OTORRHINOLARYNGOLOGY

CHRISTIANE RIBEIRO ANIAS, MD

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Epistaxis



Introduction

Epistaxis is undoubtedly one of the most frequent causes of bleeding. In the majority of the cases, bleeding is in small quantities and self-limited, but sometimes it can be very intense and life-threatening. That’s why epistaxis should never be treated as a harmless event either from the diagnostic or therapeutic point of view.

Etiopatogeny

The interior of the nose is divided by the nasal septum in two cavities. Each side is divided into the nasal vestibule (the most anterior part of the nose) and the nasal cavity proper which extends until the choana. The blood supply of the nasal cavity is provided by both the internal and external carotid artery and their accompanying veins. Bledding from Kiesselbach’s plexus, a vascular plexus on the anterior nasal septum, is by far, the most common type of epistaxis.The mucosa in this area is very fragile and is tightly adherent to the underlying cartilage and thus offers little resistance to mechanical or functional stress. Depending on the cause, it’s possible to distinguish epistaxis due to local causes from symptomatic nosebleeds with generalized causes.

  • Local causes.
    Nasal trauma (nose picking foreign bodies, forceful nose blowing)
    Rhinitis
    Drying of the nasal mucosa from low humidity
    Deviation of nasal septum
    Bleeding polip of the septum
    Tumors, particularly malignant tumor of the nose or sinuses
    Tumors of the nasopharynx especially Nasopharyngeal Angiofibroma.
  • Secondary causes
    Systemic arterial hypertension
    Blood diseases and diseases of coagulation: such as, Thrombocytopenic Purpura, Idiopathic Thrombocytopenic Purpura, Leukemia.
    Coagulopathy: Hemophilia, overdosage with anticoagulants, deficiency of vitamin K.
    Endocrine Causes: Epistaxis during pregnancy, and pheocromocytoma which causes hypertensive crises due to circulating catecholamine.
    Hereditary hemorrhagic telangiectasia with typical mucosa lesions - Osler Weber Rendu Syndrom - which causes recurrent mild to modest, and often multifocal bleeding.

    Diagnostic Steps

  • History - In the anamnese we should ask for previous bleeding, hypertension, hepatic diseases, use of anticoagulants, nasal trauma, family history of bleeding etc.
  • Localize the source of the bleedings and determine its cause.
  • Measurement of the blood pressure.
  • Analysis of blood coagulation.
  • Radiographs of the skull, nose and sinuses and possibly tomograms.
  • Exclude generalized causes.

    Treatment

    1) General Symptomatic Treatment
  • Calming the patient (if necessary with medication).
  • The patient should sit with the upper part of the body tilted forward and the mouth open so that he can spit out the blood and don’t have to swallow it.
  • Cold compresses are applied to the nape of the neck and also to the dorsum of the nose.
  • Lowering of blood pressure in hypertension.
  • Discontinuation of anticoagulants.
  • Administration of fluid expanders in severe bleeding.

    2) Local Procedure

  • Digital compression for several minutes.
  • Cautery of the hemorrhagic point - When visible the bleeding site may be cauterized with silver nitrate or electrocautery.
  • Anterior Nasal Packing - Sometimes it is required to achieve hemostasis in more intense bleeding.
  • Posterior Nasal Packing - It’s used when the bleeding is intense and from the posterior part of nasal cavity. When we use nasal packing we should use antibiotics to avoid sinuses infection..
  • Vascular ligation - This procedure is used for uncontrolled life-treating epistaxis if the methods described before have not been effective.

    After control of epistaxis, the patient is advised to avoid vigorous exercise for several days. Avoidance of hot or spicy food and tobacco is also advisable as they may cause vasodilation. Avoiding nasal trauma, including digital self-trauma is an obvious necessity.

    Differential Diagnosis

    It includes bleeding which doesn’t arise in the nose but in which the blood escapes through the nose, for instance hemoptysis, bleeding esophageal varices, bleeding due to injure to the vessel around the base of the skull escaping via the sphenoid sinus or the eustachian tube.

    Conclusion

    Although epistaxis is very common it shouldn’t be treated as if it were unimportant. In all patients with epistaxis we should consider underlying causes of bleeding. Laboratory assessment of bleeding parameters may be indicated, especially in recurrent cases. Once the acute episode has passed, careful examination of the nose and paranasal sinuses to rule out neoplasia is very wise.

    Bibliography

    1) HUNGRIA H. - Otorrinolaringologia 6a edição 1991 pages 74-78
    2) HARRISON T.R - Medicina Interna 12a edição1991 volume 1 page 7-69
    3) BECKER W., NAUMANN H.H , PFLALTZ C. R - Ear Nose and Throat Diseases 2nd edition 1994 pages 178, 253-260
    4) PIRES M.T.B - Erazo Manual de Urgências em Pronto Socorro 4a edição 1993 pages 381-389
    5) TIERNEY L.M, MCPHEE S.J, PAPADAKIS M.A - Current Medical Diagnosis and Treatment 35th edition 1996 pages 198-199

    If you have suggestions or comments send an e-mail to Christiane Ribeiro Anias

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