Epistaxis: Background, Anatomy, Pathophysiology Pathophysiology Overview Background Epistaxis, or bleeding from the nose, is a common complaint. [ 1 ] It is rarely life threatening but may cause significant concern, especially among parents of small children. [ 2 ] Most nosebleeds are benign, self-limiting, and spontaneous, but some can be recurrent. Many uncommon causes are also noted. Epistaxis can be divided into 2 categories, anterior bleeds and posterior bleeds, on the basis of the site where the bleeding originates (see the image below). Posterior epistaxis from the left sphenopalatine artery. View Media Gallery The true prevalence of epistaxis is not known, because most episodes are self-limited and thus are not reported. When medical attention is needed, it is usually because of either the recurrent or severe nature of the problem. Treatment depends on the clinical picture, the experience of the treating physician, and the availability of ancillary services. [ 3 , 4 , 5 , 6 ] Next: Anatomy The nose has a rich vascular supply, with substantial contributions from the internal carotid artery (ICA) and the external carotid artery (ECA).

The ECA system supplies blood to the nose via the facial and internal maxillary arteries. The superior labial artery is one of the terminal branches of the facial artery. This artery subsequently contributes to the blood supply of the anterior nasal floor and anterior septum through a septal branch. The internal maxillary artery enters the pterygomaxillary fossa and divides into 6 branches: posterior superior alveolar, descending palatine, infraorbital, sphenopalatine, pterygoid canal, and pharyngeal. The descending palatine artery descends through the greater palatine canal and supplies the lateral nasal wall. It then returns to the nose via a branch in the incisive foramen to provide blood to the anterior septum. The sphenopalatine artery enters the nose near the posterior attachment of the middle turbinate to supply the lateral nasal wall. It also gives off a branch to provide blood supply to the septum. The ICA contributes to nasal vascularity through the ophthalmic artery. This artery enters the bony orbit via the superior orbital fissure and divides into several branches.

The posterior ethmoidal artery exits the orbit through the posterior ethmoidal foramen, located 2-9 mm anterior to the optic canal. The larger anterior ethmoidal artery leaves the orbit through the anterior ethmoidal foramen (see the image below). Nasal vascular anatomy Pathophysiology Bleeding typically occurs when the mucosa is eroded and vessels become exposed and subsequently break. More than 90% of bleeds occur anteriorly and arise from Little’s area, where the Kiesselbach plexus forms on the septum. [ 8 , 9 ] The Kiesselbach plexus is where vessels from both the ICA (anterior and posterior ethmoidal arteries) and the ECA (sphenopalatine and branches of the internal maxillary arteries) converge. These capillary or venous bleeds provide a constant ooze, rather than the profuse pumping of blood observed from an arterial origin. Anterior bleeding may also originate anterior to the inferior turbinate. Posterior bleeds arise further back in the nasal cavity, are usually more profuse, and are often of arterial origin (eg, from branches of the sphenopalatine artery in the posterior nasal cavity or nasopharynx).

A posterior source presents a greater risk of airway compromise, aspiration of blood, and greater difficulty controlling bleeding. Previous Next: Etiology Causes of epistaxis can be divided into local causes (eg, trauma, mucosal irritation, septal abnormality, inflammatory diseases, tumors), systemic causes (eg, blood dyscrasias, arteriosclerosis, hereditary hemorrhagic telangiectasia), and idiopathic causes. Local trauma is the most common cause, followed by facial trauma, foreign bodies , nasal or sinus infections , and prolonged inhalation of dry air. Children usually present with epistaxis due to local irritation or recent upper respiratory infection (URI). In a retrospective cohort study of 2405 patients with epistaxis (3666 total episodes), Purkey et al used multivariate analysis to identify a series of risk factors for nosebleeds. The likelihood of epistaxis was found to increase in patients with allergic rhinitis, chronic sinusitis, hypertension, hematologic malignancy, coagulopathy, or, as mentioned, hereditary hemorrhagic telangiectasia. The investigators also found increased nosebleeds in association with older age and colder weather.

[ 10 ] Trauma Self-induced trauma from repeated nasal picking can cause anterior septal mucosal ulceration and bleeding. This scenario is frequently observed in young children. Nasal foreign bodies that cause local trauma (eg, nasogastric and nasotracheal tubes) can be responsible for rare cases of epistaxis. Acute facial and nasal trauma commonly leads to epistaxis. If the bleeding is from minor mucosal laceration, it is usually limited. However, extensive facial trauma can result in severe bleeding requiring nasal packing. In these patients, delayed epistaxis may signal the presence of a traumatic aneurysm. Patients undergoing nasal surgery should be warned of the potential for epistaxis. As with nasal trauma, bleeding can range from minor (due to mucosal laceration) to severe (due to transection of a major vessel). Dry weather Low humidity may lead to mucosal irritation. Epistaxis is more prevalent in dry climates and during cold weather due to the dehumidification of the nasal mucosa by home heating systems. Drugs Topical nasal drugs such as antihistamines and corticosteroids may cause mucosal irritation.

Especially when applied directly to the nasal septum instead of the lateral walls, they may cause mild epistaxis. Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) are also frequently involved. Septal abnormality Septal deviations ( deviated nasal septum ) and spurs may disrupt the normal nasal airflow, leading to dryness and epistaxis. The bleeding sites are usually located anterior to the spurs in most patients. The edges of septal perforations frequently harbor crusting and are common sources of epistaxis. Inflammation Bacterial, viral, and allergic rhinosinusitis causes mucosal inflammation and may lead to epistaxis. Bleeding in these cases is usually minor and frequently manifests as blood-streaked nasal discharge. Granulomatosis diseases such as sarcoidosis, Wegener granulomatosis, tuberculosis, syphilis, and rhinoscleroma often lead to crusting and friable mucosa and may be a cause of recurrent epistaxis. Young infants with gastroesophageal reflux into the nose may have epistaxis secondary to inflammation. Tumors Benign and malignant tumors can manifest as epistaxis.

Affected patients may also present with signs and symptoms of nasal obstruction and rhinosinusitis, often unilateral. Intranasal rhabdomyosarcoma, although rare, often begins in the nasal, orbital, or sinus area in children. Juvenile nasal angiofibroma in adolescent males may cause severe nasal bleeding as the initial symptom. Blood dyscrasias Congenital coagulopathies should be suspected in individuals with a positive family history, easy bruising, or prolonged bleeding from minor trauma or surgery. Examples of congenital bleeding disorders include hemophilia and von Willebrand disease. [ 7 ] Acquired coagulopathies can be primary (due to the diseases) or secondary (due to their treatments). Among the more common acquired coagulopathies are thrombocytopenia and liver disease with its consequential reduction in coagulation factors. Even in the absence of liver disease, alcoholism has also been associated with coagulopathy and epistaxis. Oral anticoagulants predispose to epistaxis. Vascular abnormalities Arteriosclerotic vascular disease is considered a reason for the higher prevalence of epistaxis in elderly individuals.

