Nosebleed

Question 1

Describe anterior epistaxis

Answer 1

Anterior often has a visible source of bleeding and usually occurs due to an insult to the network of capillaires that form Kiesselbach’s plexus

Question 2

Describe posterior epistaxis

Answer 2

Posterior haemorrhages tend to be more profuse and originate from deeper structures.
Occur more frequently in older patients and have higher risk of aspiration and airway compromise.

Question 3

What are causes of epistaxis?

Answer 3

Trauma - foreign body, nose picking, nose blowing

Question 4

What can epistaxis indicate?

Answer 4

Platelet function: thrombocytopenia, splenomegaly, leukaemia, Waldenstrom’s macroglobulinaemia, ITP

Wegeners granulomatosis with polyangitis
Cocaine use

Question 5

What is the blood supply to the nasal septum?

Answer 5

Littles area: anteiror ethmoidal, sphenopalatine, facial arteries anastomose to form anterior anastomotic arcade

Anteior ethmoidal
Poisteior ethmoidal
Sphenopalatine
Septal branch
Greater palatine
Superior labial artery

Question 6

What arteries form Little’s area?

Answer 6

anteiror ethmoidal, sphenopalatine, facial arteries anastomose to form anterior anastomotic arcade

Question 7

What is management if the patient is haemodynamically stable? What should you advise the patient?

Answer 7

Sit with those forward and mouth open
avoid lying down
Spit out any blood
Pinch lower cartilaginous area of the nose firmly and consistently for 15 minutes and breathe through the mouth
Place ice pack on dorsal of nose

Question 8

When should cautery be used?

Answer 8

If bleeding does not stop after 10-15 minutes of continuous pressure on nose
IF the source of bleed is visible and cautery is tolerated

Question 9

Describe cautery.

Answer 9

Ask patient to blow nose to remove clots
Use topical anaesthetic spread and wait 3-4 mins
Identify bleeding point and apply the silver nitrate stick for 3-10 seconds until it becomes grey-white
Avoid touching areas that do not require treatment
Only cauteries one side of septum as there is risk of perforation
Dab with Naseptin topical antiseptic

Question 10

What should you do if the source of bleed is not visible?

Answer 10

Refer to ENT

Nasal packing

Question 11

Describe packing.

Answer 11

Anaesthetise with topical local anaesthetic and wait
Pack the patients nose while they are sitting forward
Lubricate soak pack
Advance into nose horizontally and parallel to the hard palate
Remove after 24h

Post-nasal pack - Pass via nostril into nasopharyngeal and inflate balloon with 10ml water and pull anteriorly
Clamp at nasal vestibule

Question 12

What is management for serious posterior epistaxis?

Answer 12

Admit

Examination under anaesthesia - if discrete bleeding point is found, treat directly with diathermy
Arterail ligation - endoscopic ligation of artery
Embolization of artery can help

Question 13

What advice should be given to patients?

Answer 13

Blowing nose, picking nose, heavy lifting, exercise, lying flat, drinking alcohol and hot drinks should be avoided.
If sneezing, sent it through open mouth