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Symptoms and Signs – Differential diagnosis of Epistaxis
An often seen indication, epistaxis (nosebleed) can occur either spontaneously or be caused by injuries to the front or rear of the nose. Rhystoles commonly manifest in the anterior-inferior nasal septum, also known as Kiesselbach's plexus, although they can also arise at the junction of the inferior turbinates and the nasopharynx. Although typically unilateral, they may appear bilateral when blood flows from the side of the nose where bleeding occurs behind the nasal septum and out the other side. Epistaxis can vary from superficial seeping to serious, perhaps life-threatening, hemorrhage.
Extensive network of delicate blood arteries renders the nose especially susceptible to bleeding. Passage of air via the nasal passages can cause desiccation and irritation of the mucous membranes, resulting in the formation of crusts that bleed upon removal. Additionally, dry mucous membranes are more vulnerable to infection, thereby increasing the risk of epistaxis. Another frequent etiology of epistaxis is trauma. Other contributing factors include septal abnormalities; hematologic, coagulation, renal, and gastrointestinal disease; as well as specific medications and therapies.
Acute medical interventions
In the event of severe epistaxis, promptly assess the patient's vital status. Maintain vigilance for tachypnea, hypotension, and other indications of hypovolemic shock. Introduce a high-pressure intravenous line to provide quick replenishment of fluids and blood, and endeavour to manage bleeding by pinching the nasal passages shut. In the event of a suspected nasal fracture, refrain from pinching the nares. Instead, position gauze beneath the patient's nose to uptake the blood. Arrange a hypovolemic patient in a supine position and rotate their head laterally to avoid the drainage of blood down the posterior aspect of their neck, which may lead to aspiration or vomiting of ingested blood. In the absence of hypovolemia, instruct the patient to assume an upright position and tilt their head forward. Continuously monitor the patency of the airways. Should the patient's condition exhibit instability, initiate cardiac monitoring and administer supplementary oxygen via mask.
Historical Background and Physical Assessment
If the patient is not experiencing any acute pain, obtain a medical history. Does he have a recent medical history including
What is trauma? What is the frequency of his previous occurrences of nosebleeds? Did the nosebleeds exhibit prolonged duration or atypical severity? Has the patient undergone recent surgical intervention concerning the sinus region? Request information regarding a medical history of hypertension, hemorrhage or hepatic diseases, and any recent medical conditions. Assess the patient's susceptibility to bruising. Determine his medication usage, particularly analgesics like aspirin and anticoagulants like warfarin. Inquire about any past record of cocaine consumption.
Commence the physical examination by examining the patient's skin for any additional indications of bleeding, such as ecchymoses and petechiae, and observing jaundice, pallor, or any other irregularities. When assessing a trauma patient, inspect for concomitant injuries, such ocular trauma or face fractures.
Medical etiology
Anaplastic anemia
Aplastic anemia progresses gradually, ultimately resulting in nosebleeds, ecchymoses, retinal hemorrhages, menorrhagia, petechiae, bleeding from the lips, and indications of gastrointestinal bleeding. In addition, fatigue, dyspnea, headache, tachycardia, and pallor also may manifest.
Barotrauma
Often observed in individuals who travel by air or engage in scuba diving, barotrauma can lead to intense and agonizing epistaxis when the patient has an upper respiratory tract infection.
Coagulation disorders
Patients with coagulation abnormalities such as hemophilia and thrombocytopenic purpura may develop epistaxis, accompanied by ecchymoses, petechiae, and bleeding from the gums, mouth, and sites of intravenous puncture. Signs of gastrointestinal bleeding, including melena and hematemesis, can also manifest as menorrhagia.
Glomerulonephritis (chronic)
The clinical manifestations of glomerulonephritis include nosebleeds, hypertension, proteinuria, hematuria, headache, edema, oliguria, hemoptysis, nausea, vomiting, itching, dyspnea, malaise, and exhaustion.