Hereditary hemorrhagic telangiectasia (HHT; also known as Osler-Weber-Rendu syndrome ) is an autosomal dominant disease associated with recurrent bleeding from vascular anomalies. The condition can affect vessels ranging from capillaries to arteries, leading to the formation of telangiectasias and arteriovenous malformations. Pathologic examination of these lesions reveals a lack of elastic or muscular tissue in the vessel wall. As a result, bleeding can occur easily from minor trauma and tends not to stop spontaneously. Various organ systems such as the respiratory, gastrointestinal, and genitourinary systems may be involved. The epistaxis in these individuals is variable in severity but is almost universally recurrent. Other vascular abnormalities that predispose to epistaxis include vascular neoplasms, aneurysms, and endometriosis. Migraine Children with migraine headaches have a higher incidence of recurrent epistaxis than children without the disease. [ 11 ] The Kiesselbach plexus, which is part of the trigeminovascular system, has been implicated in the pathogenesis of migraine. [ 12 ] Hypertension The relationship between hypertension and epistaxis is often misunderstood.

Patients with epistaxis commonly present with an elevated blood pressure. Epistaxis is more common in hypertensive patients, perhaps owing to vascular fragility from long-standing disease. Hypertension, however, is rarely a direct cause of epistaxis. More commonly, epistaxis and the associated anxiety cause an acute elevation of blood pressure. Therapy, therefore, should be focused on controlling hemorrhage and reducing anxiety as primary means of blood pressure reduction. A study by Sarhan and Algamal, which included 40 patients with epistaxis and 40 controls, reported that the number of attacks of epistaxis was higher in patients with a history of hypertension, but the investigators were unable to determine whether a definite link existed between nosebleeds and high blood pressure. They did find, however, that control of epistaxis was more difficult in hypertensive patients; patients whose systolic blood pressure was higher at presentation tended to need management with packing, balloon devices, or cauterization. [ 13 ] Excessive coughing causing nasal venous hypertension may be observed in pertussis or cystic fibrosis . Idiopathic causes The cause of epistaxis is not always readily identifiable.

Approximately 10% of patients with epistaxis have no identifiable causes even after a thorough evaluation. [ 14 ] Previous Next: Epidemiology The frequency of epistaxis is difficult to determine because most episodes resolve with self-treatment and, therefore, are not reported. [ 15 ] However, when multiple sources are reviewed, the lifelong incidence of epistaxis in the general population is about 60%, with fewer than 10% seeking medical attention. [ 7 , 16 , 15 ] The age distribution is bimodal, with peaks in young children (2-10 y) and older individuals (50-80 y). Epistaxis is unusual in infants in the absence of a coagulopathy or nasal pathology (eg, choanal atresia, neoplasm). Local trauma (eg, nose picking) does not occur until later in the toddler years. Older children and adolescents also have a less frequent incidence. Consider cocaine abuse in adolescent patients. Prevalence of epistaxis tends to be higher in males (58%) than in females (42%). Previous Next: Prognosis For most of the general population, epistaxis is merely a nuisance.

However, the problem can occasionally be life-threatening, especially in elderly patients and in those patients with underlying medical problems. Fortunately, mortality is rare and is usually due to complications from hypovolemia, with severe hemorrhage or underlying disease states. Overall, the prognosis is good but variable; with proper treatment, it is excellent. When adequate supportive care is provided and underlying medical problems are controlled, most patients are unlikely to experience any rebleeding. Others may have minor recurrences that resolve spontaneously or with minimal self-treatment. A small percentage of patients may require repacking or more aggressive treatments. Patients with epistaxis that occurs from dry membranes or minor trauma do well, with no long-term effects. Patients with HHT tend to have multiple recurrences regardless of the treatment modality. Patients with bleeding from a hematologic problem or cancer have a variable prognosis. Patients who have undergone nasal packing are subject to increased morbidity. Posterior packing can potentially cause airway compromise and respiratory depression. Packing in any location may lead to infection.

Previous Next: Patient Education Contributor Information and Disclosures Author Quoc A Nguyen, MD Associate Clinical Professor, Director, Sinus and Allergy Center, Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Medical Center Disclosure: Nothing to disclose. Specialty Editor Board Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape. Ted L Tewfik, MD Professor of Otolaryngology-Head and Neck Surgery, Professor of Pediatric Surgery, McGill University Faculty of Medicine; Senior Staff, Montreal Children's Hospital, Montreal General Hospital, and Royal Victoria Hospital Ted L Tewfik, MD is a member of the following medical societies: American Society of Pediatric Otolaryngology , Canadian Society of Otolaryngology-Head & Neck Surgery Disclosure: Nothing to disclose.

Chief Editor Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery , American Academy of Otolaryngology-Head and Neck Surgery , American Head and Neck Society Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors Hassan H Ramadan, MD, MSc Professor and Vice-Chair, Department of Otolaryngology-Head and Neck Surgery, Professor, Department of Pediatrics, West Virginia University School of Medicine Management of Epistaxis - American Family Physician Management of Epistaxis CORRY J. KUCIK, LT, MC, USN, and TIMOTHY CLENNEY, CDR, MC, USN, Naval Hospital Jacksonville, Jacksonville, Florida Am Fam Physician. 2005 Jan 15;71(2):305-311. References Family physicians frequently encounter patients with epistaxis (nasal bleeding). In rare cases, this condition may lead to massive bleeding and even death. Although epistaxis can have an anterior or posterior source, it most often originates in the anterior nasal cavity. A directed history and physical examination generally determine the cause of the bleeding. Both local and systemic processes can play a role in epistaxis. Nasal bleeding usually responds to first-aid measures such as compression. When epistaxis does not respond to simple measures, the source of the bleeding should be located and treated appropriately.

Treatments to be considered include topical vasoconstriction, chemical cautery, electrocautery, nasal packing (nasal tampon or gauze impregnated with petroleum jelly), posterior gauze packing, use of a balloon system (including a modified Foley catheter), and arterial ligation or embolization. Topical or systemic antibiotics should be used in selected patients. Hospital admission should be considered for patients with significant comorbid conditions or complications of blood loss. Referral to an otolaryngologist is appropriate when bleeding is refractory, complications are present, or specialized treatment (balloon placement, arterial ligation, angiographic arterial embolization) is required. Epistaxis, or nasal bleeding, has been reported to occur in up to 60 percent of the general population. 1 – 3 The condition has a bimodal distribution, with incidence peaks at ages younger than 10 years and older than 50 years. Epistaxis appears to occur more often in males than in females. 1 , 4 Epistaxis is common, and affected persons usually do not seek medical attention, particularly if the bleeding is minor or self-limited.

