Nosebleed (Epistaxis) - Symptom Evaluation

What is Nosebleed?

Nosebleed (Epistaxis) almost always causes panic and is a common ENT emergency in hospitals. In most instances it will stop spontaneously. It is estimated that almost 50% of the population experience at least one nose bleed in their lifetime and very few will require hospitalization. It occurs due to nasal mucosal irritation, usually due to nose picking or blow to the face or due to allergies.

Most of the time, the bleeding can be stopped with measures taken at home.In case of prolonged, heavy bleeding for more than 30 minutes or if the bleeding is heavy and if accompanied by blood being spit out or if there are symptoms of dizziness, altered sensorium, or vomiting, immediate medical help is required.

Depending upon the location of bleeding, there are two types of nasal bleeds namely, anterior and posterior. Anterior nasal bleed is due to damage to the mucosal membrane in the nostrils, while posterior nasal bleed is due to damage to the artery that runs behind the nasal cavity and these are more serious.

Anterior nosebleeds are more common in comparison to posterior nasal bleeds. They are common during winter season.

Trauma, hypertension, use of anticoagulants, liver disorders and tumors of the nose are some of the causes leading to nosebleed.

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Common Symptoms of Nosebleed:

• Bleeding from one or both the nostrils
• Spitting or vomiting of blood if bleeding is heavy
• Dizziness, altered sensorium if bleeding is heavy

First aid with compression over the point of bleeding usually helps in cessation of bleeding. But in case the bleeding is heavy, continued or recurrent, it requires further evaluation with examination, assessment of underlying conditions, drug history and necessary investigations to conclude on the actual cause for nasal bleeding.

Some of the conditions that can cause nasal bleed include:

• Environmental factors – Dry climates, dryness due to central heating or the use of air conditioners may cause mild bleeding from the nasal cavity. Humidified air from steamers may help to make the patient more comfortable.
• Hypertension – An increase in blood pressure is a common cause for nasal bleeding. The patient may also suffer from a headache. Measurement of the blood pressure helps in diagnosing the cause of nasal bleed.

• Inflammation in the nose like allergic rhinitis – Allergic rhinitis is a type of inflammation of the nasal mucosal membranes leading to watery discharge from the nose, sneezing, itchy nose and red eyes. Itchy nose and rubbing causes nasal mucosal irritation and bleeding from nose. Diagnosis is always clinical.

• Upper respiratory infection – Infection of the nose and the nasal sinuses may be accompanied by mild bleeding mixed with thick nasal discharge. The patient may have fever in some cases. The bleeding may also be associated with vigorous blowing of the nose to remove secretions.
• Foreign body in the nose – A foreign body in the nose can be life-threatening if the it lodges in the airway. It can also result in mucosal irritation and damage. Rhinoscopy (inspection of the nose), CT scan of face, X-ray of face and chest are used to arrive at the diagnosis. Von Willebrand disease- This is a genetically inherited condition occurring due to deficiency of von Willebrand factor, which is required for clotting of blood. It presents with nasal bleeding, bleeding from minor wounds, heavy menstrual bleeding, heavy and prolonged bleeding after minor trauma or surgery, oral cavity bleeding etc. Diagnosis is made with assessment of von Willebrand factor levels, antigen to von Willebrand factor, prothrombin time, activated partial thromboplastin time, ristocetin co-factor activity etc.

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• Tumors of the nose – Tumors of the nose can be benign or malignant. They present with unilateral or bilateral nostril obstruction, nasal crusting, bleeding or discharge. Tissue biopsy and examination help in concluding on the diagnosis.
• Nonsteroidal Anti-inflammatory Drugs (NSAIDs) toxicity – Some NSAID painkillers especially mefenamic acid and phenylbutazone are associated with bleeding. Excessive intake of these can result in nasal bleeding, gastrointestinal bleeding, altered level of consciousness, nausea, vomiting, coma, seizures etc. Multi system organ failure is common with large doses and delayed medical help. Common investigations required are renal function tests, liver function tests, electrolytes, prothrombin time, complete blood count and arterial blood gases assessment.

