Definition & Overview

Nasal haemorrhage is a medical condition characterised by excessive bleeding in the nostril, nasal cavity, and nasopharynx. It is also known as epistaxis or, more commonly, nosebleed.

This condition is quite common and rarely fatal. However, the sight of blood flowing out from one or both nostrils could cause significant emotional distress to patients.

Nasal haemorrhage commonly originates from the anterior portion of the nose where there are a number of blood vessels. When haemorrhage occurs from the posterior part of the nasal septum, it is quite difficult to control and typically lasts longer. This condition occurs when blood vessels in the nasal mucosa rupture. There are certain factors that affect the occurrence of epistaxis. One is the intake of anticoagulant medication that predisposes the patient to this condition.

In some cases, a pseudoepistaxis occurs. This condition is characterised by blood originating from other sources, like the lungs or airway, and gets up into the nasal cavity and out of the nostrils.

Who Should Undergo and Expected Results

Persons who suffered blunt force trauma to the face typically experience fractures in the structures of the nose. This could lead to excessive bleeding that might be difficult to stop.

Nosebleed could also occur in patients with foreign bodies lodged in their nasal cavity. If left unattended, the foreign body could cause extensive damage to the nasal mucosa and may even be fatal if it moves to the airway.

Patients diagnosed with Hemophilia A or B are also prone to excessive nasal bleeding, which may need controlling. This condition is inherited, but there are cases in which it is caused by spontaneous mutation. It is characterised by the inability of the blood to clot.

Another condition similar to haemophilia is von Willebrand disease, which causes the inability of the blood to coagulate and achieve hemostasis, an important stage in healing any wound. Epistaxis is one of the manifestations of this disease.

People who ingested toxic substances could also suffer from nasal haemorrhage. Examples of these substances are nonsteroidal anti-inflammatory agents, warfarin, cocaine, and rodenticides.

Persons suffering from extreme cases of rhinitis and sinusitis might also need to take steps in controlling nasal haemorrhage. Rhinitis is the inflammation of the nasal membranes, characterised by constant sneezing, itching of the eyes and nose, headache, and general malaise. On the other hand, sinusitis is the inflammation of the linings of the paranasal sinuses.

There are several approaches in controlling nasal haemorrhages, and all have high success rates in stopping the bleeding. Patients should rest and are closely monitored a few hours after treatment. Medication to address the cause of the bleeding should also be administered. However, patients should avoid ingesting nonsteroidal anti-inflammatory agents as these can promote another bleeding episode. To avoid recurrence, patients should avoid performing strenuous activities and disturbing the insides of their nasal cavities.

How is the Procedure Performed?

Controlling nasal haemorrhage is achieved through several techniques. The most common initial treatment is manual haemostasis. The physician applies direct pressure, and the nostrils are squeezed together continuously for as long as 10 minutes. The patient should keep the head elevated without extending the neck. A piece of gauze moistened with epinephrine or phenylephrine could also be placed in the nostrils to promote constriction of blood vessels.

Using electrocautery, the physician can also stop nasal haemorrhage by applying a low voltage of electric current to the affected blood vessels. The probe is inserted into the nostril and guided into the source of the bleeding. In some cases, the physician may opt to use chemical cautery. If the bleeding originates from the posterior part of the nostril, such as the Kiesselbach plexus, the physician may use a lunar stick to stop bleeding. The device has silver nitrate, which effectively destroys the bleeding vessels and stops the flow of blood.

Another technique used in controlling nasal haemorrhage is the use of nasal packing. Anterior epistaxis can be stopped by inserting nasal packing filled with antibiotic ointment. The physician first applies local anaesthesia to the affected nostril before inserting the nasal packing. The nasal packing stays inside the nostril for around 12 hours and then discarded. The packing serves both to stop the bleeding and prevent infection at the same time. If the bleeding occurs posteriorly, the physician can also apply gauze packing filled with antibiotics after putting local anaesthesia. Recent advancement involves inserting an inflatable balloon device or catheter to stop bleeding.

For bleeding involving larger blood vessels, arterial ligation may be considered. The patient is placed under local or general anaesthesia, and the surgeon makes an incision to reach the affected blood vessels. Epistaxis can be caused by damage to the external carotid artery, internal maxillary artery, or the ethmoid artery. In most cases, the surgeon can use endoscopy to identify, cut off, and tie the affected artery.

In some cases, the physician may determine that embolisation is the proper technique for treating epistaxis or nasal haemorrhage originating from the internal carotid artery. This option is considered for those who are unsuitable for surgery or when other treatments proved unsuccessful. An embolus is purposely introduced into the artery to block blood flow. A catheter or guidewire is inserted into the blood vessel and guided into the determined location to place the artificial embolus.

Possible Risks and Complications

One common complication of controlling nasal haemorrhage is the formation of scar tissue in the affected treatment site. This can happen after the patient undergoes cauterisation or was inserted with nasal packing in the anterior or posterior part of the nasal cavity. Rhinosinusitis or the infection of the nasal sinuses can also occur after treatment. This is characterised by the presence of thick nasal mucus, pain in the face, and a plugged nose.

Ligation of the blood vessels can also result in adverse reaction to anaesthesia and numbness in certain parts of the face, particularly the cheek.

Embolisation carries the risk of facial paralysis and recurring pain.

References:

  • Cummings CW. Epistaxis. Cummings. Otolaryngology: Head and Neck Surgery. 4th ed. Philadelphia, Pa: Elsevier, Mosby; 2005. Chap 40.

  • Padgham N. Epistaxis: anatomical and clinical correlates. J Laryngol Otol. 1990 Apr. 104(4):308-11. [Medline].

  • Guarisco JL, Graham HD 3rd. Epistaxis in children: causes, diagnosis, and treatment. Ear Nose Throat J. 1989 Jul. 68(7):522, 528-30, 532 passim.

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