In rare cases, however, massive nasal bleeding can lead to death. 5 – 7 Label References If local treatments fail to stop anterior bleeding, the anterior nasal cavity should be packed from posterior to anterior with ribbon gauze impregnated with petroleum jelly or antibiotic ointment. C Based on one study, chemical cautery (silver nitrate sticks) can be used for simple anterior epistaxis because it has efficacy and complication rates similar to electrocautery. C Because of the possibility of toxic shock syndrome with prolonged nasal packing, use of a topical antistaphylococcal antibiotic ointment on the packing materials has been recommended. C Either ribbon gauze packing or nasal tampons can be used for packing; one study found no significant difference in patient comfort or efficacy. B A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, opinion, or case series. See page 225 for more information. Strength of Recommendations Label References If local treatments fail to stop anterior bleeding, the anterior nasal cavity should be packed from posterior to anterior with ribbon gauze impregnated with petroleum jelly or antibiotic ointment.

C Based on one study, chemical cautery (silver nitrate sticks) can be used for simple anterior epistaxis because it has efficacy and complication rates similar to electrocautery. C Because of the possibility of toxic shock syndrome with prolonged nasal packing, use of a topical antistaphylococcal antibiotic ointment on the packing materials has been recommended. C Either ribbon gauze packing or nasal tampons can be used for packing; one study found no significant difference in patient comfort or efficacy. B A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, opinion, or case series. See page 225 for more information. Anatomy References The rich vascular supply of the nose originates from the ethmoid branches of the internal carotid arteries and the facial and internal maxillary divisions of the external carotid arteries. 5 Although nasal circulation is complex ( Figure 1 ), epistaxis usually is described as either anterior or posterior bleeding. This simple distinction provides a useful basis for management. Vascular anatomy of nasal septal blood supply. Figure 1. Vascular anatomy of nasal septal blood supply.

Most cases of epistaxis occur in the anterior part of the nose, with the bleeding usually arising from the rich arterial anastomoses of the nasal septum (Kiesselbach’s plexus). Posterior epistaxis generally arises from the posterior nasal cavity via branches of the sphenopalatine arteries. 8 Such bleeding usually occurs behind the posterior portion of the middle turbinate or at the posterior superior roof of the nasal cavity. In most cases, anterior bleeding is clinically obvious. In contrast, posterior bleeding may be asymptomatic or may present insidiously as nausea, hematemesis, anemia, hemoptysis, or melena. Infrequently, larger vessels are involved in posterior epistaxis and can result in sudden, massive bleeding. Etiology References Most causes of nasal bleeding can be identified readily through a directed history and physical examination. The patient should be asked about the initial presentation of the bleeding, previous bleeding episodes and their treatment, comorbid conditions, and current medications, including over-the-counter medicines and herbal and home remedies. Although the differential diagnosis should include both local and systemic causes ( Table 1 ), 1 , 5 , 9 environmental factors such as humidity and allergens also must be considered.

5 , 10 Often, no cause for the bleeding is identified. Medications (e.g., aspirin, anticoagulants, nonsteroidal anti-inflammatory drugs) Platelet dysfunction Information from references 1 , 5 , and 9 . TABLE 1 Medications (e.g., aspirin, anticoagulants, nonsteroidal anti-inflammatory drugs) Platelet dysfunction Information from references 1 , 5 , and 9 . Management References GENERAL APPROACH Initial management includes compression of the nostrils (application of direct pressure to the septal area) and plugging of the affected nostril with gauze or cotton that has been soaked in a topical decongestant. Direct pressure should be applied continuously for at least five minutes, and for up to 20 minutes. Tilting the head forward prevents blood from pooling in the posterior pharynx, thereby avoiding nausea and airway obstruction. Hemodynamic stability and airway patency should be confirmed. Fluid resuscitation should be initiated if volume depletion is suspected. Every attempt should be made to locate the source of bleeding that does not respond to simple compression and nasal plugging.

The examination should be performed in a well-lighted room, with the patient seated and clothing protected by a sheet or gown. The physician should wear gloves and other appropriate protective equipment (e.g., surgical mask, safety glasses). A headlamp or head mirror and a nasal speculum should be used for optimal visualization. An epistaxis tray can be created using common supplies and a few specialized instruments ( Figure 2 ). Clots and foreign bodies in the anterior nasal cavity can be removed with a small (Frazier) suction tip, irrigation, forceps, and cotton-tipped applicators. View/Print Figure Figure 2. Typical contents of an epistaxis tray. Top row: nasal decongestant sprays and local anesthetic, silver nitrate cautery sticks, bayonet forceps, nasal speculum, Frazier suction tip, posterior double balloon system and syringe for balloon inflation. Bottom row: Packing materials, including nonadherent gauze impregnated with petroleum jelly and 3 percent bismuth tribromophenate (Xeroform), Merocel, Gelfoam, and suction cautery. Figure 2. Typical contents of an epistaxis tray.

Top row: nasal decongestant sprays and local anesthetic, silver nitrate cautery sticks, bayonet forceps, nasal speculum, Frazier suction tip, posterior double balloon system and syringe for balloon inflation. Bottom row: Packing materials, including nonadherent gauze impregnated with petroleum jelly and 3 percent bismuth tribromophenate (Xeroform), Merocel, Gelfoam, and suction cautery. When posterior bleeding is suspected, the general location of the source should be determined. This step is important because different arteries supply the floor and roof of the posterior nasal cavity; therefore, selective ligation may be required. 5 , 11 Diffuse oozing, multiple bleeding sites, or recurrent bleeding may indicate a systemic process such as hypertension, anticoagulation, or coagulopathy. In such cases, a hematologic evaluation should be performed. Appropriate tests include a complete blood count, anticoagulant levels, a prothrombin time, a partial thromboplastin time, a platelet count and, if indicated, blood typing and crossmatching.

9 , 12 Although most patients with epistaxis can be treated as outpatients, hospital admission and close observation should be considered for elderly patients and patients with posterior bleeding or coagulopathy. Admission also may be prudent for patients with complicating comorbid conditions such as coronary artery disease, severe hypertension, or significant anemia. ANTERIOR EPISTAXIS If a single anterior bleeding site is found, vasoconstriction should be attempted with topical application of a 4 percent cocaine solution or an oxymetazoline or phenylephrine solution. For bleeding that is likely to require more aggressive treatment, a local anesthetic, such as a 4 percent cocaine solution or tetracaine or lidocaine (Xylocaine) solution, should be used. Adequate anesthesia should be obtained before treatment proceeds. Intravenous access should be obtained in difficult cases, especially when anxiolytic medications are to be used. Cotton pledgets soaked in vasoconstrictor and anesthetic should be placed in the anterior nasal cavity, and direct pressure should be applied at both sides of the nose for at least five minutes. Then the pledgets can be removed for reinspection of the bleeding site.

