causes 

1. Acute bleeding from the nose after physical injury barotrauma/ nose picking/ physical exertion.
2. Acute bleeding from the nose in hypertensive/haematological disorders.
3. Acute bleeding from the nose without any obvious cause.

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Evaluation

1. Assessment of a patient with epistaxis requires meticulous planning. Place the bed at the appropriate height and provide enough lighting, suction, eye protection, gloves, and a mask. Ensure that the equipment is accessible and that support is available. Access to a hands-free light, such as a headlamp, is beneficial since it enables the use of both hands to further evaluate and treat the patient.

2. To have a clear vision, the patient may need to blow their nose and remove any clots. Be careful that this may result in a repeat of bleeding, however, it may help locate the bleeding site. Try to visualise the nasal cavity with a nasal speculum in one hand and a suctioning device in the other. A thorough inspection of the nasal cavity should be conducted. Pay close attention to the septum and Little's region for any signs of an anterior bleed, and keep an eye out for any scabbed or excoriated areas.

3. Depending on the results of the examination, it may be necessary to prepare the nose with enough anaesthesia and a vasoconstrictor at this time. A well-trained nose is priceless. Apply a spray containing 5% lignocaine and 0.5% phenylephrine to each nostril. Alternately, a cotton ball soaked in the spray and gently put into the nasal cavity might be used. The application of topical sprays lowers bleeding to improve visibility and analgesia for potential cauterisation or nasal packing.

4. Examining for posterior bleeds is necessary if an anterior bleeding location is not visible. Bleeding from both nostrils, or blood flowing down the posterior pharynx, are indicators. If further concerns exist, consider referring the patient to an ENT specialist or emergency department. An ENT expert may do nasendoscopy using a rigid endoscope, and in 80% of instances, the cause of bleeding can be identified.3 The majority of patients tolerate this treatment with topical anaesthesia. Rigid endoscopy permits examination of the whole nasal cavity, including the nasopharynx, to detect posterior bleeding.

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Clinically important examination

Essential

• Local examination by anterior rhinoscopy/ endoscopy to look for a source of bleeding (scanty/moderate).
• Little’s area bleeder/clot/congestion
• Sharp septal spur
• Congested nasal mucosa as in URTI
• General physical examination to estimate other systems (Cardiovascular/Lower Respiratory/Neurological) clinically.

Systemic assessment

Screen for coagulation disorders/ anticoagulant medications/ hematological malignancies.

Investigations

Essential-

• Haemoglobin level
• Coagulation profile
• Complete blood count

Desirable

CT scan with contrast in cases with no obvious cause// suspected benign or malignant lesion.

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Management

Resuscitation

1. Priority is given to primary first aid in patients with epistaxis, which comprises the ABCs of resuscitation (airway, breathing, circulation). Clinicians must check patients for haemodynamic stability, including pulse and respiratory rate, and search for indications of shock, including perspiration and pallor. If a patient is actively bleeding, they should be seated upright.
2. Lean the patient forward to reduce blood swallowing and provide digital pressure on the cartilaginous portion of the nose for at least 10 minutes. Insert a large-bore intravenous cannula and, if necessary, get a blood sample (for comprehensive blood examination and blood group testing) and maintain the sample.
3. If bleeding persists, consider transfer to an emergency facility or referral to an ENT specialist. The urgency of this transfer will depend on the current clinical state, but considering the age distribution of epistaxis, immediate treatment is of the utmost importance.

In recent years, epistaxis treatment has developed dramatically. Successful treatment of epistaxis involves familiarity with its potential causes and a thorough understanding of nasal anatomy. Epistaxis may be categorised as either anterior or posterior bleeding, with the former being more prevalent. Generally, cauterisation with silver nitrate sticks may be used to treat anterior bleeds if there is enough preparation, the proper equipment, and support nearby. If any of these conditions are lacking, urgent nasal packing and referral to an emergency department or specialised ENT care are advised.

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Principle of step-by-step management

1. Make sure a patent airway and prevent aspiration by placing the head down / laterally.
2. Stabilise blood pressure and heart rate with intravenous fluids.
3. Big digital compression of the nose for 10 minutes in the Trotter's posture (cotton pledgets soaked in 4% xylocaine and adrenaline may be utilised) • Chemical/electro cauterisation of Little's area bleeder.
4. Stoppage of bleeding via nasal packing/epistaxis balloon.
5. Packing the anterior nasal cavity if bleeding is not controlled by the preceding steps.
6. Antibiotic prophylaxis and hospitalisation are advised following nasal packing.
7. In the event of blood aspiration, H2blockers/PPI should be administered to prevent gastritis.
8. Consider vascular ligation (sphenopalatine/anterior ethmoidal artery) if bleeding persists after nasal packing.
9. Selective embolisation is a surgical option.
10. If any, treat the diagnosed aetiology.

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Follow up care

1. Two weeks of continued nasal lubrication with liquid paraffin.
2. Repeat anterior rhinoscopy/endoscopy to determine/confirm the source of bleeding.
3. If necessary, oral hematinics should be considered.

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Warning signs

• Features suggestive of neoplasia 

Unilateral bleeding, Nasal obstruction, Visual/orbital symptoms, Obvious mass lesion

• Recurrent profuse bleeding 

Consider JNA (Juvenile Nasopharyngeal Angiofibroma) in teenage boys - Aneurysmal bleeding (especially the following trauma) to be ruled out by DSA - To be managed by appropriate treatment at the tertiary level­.

• Persistent bleeding despite nasal packing
• Altered blood counts/ coagulation profile

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Considerations for epistaxis management

1. Epistaxis in children is usually invariably anterior and originates from the Little's region as a result of mucosal dryness caused by dry air.
2. Epistaxis in adults is often associated with hypertension and originates at the posterior end of the inferior turbinate.
3. Initial noninvasive approaches may be enough for the vast majority of individuals.

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Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Monish Raut is a practising super specialist from New Delhi.