Hepatitis
The interference of hepatitis with the coagulation process can lead to epistaxis and aberrant bleeding tendencies. The common indications and manifestations usually consist of jaundice, feces of clay color, itching, enlargement of the liver, stomach discomfort, fever, exhaustion, weakness, urine of dark amber color, loss of appetite, nausea, and vomiting.
Hypertension
Profound hypertension can cause severe epistaxis, often occurring in the posterior nasal region, accompanied by pulsation above the middle turbinate. Adverse effects of this condition include dizziness, a throbbing headache, anxiety, peripheral edema, nocturia, nausea, vomiting, drowsiness, and mental function impairment.
Leukemia
Sudden epistaxis in acute leukemia is characterized by a high temperature and many forms of abnormal bleeding, including bleeding gums, ecchymoses, petechiae, easy bruising, and prolonged menstruation. These may manifest after less apparent indications and symptoms, such as debility, lethargy, pallor, chills, repeated infections, and a little elevation in body temperature. The clinical manifestations of acute leukemia include dyspnea, weariness, malaise, tachycardia, palpitations, a systolic ejection murmur, and stomach or bone pain.
With chronic leukemia, epistaxis is a late sign that may be accompanied by other types of abnormal bleeding, extreme fatigue, weight loss, hepatosplenomegaly, bone tenderness, edema, macular or nodular skin lesions, pallor, weakness, dyspnea, tachycardia, palpitations, and headache.
Maxillofacial injury
In cases of craniofacial damage, a pumping arterial hemorrhage often leads to the development of severe epistaxis. The accompanying indications and manifestations encompass face pain, numbness, swelling, asymmetry, open-bite malocclusion or an incapacity to open the mouth, diplopia, conjunctival bleeding, lip edema, and abnormalities in the buccal, mucosal, and soft palate tissues.
Nasal fracture
Epistaxis, whether unilateral or bilateral, is characterized by nasal swelling, periorbital ecchymoses and edema, discomfort, nasal deformity, and crepitation of the nasal bones.
Nasal tumor
Nasal hemorrhage can occur when a tumor interferes with the function of the nasal blood vessels. In general, benign tumors tend to bleed upon contact, while malignant tumors result in spontaneous unilateral epistaxis, accompanied by a foul discharge, cheek swelling, and, in advanced stages, pain.
Polycythemia vera
Spontaneous epistaxis, a frequent indication of polycythemia vera, presents with bleeding gums, ecchymoses, ruddy cyanosis of the face, nose, ears, and lips, as well as congestion of the conjunctiva, retina, and oral mucous membranes. Other manifestations of the condition differ depending on the afflicted physiological system, but may encompass a headache, vertigo, tinnitus, visual impairments, hypertension, angina, sporadic constriction, premature satiety and satiety, significant enlargement of the spleen, abdominal pain, itching, and difficulty breathing.
Sarcoidosis
In sarcoidosis, oozing epistaxis may manifest with a nonproductive cough, substernal discomfort, lethargy, and weight loss. Additional observations include increased heart rate, irregular heart rhythms, enlargement of the parotid gland, lymph nodes in the cervical region, skin lesions, enlarged liver and spleen, and joint pain in the ankles, knees, and wrists.
Scleroma
In scleroma, there is gushing epistaxis characterized by a watery nasal discharge that develops a bad odor and form a crust. Progression of anosmia and turbinate atrophy may also manifest.
Acute sinusitis
Sinusitis presents with a nasal discharge that is first red or blood-tinged, which may thereafter turn purulent and abundant within 24 to 48 hours. Manifestations of the condition include nasal congestion, soreness, tenderness, malaise, headache, mild fever, and red, edematous nasal mucosa.
Skull fracture
Epistaxis can manifest as either direct, (when blood runs directly down the nares) or indirect, (when blood drains through the eustachian tube and into the nose), depending on the specific type of fracture. Common injuries encountered include abrasions, contusions, lacerations, or avulsions. An acute skull fracture can result in a severe headache, reduced consciousness, hemiparesis, dizziness, convulsions, projectile vomiting, and reduced pulse and respiration rates.