If this measure is unsuccessful, chemical cautery can be attempted using a silver nitrate stick applied directly to the bleeding site for approximately 30 seconds. 5 Other treatment options include hemostatic packing with absorbable gelatin foam (Gelfoam) or oxidized cellulose (Surgicel). Use of desmopressin spray (DDAVP) may be considered in a patient with a known bleeding disorder. 5 , 13 Larger vessels generally respond more readily to electrocautery. However, electrocautery must be performed cautiously to avoid excessive destruction of healthy surrounding tissues. Note that use of electrocautery on both sides of the septum may increase the risk of septal perforation. 9 Interestingly, at least one study 14 found no difference in efficacy or complication rate between chemical cautery (silver nitrate stick) and electrocautery. If local treatments fail to stop anterior bleeding, the anterior nasal cavity should be packed, from posterior to anterior, with ribbon gauze impregnated with petroleum jelly or polymyxin B-bacitracin zinc-neomycin (Neosporin) ointment.

Nonadherent gauze impregnated with petroleum jelly and 3 percent bismuth tribromophenate (Xeroform) also works well for this purpose. 5 , 9 Bayonet forceps and a nasal speculum are used to approximate the accordion-folded layers of the gauze, which should extend as far back into the nose as possible. Each layer should be pressed down firmly before the next layer is inserted ( Figure 3 ). Once the cavity has been packed as completely as possible, a gauze “drip pad” may be taped over the nostrils and changed periodically. View/Print Figure Figure 3. Packing of the anterior nasal cavity using gauze strip impregnated with petroleum jelly. A. Gauze is gripped with bayonet forceps and inserted into the anterior nasal cavity. B. With a nasal speculum (not shown) used for exposure, the first packing layer is inserted along the floor of the anterior nasal cavity. Forceps and speculum then are withdrawn. C. Additional layers of packing are added in an accordion-fold fashion, with the nasal speculum used to hold the positioned layers down while a new layer is inserted. Packing is continued until the anterior nasal cavity is filled.

Figure 3. Packing of the anterior nasal cavity using gauze strip impregnated with petroleum jelly. A. Gauze is gripped with bayonet forceps and inserted into the anterior nasal cavity. B. With a nasal speculum (not shown) used for exposure, the first packing layer is inserted along the floor of the anterior nasal cavity. Forceps and speculum then are withdrawn. C. Additional layers of packing are added in an accordion-fold fashion, with the nasal speculum used to hold the positioned layers down while a new layer is inserted. Packing is continued until the anterior nasal cavity is filled. Alternatively, a preformed nasal tampon (Merocel or Doyle sponge) may be used. 12 The tampon is inserted carefully along the floor of the nasal cavity, where it expands on contact with blood or other liquid. Application of lubricant jelly to the tip of the tampon facilitates placement. After the nasal tampon has been inserted, wetting it with a small amount of topical vasoconstrictor may hasten effectiveness. It may be necessary to drip saline into the nostril to achieve full expansion of the tampon if the bleeding has decreased at the time of insertion.

Although one study 15 found no significant difference in patient comfort or efficacy with nasal tampons or ribbon gauze packing, simplicity of placement makes the tampons highly useful in primary care settings. When applied in the outpatient setting, nasal packing may be left in place for three to five days to ensure formation of an adequate clot. 12 Complications of nasal packing procedures include septal hematomas and abscesses from traumatic packing, sinusitis, neurogenic syncope during packing, and pressure necrosis secondary to excessively tight packing. Because of the possibility of toxic shock syndrome with prolonged nasal packing, use of a topical antistaphylococcal antibiotic ointment on the packing materials has been recommended. 10 , 12 POSTERIOR EPISTAXIS Posterior bleeding is much less common than anterior bleeding 16 and usually is treated by an otolaryngologist. Posterior packing may be accomplished by passing a catheter through one nostril (or both nostrils), through the nasopharynx, and out the mouth ( Figure 4 ).

A gauze pack then is secured to the end of the catheter and positioned in the posterior nasopharynx by pulling back on the catheter until the pack is seated in the posterior choana, sealing the posterior nasal passage and applying pressure to the site of the posterior bleeding. 5 Although this procedure is not outside the scope of family practice, it requires special training and usually is performed by an otolaryngologist. Figure 4. ILLUSTRATION BY CHRISTY KRAMES Posterior nasal packing. A. After adequate anesthesia has been obtained, a catheter is passed through the affected nostril and through the nasopharynx, and drawn out the mouth with the aid of ring forceps. B. A gauze pack is secured to the end of the catheter using umbilical tape or suture material, with long tails left to protrude from the mouth. C. The gauze pack is guided through the mouth and around the soft palate using a combination of careful traction on the catheter and pushing with a gloved finger. This is the most uncomfortable (and most dangerous) part of the procedure; it should be completed smoothly and with the aid of a bite block (not shown) to protect the physician’s finger.

D. The gauze pack should come to rest in the posterior nasal cavity. It is secured in position by maintaining tension on the catheter with a padded clamp or firm gauze roll placed anterior to the nostril. The ties protruding from the mouth, which will be used to remove the pack, are taped to the patient’s cheek. Figure 4. ILLUSTRATION BY CHRISTY KRAMES Posterior nasal packing. A. After adequate anesthesia has been obtained, a catheter is passed through the affected nostril and through the nasopharynx, and drawn out the mouth with the aid of ring forceps. B. A gauze pack is secured to the end of the catheter using umbilical tape or suture material, with long tails left to protrude from the mouth. C. The gauze pack is guided through the mouth and around the soft palate using a combination of careful traction on the catheter and pushing with a gloved finger. This is the most uncomfortable (and most dangerous) part of the procedure; it should be completed smoothly and with the aid of a bite block (not shown) to protect the physician’s finger. D.

The gauze pack should come to rest in the posterior nasal cavity. It is secured in position by maintaining tension on the catheter with a padded clamp or firm gauze roll placed anterior to the nostril. The ties protruding from the mouth, which will be used to remove the pack, are taped to the patient’s cheek. Various balloon systems are effective for managing posterior bleeding and are less complicated than the packing procedure. The double-balloon device ( Figure 2 ) is passed into the affected nostril under topical anesthesia until it reaches the nasopharynx. The posterior balloon then is inflated with 7 to 10 mL of saline, and the catheter extending out of the nostril is withdrawn carefully so that the balloon seats in the posterior nasal cavity to tamponade the bleeding source. Next, the anterior balloon is inflated with roughly 15 to 30 mL of saline in the anterior nasal cavity to prevent retrograde travel of the posterior balloon and subsequent airway obstruction. An umbilical clamp or other device can be placed across the stalk of the balloon adjacent to the nostril to further prevent dislodgement; the clamp should be padded to prevent pressure necrosis of the nasal skin.

