Epistaxis

Question 1

Probability diagnosis

Answer 1

Idiopathic: spontaneous from Little’s area

URTI: common cold/flu/sinusitis

Rhinitis: allergic and atrophic

Vestibulitis

Trauma (incl. nose picking, nose injury)

Drugs (e.g. anticoagulants, aspirin)

Question 2

Serious disorders not to be missed

Answer 2

Vascular:

• hypertension and arteriosclerosis

Infection:

• systemic febrile illness (e.g. malaria)
• HIV/AIDS

Cancer/neoplasia:

• tumours of nose/sinuses/nasopharynx
• intracranial tumours
• leukaemia

Other:

• thrombocytopenia
• coagulopathy (e.g. haemophilia, liver disease)

Question 3

Pitfalls (often missed)

Answer 3

Exposure to toxic agents

Vitamin deficiencies: C and K

Septal granulomas and perforations

Foreign bodies (esp. in children)

Cocaine abuse

Rarities:

• hereditary haemorrhagic telangiectasia

Question 4

Masquerades checklist

Answer 4

Drugs:

• anticoagulants
• aspirin
• nasal sprays

Anaemia: aplastic anaemia

Question 5

Key history

Answer 5

Recent trauma to nose.

Significant past history (e.g. hypertension).

Drug and alcohol history (e.g. anticoagulants).

Bleeding or bruising tendency.

Question 6

Key examination

Answer 6

Nasal airways and sinuses

Skin for evidence of purpura or ecchymoses

Lymph node areas and abdomen for hepatosplenomegaly

Vital signs (esp. blood pressure)

Question 7

Key investigations

Answer 7

Probably none.

Consider:

• FBE
• clotting studies
• sinus X-ray
• INR
• CT scan (occasionally).

Question 8

Diagnostic tips

Answer 8

Recent onset of persistent bleeding in elderly points to carcinoma.

Severe epistaxis is often caused by liver disease coagulopathy.

Difficult-to-control posterior bleeding is a feature of the hypertensive elderly.

Question 9

Mangement

Answer 9

Simple tamponade

• Pinch ‘soft’ part of nose between thumb and finger for 5 mins.
• Apply ice packs to bridge of nose.

Simple cautery of Little’s area

Under LA, e.g. Cophenylcaine forte nasal spray ± 5% cocaine solution

Use one of three methods:

• electrocautery
• trichloracetic acid or
• silver nitrate stick (preferred).

Question 10

Persistent anterior bleed

Answer 10

• Merocel (surgical sponge) nasal tampon
• or Kaltostat pack
• or BIPP with ribbon gauze

‘Trick of the trade’ for recurrent anterior epistaxis:

• apply Nasalate nose cream tds for 7–10 d or
• Rectinol ointment

Question 11

Severe posterior epistaxis

Answer 11

Use a Foley’s catheter

or

an Epistat catheter with or without Kaltostat.