A basilar fracture can also result in hemorrhage from the throat, ears, and conjunctiva, as well as visual impairment known as raccoon eyes and Battle's sign. Possible leakage of cerebrospinal fluid or brain tissue might occur from the nasal or auditory canals. A sphenoid fracture can result in irreversible vision loss, while a temporal fracture can lead to either unilateral hearing loss or facial paralysis.
Systemic lupus erythematosus (SLE)
Typically impacting women under the age of 50, Systemic Lupus Erythematosus often leads to gushing epistaxis. Additional distinctive manifestations for this condition include butterfly rash, lymphadenopathy, joint pain and stiffness, anorexia, nausea, vomiting, myalgia, and weight loss.
Typhoid fever
Common manifestations include oozing epistaxis and a dry cough. Typhoid fever can also result in a sudden onset of chills and a high temperature, vomiting, abdominal distension, constipation or diarrhea, enlarged spleen, enlarged liver, distinctive "rose-spot" rash, jaundice, loss of appetite, weight loss, and extreme exhaustion.
Special Considerations
External methods to help control a nosebleed should include having the patient sit upright and lean forward, pinch his nose for 10 minutes, and breathe through his mouth. Until the bleeding is completely under control, continue to monitor the patient for signs of hypovolemic shock, such as tachycardia and clammy skin. If external pressure doesn’t control the bleeding, insert cotton that has been impregnated with a vasoconstrictor and local anesthetic into the patient’s nose.
If bleeding persists, expect to insert anterior or posterior nasal packing. (See Controlling Epistaxis with Nasal Packing, page 293.) Administer humidified oxygen by face mask to a patient with posterior packing.
Management of Epistaxis with Nasal Packing
Should direct pressure and cautery be ineffective in managing epistaxis, nasal packing may become necessary. In cases when the patient experiences significant bleeding in the front of the nose, anterior packing may be employed. A series of petroleum jelly gauze strips are placed horizontally into the nostrils in close proximity to the turbinates.
In cases when the patient experiences significant bleeding in the posterior nose or when blood from anterior bleeding begins to flow in the opposite direction, posterior packing may be necessary. This packing method involves a compressed gauze pack that is fastened by three robust silk sutures. Once anesthesia is administered to the nose, sutures are inserted through the nostrils using a soft catheter and the pack is placed beneath the soft palate. Two sutures are fastened to a gauze roll positioned behind the patient's nose, therefore securing the pack in positioning. The third suture is affixed to his cheek using tape. In lieu of a gauze pack, a urinary or nasal epistaxis catheter can be placed through the nasal passage into the region behind the soft palate and filled with 10 mL of water to apply pressure on the site of bleeding.
Watch for signs of respiratory distress, such as dyspnea, which may occur if the packing slips and obstructs the airway.
Keep emergency equipment (flashlights, scissors, and a hemostat) at the patient’s bedside. Expect to cut the cheek suture (or deflate the catheter) and remove the pack at the first sign of airway obstruction.
Avoid tension on the cheek suture, which could cause the posterior pack to slip out of place.
Keep the call bell within easy reach.
Monitor the patient’s vital signs frequently. Watch for signs of hypoxia, such as tachycardia and restlessness.
Elevate the head of the patient’s bed, and remind him to breathe through his mouth.
Administer humidified oxygen as needed.
Instruct the patient not to blow his nose for 48 hours after the packing is removed.
Patient Counseling
Pediatric Pointers
Children are more likely to experience anterior nosebleeds, usually the result of
A complete blood count may be ordered to evaluate blood loss and detect anemia. Clotting studies, such as prothrombin time and partial thromboplastin time, may be required to test coagulation time. Prepare the patient for multiple radiology tests if he has had a recent trauma.
Teach the patient or caregiver pinching pressure techniques. Discuss ways to prevent nosebleeds.
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