Balloon packs generally are left in place for two to five days. As with anterior packing, tissue necrosis can occur if a posterior pack is inserted improperly or balloons are overinflated. If a specialized balloon device is not available, a Foley catheter (10 to 14 French) with a 30-mL balloon may be used. The catheter is inserted through the bleeding nostril and visualized in the oropharynx before inflation of the balloon. 18 The balloon then is inflated with approximately 10 mL of saline, and the catheter is withdrawn gently through the nostril, pulling the balloon up and forward. The balloon should seat in the posterior nasal cavity and tamponade a posterior bleed. With traction maintained on the catheter, the anterior nasal cavity then is packed as previously described. Traction is maintained by placing an umbilical clamp on the catheter beyond the nostrils, which should be padded to prevent soft tissue damage. As with anterior epistaxis, topical antistaphylococcal antibiotic ointment may be used to prevent toxic shock syndrome. However, use of oral or intravenous antibiotics for posterior nasal packing most likely is unnecessary.

19 PERSISTENT BLEEDING Patients with anterior or posterior bleeding that continues despite packing or balloon procedures may require treatment by an otolaryngologist. Endoscopy may be used to locate the exact site of bleeding for direct cauterization. Hot water irrigation, a technique described more than 100 years ago, has been reexamined recently. This technique has shown promise in reducing discomfort and length of hospitalization in patients with posterior epistaxis. 20 , 21 More invasive alternatives include arterial ligation and angiographic arterial embolization. Read the full article. Get immediate access, anytime, anywhere. Choose a single article, issue, or full-access subscription. Earn up to 6 CME credits per issue. Already a member/subscriber? Epistaxis & Nose Bleeds: What Causes Nosebleeds? | Cleveland Clinic Share Facebook Twitter Linkedin Email Print What causes nosebleeds? The purpose of the nose is to warm and humidify the air that we breathe in. The nose is lined with many blood vessels that lie close to the surface where they can be injured and bleed. Once a vessel starts to bleed, the bleeding tends to recur since the clot or scab is easily dislodged.

Nosebleeds, called epistaxis, can be messy and even scary, but often look worse than they are. Many can be treated at home, but some do require medical care. Common causes of nosebleeds include: Dry, heated, indoor air, which dries out the nasal membranes and causes them to become cracked or crusted and bleed when rubbed or picked or when blowing the nose (more common in winter months) Dry, hot, low-humidity climates, which can dry out the mucus membranes Colds (upper respiratory infections) and sinusitis , especially episodes that cause repeated sneezing, coughing, and nose blowing Vigorous nose blowing or nose picking The insertion of a foreign object into the nose Injury to the nose and/or face Follow these steps to stop a nosebleed: Relax Sit down and lean your body and your head slightly forward. This will keep the blood from running down your throat, which can cause nausea, vomiting , and diarrhea . (Do NOT lay flat or put your head between your legs.) Breathe through your mouth. Use a tissue or damp washcloth to catch the blood. Use your thumb and index finger to pinch together the soft part of your nose.

Make sure to pinch the soft part of the nose against the hard bony ridge that forms the bridge of the nose. Squeezing at or above the bony part of the nose will not put pressure where it can help stop bleeding. Keep pinching your nose continuously for at least 5 minutes (timed by clock) before checking if the bleeding has stopped. If your nose is still bleeding, continue squeezing the nose for another 10 minutes. You can spray an over-the-counter decongestant spray , such as oxymetazoline (Afrin®, Dristan®, Neo-Synephrine®, Vicks Sinex®, others) into the bleeding side of the nose and then hold apply pressure to the nose as described above. WARNING: These topical decongestant sprays should not be used over the long term. Once the bleeding stops, DO NOT bend over; strain and/or lift anything heavy; and DO NOT blow, rub, or pick your nose for several days. Under what conditions should I seek physician or emergency care? Seek medical care through your physician or an emergency room if: You cannot stop the bleeding after more than 15 to 20 minutes of applying direct pressure.

You experience repeated episodes of bleeding. The bleeding is rapid or the blood loss is large (exceeds a coffee cupful). The bleeding was caused by an injury, such as a fall or other blow to the nose or face. You feel weak or faint. The blood goes down the back of your throat rather than out front through the nose even though you are sitting down with body and head leaning slightly forward. (This may indicate the rarer, but more serious, "posterior nosebleed," which almost always requires a physician's care. This condition occurs more frequently in older people and individuals with high blood pressure). Call your physician if: You get nosebleeds often. You get a nosebleed that seems to have occurred with the start of a new medication. You get nosebleeds accompanied by unusual bruising all over your body. (This combination may indicate a more serious condition and will need to be investigated by your doctor.) How might an emergency room doctor treat the nosebleed? The doctor will ask you questions about your nosebleed and examine your nose to try to determine the source of the nosebleed.

He or she will use a small speculum to hold the nose open and can use various light sources or an endoscope (lighted scope) to see inside your nasal passages. Your doctor may use topical medications to anesthetize (numb) the lining of the nose and to constrict blood vessels. The doctor is also likely to remove clots and crusts from inside your nose. This can be unpleasant but need not be painful. Occasionally x-rays or blood tests are ordered. Treatments, depending on the cause, could include: Cauterization – the application of a chemical substance (silver nitrate) or heat energy (electrocautery) to seal the bleeding blood vessel. Nasal packing – the placement of strips of gauze into the nasal cavity to create pressure on the bleeding site. Alternately, other materials that promote clotting may be used. Medication adjustments – reducing or stopping the amount of blood thinning medications can be helpful. In addition, medications for controlling blood pressure may be necessary. Foreign body removal Correction of a deviated septum Are there any steps I can take to prevent nosebleeds? Use a saline nasal spray or saline nose drops two to three times a day in each nostril.

These products can be purchased over-the-counter or made at home. (To make the saline solution at home: mix 1 teaspoon of salt into 1 quart of tap water. Boil water for 20 minutes, cool until lukewarm.) Add a humidifier to your furnace or run a humidifier in your bedroom at night. Place water-soluble nasal gels or ointments in your nostrils with a cotton swab. Bacitracin®, Vaseline®, or Ayr Gel® are examples of over-the-counter ointments that you can use. Be sure not to insert the swab more than ¼ inch into your nose. These gels and ointments can be purchased in most pharmacies. Avoid blowing your nose too forcefully, but you may choose to blow your nose after using nasal saline sprays or drops. Sneeze through an open mouth. Avoid putting anything solid into your nose, including fingers and cotton applicators. Limit your use of medications that can increase bleeding, such as aspirin and ibuprofen.

Please remember that any adjustment to medication, especially prescribed medication such as warfarin (Coumadin®), and non-steroidal anti-inflammatory drugs ( NSAIDs ), should only be done under your physician's supervision. See your doctor if your nasal allergy symptoms are not easily controlled with over-the-counter or prescription medications. Quit smoking . Smoking dries out your nose and irritates it. If you have any questions or concerns, do not hesitate to call your physician. References American Academy of Otolaryngology—Head and Neck Surgery. Nosebleeds Accessed 2/12/2015. American Academy of Rhinology. Epistaxis (Nosebleeds) Accessed 2/12/2015. Friedman NR, Scholes MA, Yoon PJ. Ear, Nose, & Throat. In: Hay WW, Jr., Levin MJ, Deterding RR, Abzug MJ. eds. CURRENT Diagnosis & Treatment: Pediatrics, 22e. New York, NY: McGraw-Hill; 2013. library.ccf.org Accessed 2/12/ 2015.