• Barotrauma and other trauma – Barotrauma is the tissue damage that occurs due to changes in pressure leading to compression or expansion of gas that is present in the different structures of the body. Nasal bleeding can happen due to Sinus Barotruma. Changes in pressure during ascent can cause a feeling of nasal congestion and bleeding in the nose. During descent due to sinus barotrauma patient might experience facial pain and headaches. Clinical assessment, history, X-ray nasal sinuses are useful in arriving a diagnosis. Frequent picking of the nose can also result in trauma and nasal bleeding.
• Frequent use of nasal decongestants – Excessive use of nasal decongestants makes the nasal mucosal membranes dry leading to itching, irritation, followed by nasal bleeding.
• Disseminated intravascular coagulation – This is a condition that occurs due to other underlying pathologies like sepsis, neurotrauma, blood vessel abnormalities like aneurysms, liver failure, hemorrhagic skin necrosis, antiphospholipid syndrome etc. Bleeding can happen in the nasal cavity, gums, digestive tract, skin etc. Along with an increased tendency to bleed, renal failure, liver failure, shock, and respiratory failure are common in this situation. Bleeding happens due to clots in the microvasculature, which deplete the blood of the clotting substances. Diagnosis is made with tests to assess D-dimer levels, fibrin degradation products levels, clotting times, platelet count etc. Apart from these investigations, further evaluation for the underlying cause should be made.

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• Warfarin toxicity – This drug (an anticoagulant) is used in many conditions such atrial fibrillation, pulmonary thromboembolism, dilated cardiomyopathy, deep vein thrombosis etc. as a prophylactic measure. Repeated use even in small doses in patients with underlying pathologies like liver disease, malnutrition and bleeding disorders results in a high risk of developing warfarin toxicity. Clinical symptoms and drug history are helpful in making diagnosis. Prothrombin time and INR measurement daily for 3-4 days after suspected ingestion can help concluding the cause. Assessment of vitamin K dependent clotting factors (factors 2, 7, 9, 10) helps in confirming the cause for bleeding.
• Cocaine toxicity – Intranasal use of cocaine causes nasal mucosal irritation, which is accelerated further due to vasoconstriction within the nose caused by cocaine itself. This leads to inflammation of nasal mucosal membranes. Common symptoms of prolonged cocaine use include frequent nosebleeds, nasal congestion, sneezing, and perforation of nasal septum.
• Osler-Weber Rendu syndrome – This is a hereditary (dominant pattern) blood vessel disorder that causes excessive bleeding. Prominent symptoms include port wine stain (large red birth mark) and telangectasias (small red marks) on the skin. Nosebleeds are the most common symptom. Excessive bleeding happens due to arterio-venous malformations (AVM). AVM can happen externally on the skin or internally in the organs. Diagnosis is made with the help of chest x-ray, endoscopy, MRI brain, echo cardiogram and CBP.

Frequently Asked Questions

1. Is Nosebleed always serious?

No, in most cases, nosebleed is not serious and is quite common. If nosebleed occurs after a head injury or if it does not stop or is heavy even after 30 minutes, then it should be considered as an emergency.

2. Who get Nosebleeds?

There are no risk factors as such to predict the probability of nosebleeds in individuals, but children between 2-10 years and elderly individuals are more prone to nosebleeds. Trauma, head injury, allergic rhinitis, infection, cold climates, hypertension and use of anticoagulants and certain medications like NSAIDs and dipyridamole are some of the situations in which nosebleeds tend to occur.

3. What initial measures are to be taken to stop Nasal Bleeding?

Direct pressure over the site of bleeding for at-least 15 minutes should be applied. If the bleeding does not stop, further evaluation may be required.

4. What lab investigations are required for diagnosing the cause for Nosebleed?

Complete blood count, platelet count, bleeding and clotting times, thromboplastin and partial thromboplastin time are often used for assessment of nasal bleeding. Additional tests may be necessary depending on the suspected underlying condition.