ENT - nosebleeds

Question 1

Where does bleeding usually originate from?

Answer 1

Kiesselbach’s plexus in Little’s area

Question 2

What can trigger nosebleeds?

Answer 2

Nose picking
Colds
Sinusitis
Vigorous nose blowing
Trauma

Coagulation disorders
Anticoagulants

Cocaine use

Tumours e.g. squamous cell carcinoma

Question 3

Presentation of nosebleeds

Answer 3

Usually unilateral bleeding

Bleeding from both nostrils may indicate posterior bleed

May present with haematemesis, if patient swallows blood during nosebleed

Question 4

Management of nosebleeds

Answer 4

Sit up and tilt head forward
Squeeze soft part of the nose for 10-15m
Spit out blood in mouth, don’t swallow

If longer than 15m:

• Nasal packing using rapid rhino
• Silver nitrate cautery to bleeding vessel (ONLY if vessel can be visualised)
• Consider reversing/stopping anticoagulation

Once bleeding has stopped discharge with Naseptin (chlorhexidine and neomycin) four times daily for 10 days to reduce any crusting, inflammation and infection.

Question 5

Posterior bleed presentation and treatment

Answer 5

Suspect posterior bleed if:

• Profuse bleeding (vessels at back of nose tend to be larger)
• Bilateral nosebleed
• Unable to visualise bleeding point
• Suspected anterior bleed not responsive/resolved to packing or cautery

Treatment:

• More likely to need to admit
• Bilateral posterior packing
• Antibiotics may be used in some trusts if using posterior packing or leaving packing in for over 24h to prevent toxic shock syndrome
• Surgery if it still doesn’t resolve to cauterise the vessel