© Copyright 1995-2015 The Cleveland Clinic Foundation. All rights reserved. This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 2/6/2015…#13464 Epistaxis | definition of epistaxis by Medical dictionary Epistaxis | definition of epistaxis by Medical dictionary epistaxis [ep″ĭ-stak´sis] hemorrhage from the nose, usually due to rupture of small vessels overlying the anterior part of the cartilaginous nasal septum. Minor bleeding may be caused by a blow on the nose, irritation from foreign bodies, or vigorous nose-blowing during a cold; sometimes it occurs in connection with menstruation. If bleeding persists in spite of first aid measures, medical attention is advisable. Called also nosebleed . Sometimes nosebleed has serious underlying causes. Arteriosclerosis is a possible cause in the elderly.

Polyps, other fleshy growths in the nose, food allergy, hypertension, vitamin deficiencies, or a disease producing a bleeding tendency may produce nosebleed. If the nose bleeds often or profusely, or if the bleeding is difficult to stop, a health care provider should be consulted. Bleeding from the nose that does not originate in the nose itself is a serious indication that some damage has been done internally, either by injury or disease. Medical attention is necessary to trace the bleeding to its source. The blood probably originates in the stomach, the lungs, within the skull, or in passages related to these parts. First Aid Measures: The victim should sit up with the head tilted forward to avoid aspiration of blood. The soft portion of the nose is grasped firmly between the thumb and forefinger, for 5 to 15 minutes. Once bleeding stops the patient should rest for an hour or so and for several hours should avoid stooping, lifting, or vigorously blowing the nose. If bleeding continues, a health care provider may have to pack the nose. Sometimes cauterization of the bleeding vessel is necessary. In some cases surgery to clip the vessels may be done.

Blood loss from a nosebleed can be considerable and there is danger of hemorrhagic shock. ep·i·stax·is [G. fr. epistazō, to bleed at the nose, fr. epi, on, + stazō, to fall in drops] epistaxis /ep·i·stax·is/ (-stak´sis) nosebleed; hemorrhage from the nose, usually due to rupture of small vessels overlying the anterior part of the cartilaginous nasal septum. epistaxis n. pl. epi·staxes (-stăk′sēz′) A nosebleed. [ep′istak′sis] Etymology: Gk, a dropping bleeding from the nose caused by local irritation of mucous membranes, violent sneezing, fragility or manipulation of the mucous membrane, chronic infection, trauma, hypertension, coagulopathy, vitamin K deficiency, or, thrombocytopenia. Also called nosebleed . observations Epistaxis may result from the rupture of tiny vessels in the anterior nasal septum. This occurs most frequently in early childhood and adolescence.

In adults it occurs more commonly in men than in women; may be severe in elderly persons; may be accompanied by respiratory distress, apprehension, restlessness, vertigo, and nausea; and may lead to syncope. interventions The patient suffering epistaxis is instructed to breathe through the mouth, to sit quietly with the head tilted slightly backward. The bleeding may be controlled by inserting a cotton ball soaked in a topical vasoconstrictor and applying pressure to the skin on both sides of the nose, occluding the blood supply to the nostrils; or by placing an ice compress over the nose. The nasal mucosa may be anesthetized with topical lidocaine, cauterized with a silver nitrate stick or an electrical cautery, and then sprayed with epinephrine. Severe bleeding, especially from the posterior nasal septum, may be treated by packing, which is left in place for 1 to 3 days. Persistent or recurrent profuse epistaxis may be treated by ligating an artery supplying the nose, such as the external carotid, ethmoid, or internal maxillary artery. epistaxis [G. fr. epistazō, to bleed at the nose, fr.

epi, on, + stazō, to fall in drops] epistaxis epistaxis (e·p ·stakˑ·sis), n nosebleed; caused most commonly by picking but can occur as a result of vigorous sneezing, trauma, irritated mucous membranes, leukemia, vitamin K deficiency, hypertension, and other conditions. ep·i·stax·is (ep'i-stak'sis) Bleeding from the nose. [G. fr. epistazō, to bleed at the nose, fr. epi, on, + stazō, to fall in drops] epistaxis (ep´istak´sis), n (nosebleed) bleeding from the nose. epistaxis bleeding from the nose. This is usually from damaged vessels in the nasal mucosa but can also be due to an increased fragility of capillaries or bleeding tendencies, particularly thrombocytopenia. Injury may be due to erosion or ulceration of the mucosa by a systemic disease, e.g. glanders in the horse, or by a local disease of the mucosa, e.g.

allergic rhinitis, trauma to the face or to the head generally, in which case the bleeding is likely to be due to a serious lesion, or to foreign bodies up the nose, a common cause. Bleeding from the nose originating from sites other than the nasal mucosa is a common and serious occurrence in all species but particularly in the horse because of its implication for safety while racing. The passage of large amounts of blood suddenly is usually associated with pulmonary hemorrhage and is often fatal in horses and cattle. In horses this usually occurs during hard exercise. When the bleeding in the horse occurs at rest the origin is commonly from the guttural pouch and due to mycotic erosion of the blood vessels there. See also guttural pouch mycosis, pulmonary hemorrhage, caudal vena caval thrombosis, cranial vena caval thrombosis . Epistaxis in a horse. By permission from Knottenbelt DC, Pascoe RR, Diseases and Disorders of the Horse, Saunders, 2003 Patient discussion about epistaxis Q. Why do litlle kids' nose's begin to bleed? A. A nose starts to bleed when one of the small veins in its lining bursts.

This is usually caused by something completely harmless, such as the child picking their nose, blowing it too hard or having their nose knocked while playing. Another reason could be that the child has pushed something inside their nose. Some children have veins that are closer to the mucous membrane of their nose than other children. Because the veins are very close to the skin, they are more likely to burst when the child picks, blows or rubs their nose, or plays rough games. Q. Hi this is Wilson; I have a daughter, who is 5. She has frequent nose bleeds when she is behaving badly. Hi this is Bell; I have a daughter, who is 5. She has frequent nose bleeds when she is behaving badly. She has been screened by her school for ADHD and I haven’t had a chance to consult a doctor for her screening and exam for ADHD. I thought that her nose bleeds cause due to her behavior? I need help. A. I don’t have an idea about this. But I think that you should first discuss these issues with your doctor. Also mention to the doctor if she has any problems with sleeping, like only sleeping 6 hours a night.

