Epistaxis (ENT) Flashcards
Define epistaxis.
Nosebleed - bleeding from the nostril, nasal cavity and/or nasopharynx
What is the most common site of bleeding in epistaxis?
95% arise at Little’s area of the anterior septum - Kiesselbach plexus (where vessels supplying nasal mucosa anastomose with each other)
Who is epistaxis most common in?
Children and older people
How can epistaxis be classified? (2)
- anterior epistaxis (90%) - blood flowing out of one nostril, mostly originating from Kiesselbach plexus
- posterior epistaxis (rare) - blood running down throat, high risk of aspiration and airway compromise, both nostrils, originates from Woodruff plexus (vascular network in lateral wall)
What are the clinical features of epistaxis? (4)
- blood in one nostril or both
- bleeding starting at the nostrils (anterior epistaxis if blood not in throat)
- septal deviation - increased likelihood of epistaxis
- elevated BP
What are the risk factors for epistaxis?
- dry weather / humidity
- allergies
- minor nasal trauma (nose picking/rubbing)
- primary coagulopathy (haemophilia, VWD)
- anatomical irregularities - deviated septum
- hyperaemia
- hypertension
- inflammation
- familial hereditary haemorrhagic telangiectasia
- granulomatosis with polyangiitis
- thrombocytopenia - ITP, TTP
What is familial hereditary haemorrhagic telangiectasia (risk factor for epistaxis)?
- autosomal dominant condition
- characterised by multiple telangiectasia (small dilated broken blood vessels) over skin and mucous membranes
- causes spontaneous, recurrent nosebleeds
- first-degree relatives will also have it
What are the features of granulomatosis with polyangiitis (risk factor for epistaxis)? (6)
- epistaxis
- sinusitis
- dyspnoea
- saddle-shaped nose
- rapidly progressive glomerulonephritis
- cANCA positive
What is the difference between idiopathic thrombocytopenia purpura (ITP) and thrombotic thrombocytopenia purpura (TTP)?
- ITP - isolated thrombocytopenia in a well person, also causes petechiae and purpura, treatment with oral prednisolone
- TTP - isolated thrombocytopenia in an unwell person: HUS (haemolytic anaemia, thrombocytopenia, AKI), fever, neurological signs
How is epistaxis diagnosed?
Clinical diagnosis - bleeding from nose or back of throat
When do you do FBC & group and save for epistaxis? (5)
If haemodynamically unstable, significant blood loss, frail and elderly, bleeding tendency, on anticoagulation
What form of imaging might we do for epistaxis?
CT paranasal sinuses - may demonstrate fracture, neoplasm, polyposis
What are some differential diagnoses for epistaxis? (2)
- haemoptysis - respiratory signs (cough, dyspnoea, wheeze, abnormal breath sounds)
- haematemesis - GI symptoms (abdominal pain, melaena, Hx PUD)
How do we manage epistaxis if haemodynamically unstable (>110bpm and/or SBP<90mmHg)?
- ABC approach
- begin fluid resuscitation
- may need blood, FFP, platelet transfusion and fibrinogen supplementation
- consider vasoconstrictor +/- local anaesthetic spray, safeguarding in children, supportive care, admission, analgesia
How do we manage epistaxis if haemodynamically stable?
- nasal first aid - pinch cartilaginous (soft) area of nose firmly and bend head forward (NOT BACK as blood may enter pharynx and cause haematemesis)
- if this does not work (after 10-15min): then cautery, then nasal packing
