Epistaxis

Question 1

Where is the most common site of epistaxis?

Answer 1

Bleeding usually originates from Kiesselbach’s plexus, which is located in Little’s area. This is an area of the nasal mucosa at the front of the nasal cavity that contains a lot of blood vessels. When the mucosa is disrupted and the blood vessels are exposed, they become prone to bleeding.

Question 2

What are the 2 different types of epistaxis?

Answer 2

They are anterior or posterior; anterior bleeds that can be easily seen with rhinoscopy are simpler to treat and are usually less severe.

Question 3

What can cause epistaxis?

Answer 3

Nosebleeds are common in young children and older adults. They can be triggered by:

• Nose picking
• Colds
• Sinusitis
• Vigorous nose-blowing
• Trauma
• Changes in the weather
• Coagulation disorders (e.g. thrombocytopenia or Von Willebrand disease)
• Anticoagulant medication (e.g. aspirin, DOACs or warfarin)
• Snorting cocaine
• Tumours (e.g. squamous cell carcinoma)

Question 4

How does epistaxis present?

Answer 4

When a patient swallows blood during a nosebleed, they may present with vomiting blood.

Bleeding is usually unilateral. Bleeding from both nostrils may indicate bleeding posteriorly in the nose. Posterior bleeding presents a higher risk of aspiration of blood.

Question 5

How are the majority of epistaxis treated?

Answer 5

Nosebleeds will usually resolve without needing any medical assistance. Recurrent and significant nosebleeds might require further investigation to look for an underlying cause, such as thrombocytopenia or clotting disorders.

Question 6

What advice should be given to a patient to manage a nosebleed?

Answer 6

You may have to advise patients on how to manage a nosebleed:

• Sit up and tilt the head forwards (tilting the head backwards is not advised as blood will flow towards the airway)
• Squeeze the soft part of the nostrils together for 10 – 15 minutes
• Spit out any blood in the mouth, rather than swallowing

Question 7

When does epistaxis require further treatment and hospital admission?

Answer 7

When bleeding does not stop after 10 – 15 minutes, the nosebleed is severe, bleeding is from both nostrils or haemodynamically unstable.

Question 8

What further treatment may be required for epistaxis?

Answer 8

When bleeding does not stop after 10 – 15 minutes, the nosebleed is severe, bleeding is from both nostrils, or haemodynamically unstable, patients may require hospital admission. Treatment options are:

• Nasal packing using nasal tampons or inflatable packs
• Nasal cautery using silver nitrate sticks

Question 9

After treating an acute nosebleed, what cream should be prescribed?

Answer 9

After treating an acute nosebleed, consider prescribing Naseptin nasal cream (chlorhexidine and neomycin) four times daily for 10 days to reduce any crusting, inflammation and infection.

Question 10

When is Naseptin nasal cream (chlorhexidine and neomycin) contraindicated?

Answer 10

This is contraindicated in peanut or soya allergy.