Try with occupational Therapists which help children and adults with small motor issues like handwriting and also with sensory issues like learning how to calm down. Early intervention is always best. Q. My son often has severe nose bleeds. What if any illness' holds this symptom? They wake him in the night. My son has these terrible nose bleeds and I am sooo worried. I have no health insurance and would appreciate some info if anyone has any. Since he was about 4, now 12, he usually has them in the middle of the night. He does have allergies and takes over the counter allergy meds for seasonal allergies. He also has a heat lamp in his bedroom for his dragon. However; I never thought the lamp could cause this because they started 5 years before he had his dragon that uses the heat lamp. I am very worried it could be serious. Any info would be appreciated. A. does it happen when the allergy attack occur? because it can cause nose bleeding. does he have a bleeding problem? when he get's a cut, how long it takes until the bleeding stops? deviated septum in the nose can also cause... but my nephew has seasonal allergies, and he bleed from his nose sometimes.

so i guess it's common. Nosebleed (Epistaxis). What causes a nosebleed? Treatment | Patient 284 Having a nosebleed (epistaxis) is common in children. Nosebleeds are usually mild and easily treated. Sometimes bleeding can be more severe. This is usually in older people, or in people with other medical problems such as blood disorders. Get medical help quickly if the bleeding is severe, or if it does not stop within 20-30 minutes. What causes a nosebleed (epistaxis)? The common site for a nosebleed to start is from just inside the entrance of the nostril, on the middle harder part of the nostril (the nasal septum). Here the blood vessels are quite fragile and can rupture easily for no apparent reason. This happens most commonly in children. This delicate area is also more likely to bleed with the following: Picking the nose. Minor injuries to the nose. Cocaine use. In the above situations, the bleeding tends to last only a short time and is usually easy to control.

The bleeding may last longer and be harder to stop if you have heart failure, a blood clotting disorder, or are taking 'blood thinning' medicines such as warfarin or aspirin. Some people with high blood pressure (hypertension) have a higher risk of having a nosebleed. Bleeding sometimes comes from other areas further back in the nose. It is sometimes due to uncommon disorders of the nose, or to serious injuries to the nose. What is the treatment for a nosebleed (epistaxis)? For most nosebleeds, simple first aid can usually stop the bleeding. If you are not feeling faint, sit up and lean slightly forward. With a finger and thumb, pinch the lower fleshy end of the nose completely blocking the nostrils. It is useless to put pressure over the root of the nose or nasal bones. Usually, if you apply light pressure for 10-20 minutes, the bleeding will stop. If available, a cold flannel or compress around the nose and front of face will help. The cold helps the blood vessels to close down (constrict) and stop bleeding.

Once the nosebleed has stopped, do not pick the nose or try to blow out any of the blood remaining in the nostrils. This may cause another nosebleed. If you feel faint it is best to lie flat on your side. Get medical help quickly if bleeding is heavy, or it does not stop within 20-30 minutes. Sometimes, to stop the bleeding, the nose needs to be packed by a doctor. Rarely, a nosebleed is so heavy that a blood transfusion is needed, and surgery may be required to stop it. Acute Epistaxis: Overview, Clinical Presentation, Differential Diagnosis Differential Diagnosis Overview Overview Epistaxis is defined as acute hemorrhage from the nostril, nasal cavity, or nasopharynx. It is a frequent emergency department (ED) complaint and often causes significant anxiety in patients and clinicians. However, the vast majority of patients who present to the ED with epistaxis (likely more than 90%) may be successfully treated by an emergency physician. [ 1 ] Patient history Controlling significant bleeding or hemodynamic instability should take precedence over obtaining a lengthy history. Note the duration, severity of the hemorrhage, and the side of initial bleeding.

Inquire about previous epistaxis, hypertension, hepatic or other systemic disease, family history, easy bruising, or prolonged bleeding after minor surgical procedures. Recurrent episodes of epistaxis, even if self-limited, should raise suspicion for significant nasal pathology. [ 2 ] Use of medications, especially aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), warfarin, heparin, ticlopidine, and dipyridamole should be documented, as these not only predispose to epistaxis but make treatment more difficult. Physical examination Perform a thorough and methodical examination of the nasal cavity. Blowing the nose decreases the effects of local fibrinolysis and removes clots, permitting a better examination. Application of a vasoconstrictor before the examination may reduce hemorrhage and help to pinpoint the precise bleeding site. Topical application of a local anesthetic reduces pain associated with the examination and nasal packing. Gently insert a nasal speculum and spread the naris vertically. This permits visualization of most anterior bleeding sources. Approximately 90% of nosebleeds can be visualized in the anterior portion of the nasal cavity.

Massive epistaxis may be confused with hemoptysis or hematemesis. Blood dripping from the posterior nasopharynx confirms a nasal source. A posterior bleeding source is suggested by failure to visualize an anterior source, by hemorrhage from both nares, and by visualization of blood draining in the posterior pharynx. Previous Other problems to be considered include the following: Chemical irritants Trauma Tumor A study by Szyszkowicz et al suggested that an association exists between air pollution exposure and ED visits for epistaxis. The report indicated that the number of such ED visits rises with increases in the interquartile range for the concentration of ozone and PM-10 (particles with a diameter of up to 10 micrometers). [ 3 ] A prospective study on the influence of meteorologic factors on nosebleeds indicated that air temperature affects epistaxis rates, although the report, which involved 310 patients, did not find the incidence to be linked to air pressure, rainfall, humidity, wind speed, or duration of sunlight. [ 4 ] Previous Treatment & Management Initial measures Gowns, gloves, and protective eyewear should be worn.

Adequate light is best provided by a headlamp with an adjustable narrow beam. Patients should be positioned comfortably in a seated position, holding a basin under their chin. As always, first address the ABCs (A irway, B reathing, and C irculation). Rarely, severe epistaxis may necessitate endotracheal intubation. Stable patients should be instructed to grasp and pinch their entire nose, maintaining continuous pressure for at least 10 minutes. Make sure that they compress the soft nose tissues against the nasal septum; pinching the hard, incompressible nasal bones will not aid hemorrhage control. Patients with significant hemorrhage should receive an intravenous (IV) line and crystalloid infusion, as well as continuous cardiac monitoring and pulse oximetry. Patients frequently present with an elevated blood pressure; however, a significant reduction can usually be obtained with analgesia and mild sedation alone. Specific antihypertensive therapy is rarely required and should be avoided in the setting of significant hemorrhage. The relation between hypertension and epistaxis is often misunderstood. [ 5 , 6 , 7 ] Patients with epistaxis commonly present with an elevated blood pressure.

Epistaxis is more common in hypertensive patients, perhaps owing to vascular fragility from long-standing disease. Hypertension, however, is rarely a direct cause of epistaxis. More commonly, epistaxis and the associated anxiety cause an acute elevation of blood pressure. Therapy, therefore, should be focused on controlling hemorrhage and reducing anxiety as primary means of blood pressure reduction. Insert pledgets soaked with an anesthetic-vasoconstrictor solution into the nasal cavity to anesthetize and shrink nasal mucosa. Soak pledgets in 4% topical cocaine solution or a solution of 4% lidocaine and topical epinephrine (1:10,000) and place them into the nasal cavity. Allow them to remain in place for 10-15 minutes. If a bleeding point is easily identified, gentle chemical cauterization may be performed after the application of adequate topical anesthesia. The tip of a silver nitrate stick is rolled over mucosa until a gray eschar forms. To prevent septal necrosis or perforation, only 1 side of the septum should be cauterized at a time.

To be effective, cauterization should be performed after bleeding is controlled. Thermal cauterization using an electrocautery device is reserved for more aggressive bleeding and is done with the patient under local or general anesthesia. [ 8 ] If attempts to control hemorrhage with pressure or cauterization fail, the nose should be packed. Options include traditional nasal packing, a prefabricated nasal sponge, an epistaxis balloon, or absorbable materials. [ 9 , 10 , 11 , 12 , 13 ] Traditional (petrolatum gauze) packing Traditional anterior nasal packing with petrolatum gauze has largely been supplanted by the use of tampons and balloons, which are readily available and more easily placed. This method is commonly performed incorrectly, using an insufficient amount of packing placed primarily in the anterior naris. When placed in this way, the gauze serves as a plug rather than as a hemostatic pack. Physicians inexperienced in the proper placement of a gauze pack should use a nasal tampon or balloon instead. The proper technique for placement of a gauze pack is as follows.

Grasp the gauze ribbon about 6 inches from its end with a bayonet forceps. Place it in the nasal cavity as far back as possible, ensuring that the free end protrudes from the nose. On the first pass, the gauze is pressed onto the floor of nasopharynx with closed bayonets. Next, grasp the ribbon about 4-5 inches from the nasal alae, and reposition the nasal speculum so that the lower blade holds the ribbon against lower border of the nasal alae. Bring a second strip into the nose, and press downward. Continue this process, layering the gauze from inferior to superior until the naris is completely packed. Both ends of ribbon must protrude from the naris and should be secured with tape. If this measure does not stop the bleeding, consider bilateral nasal packing. Packing with compressed sponge Trim the compressed sponge (eg Merocel) to fit snugly through the naris. Moisten the tip with surgical lubricant or topical antibiotic ointment. Firmly grasp the length of the sponge with a bayonet forceps, spread the naris vertically with a nasal speculum, and advance the sponge along the floor of the nasal cavity.

Once wet with blood or a small amount of saline, the sponge expands to fill the nasal cavity and tamponade bleeding (see the images below). Compressed sponge - Merocel. Contributor Information and Disclosures Author Ola Bamimore, MD Resident Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center, Kings County Hospital Center Ola Bamimore, MD is a member of the following medical societies: American College of Emergency Physicians , Emergency Medicine Residents' Association Disclosure: Nothing to disclose. Coauthor(s) Mark A Silverberg, MD, MMB, FACEP Assistant Professor, Associate Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate Medical Center Disclosure: Nothing to disclose. Specialty Editor Board Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor Steven C Dronen, MD, FAAEM Chair, Department of Emergency Medicine, LeConte Medical Center Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine , Society for Academic Emergency Medicine Disclosure: Nothing to disclose. Additional Contributors Francis Counselman, MD, FACEP Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School Disclosure: Nothing to disclose. Acknowledgements The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Jeffrey A Evans, MD, and Todd Rothenhaus, MD, to the development and writing of the source article. Epistaxis - RightDiagnosis.com Epistaxis: Stories from Users Epistaxis: Introduction Epistaxis, more commonly known as a nosebleed , is a symptom of a wide variety of mild to serious diseases, disorders and conditions. Epistaxis can result from infection , inflammation, trauma , foreign body, malignancy , and other diseases and abnormal processes. There are two types of epistaxis. An anterior epistaxis is the most common and most easily treatable. A posterior epistaxis is less common and more serious, generally requiring emergency treatment.

Epistaxis can occur in any age group or population. Epistaxis can be the result of nose picking or of a mild condition, such as a mild allergy or nasal congestion . Epistaxis can also be due to a moderate condition, disorder or disease, such as chronic sinusitis . Epistaxis can also occur due to some diseases, disorders and conditions that can be serious, even life-threatening. These include hypertension hemophilia and leukemia . Depending on the cause, epistaxis can be short-term and disappear quickly, such as when epistaxis occurs due to excessively dry air then resolves when the air is humidified. Epistaxis can also occur in sudden episodes, such as epistaxis that happens with hypertensive crisis . Epistaxis can be the result of a wide variety of other conditions, including trauma to the nose or skull, allergies and sinus tumors . For more details about causes, see causes of epistaxis . Epistaxis often occurs in conjunction with other symptoms, which vary depending on the underlying disease, disorder or condition. Other common symptoms include fever , headache , deformity of the nose, weakness , dizziness and sore throat . Complications of epistaxis include nausea and vomiting due to the swallowing of blood.

More serious complications can include anemia , hypovolemic shock, airway obstruction and very rarely, death . The underlying disorder, disease or condition can also cause complications. Diagnosing epistaxis and its root cause begins with taking a thorough personal and family medical history, including symptoms, and completing a physical examination. This includes looking up the nose with a special lighted instrument called a rhinoscope. Taking a blood pressure reading and a series of blood pressure readings can reveal if hypertension is present, possibly causing or contributing to epistaxis. Making a diagnosis also includes performing a variety of other tests to help to diagnose potential underlying diseases, conditions or disorders, such as allergic rhinitis , skull fracture , or cocaine use . Depending on the suspected cause, tests can include , drug testing, blood tests, allergy skin testing, and imaging tests, such as X-ray, CT scan, nuclear scans, and MRI. A diagnosis of epistaxis and its cause can easily be delayed or missed because epistaxis may be mild or intermittent and for other reasons. For information on misdiagnosis, refer to misdiagnosis of epistaxis .

Immediate first aid and treatment of epistaxis includes pinching the nose shut or using a nose clip to hold it closed until the bleeding stops. Applying ice may be done as well. Nasal packing and cautery using medications may also be needed in some cases. Treatment of epistaxis also involves diagnosing and treating the underlying disease, disorder or condition that is causing it. Some conditions can be easily and successfully treated and cured, while others may require more intensive treatment and may not have an optimal prognosis. For more information on treatment, refer to treatment of epistaxis .... more » Epistaxis: Misdiagnosis Diagnosing epistaxis and its cause may be delayed or missed because in some cases, epistaxis may not be severe enough for a person to seek medical care. If epistaxis is caused by cocaine use , a person may not seek medical treatment and diagnosis out of shame or for fear of being reported to authorities. Epistaxis is a symptom of many different conditions, so a thorough medical evaluation is ... more misdiagnosis » Causes of Epistaxis: The following medical conditions are some of the possible causes of Epistaxis. There are likely to be other possible causes, so ask your doctor about your symptoms.

Question: What is the more common name for the minor medical complaint 'Epistaxis'?
Answer: NOSEBLEED