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ENT (Ear, Nose, Throat Conditions)

Epistaxis

Bleeding from the nasal cavity, most commonly originating from Kiesselbach's plexus on the anterior nasal septum.

Also known as: Nosebleed

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Referral and warning signs

When to refer

Refer to ENT Specialist/Hospital if: Bleeding uncontrolled by first aid and anterior packing. Suspected posterior bleeding. Recurrent severe epistaxis. Suspected underlying cause like tumour or severe bleeding disorder. Need for cautery or posterior packing.

Red flags

  • Bleeding uncontrolled with direct pressure and packing.
  • Signs of shock / haemodynamic instability.
  • Posterior bleeding.
  • Recurrent unilateral epistaxis (consider tumour).
  • Associated facial trauma or CSF leak.
  • Known severe bleeding disorder.

Signs and symptoms

  • Bleeding from one or both nostrils.
  • Blood may drip into the pharynx and be swallowed or spat out.
  • May be minor and self-limiting or severe and persistent.
  • Signs of hypovolemia/shock if bleeding is massive or prolonged.

Risk factors

  • Local Factors:
  • - Nose picking / Digital trauma (most common cause, especially children).
  • - Dry nasal mucosa (low humidity, heating).
  • - Nasal infections / inflammation (Rhinitis, Sinusitis).
  • - Nasal foreign body.
  • - Nasal trauma (fracture, blunt injury).
  • - Deviated nasal septum.
  • - Nasal tumours (benign or malignant - esp. unilateral/recurrent bleeding in adults).
  • - Use of nasal sprays (steroids, decongestants).
  • - Nasal surgery.
  • Systemic Factors:
  • - Hypertension (may prolong bleeding, less often initiates it).
  • - Bleeding disorders (Haemophilia, von Willebrand disease, thrombocytopenia).
  • - Anticoagulant / Antiplatelet medication (Warfarin, Aspirin, Clopidogrel, DOACs).
  • - Liver disease.
  • - Kidney failure.
  • - Hereditary Haemorrhagic Telangiectasia (HHT / Osler-Weber-Rendu).
  • - Certain infections (Typhoid, Viral Haemorrhagic Fevers).
  • - Alcohol abuse.

Diagnosis

Clinical assessment

History (frequency, duration, severity, laterality, triggers, trauma, medications, bleeding Hx). Examination: Identify bleeding site if possible (anterior septum - Kiesselbach's plexus commonest). Assess haemodynamic status (BP, pulse). Rule out posterior bleeding (blood dripping down throat despite anterior control).

Investigations

  • Usually clinical diagnosis.
  • Full Blood Count (FBC) / Haemoglobin (if recurrent or severe bleeding).
  • Coagulation screen (PT/INR, aPTT), Platelet count (if bleeding disorder suspected or patient on anticoagulants).
  • Nasal Endoscopy (specialist - to identify posterior source or pathology).

Diagnostic criteria

Clinical observation of bleeding from the nose.

Management

Non-pharmacological management

  • First Aid (Anterior Epistaxis): (LOC: HC2)
  • - Sit patient upright, leaning slightly forward.
  • - Pinch the soft, fleshy part of the nose firmly between thumb and index finger.
  • - Hold continuous pressure for 10-15 minutes.
  • - Breathe through the mouth.
  • - Spit out any blood in the mouth.
  • - Apply cold compress to bridge of nose/back of neck (limited evidence).
  • If Bleeding Stops: Advise rest, avoid nose blowing/picking, use lubricant (Vaseline) inside nostril.
  • If Bleeding Continues After First Aid:
  • - Anterior Nasal Packing: Impregnate gauze strip with lubricant (Vaseline/paraffin) or antibiotic ointment. Pack firmly layer by layer into the bleeding nostril using forceps. Leave for 24-48 hours. (LOC: HC3)
  • - Consider topical vasoconstrictor (e.g., adrenaline on cotton wool) before packing if available (use cautiously in hypertensives).
  • Posterior Epistaxis (Suspected if bleeding profuse, bilateral, or dripping down throat despite anterior packing): Requires specialist management with posterior packing (e.g., Foley catheter, specialized balloons) or surgical intervention. Stabilize and refer urgently.

Pharmacological treatment

  • Topical vasoconstrictors (Adrenaline, Oxymetazoline, Phenylephrine) - used cautiously during packing/cautery.
  • Lubricants / Emollients (Vaseline, paraffin gauze) for packing and prevention.
  • Topical antibiotic ointment (on pack).
  • Chemical Cautery (Silver Nitrate sticks): For visible anterior bleeding points AFTER bleeding controlled. Requires skill/local anaesthesia. (LOC: HC3/4)
  • Tranexamic acid (oral or topical) - limited evidence, specialist use.
  • Management of underlying cause (e.g., BP control, stopping anticoagulants if safe).

Monitoring

Monitor vital signs if bleeding severe. Check pack position. Observe for re-bleeding after pack removal.

Complications

  • Anaemia (if recurrent/severe).
  • Hypovolemic shock (severe cases).
  • Aspiration of blood.
  • Complications of packing (sinusitis, pressure necrosis, toxic shock syndrome - rare).
  • Complications of cautery (septal perforation).

Prevention

  • Avoid nose picking.
  • Humidify air if dryness is a trigger.
  • Use saline nasal spray/gel or lubricant (Vaseline) for dryness.
  • Control underlying conditions (hypertension, bleeding disorders).

Patient education

  • Correct first aid technique (pinch soft part, lean forward).
  • Avoid nose picking/blowing after bleed.
  • Use of lubricant/saline for dryness.
  • When to seek medical attention for recurrence or severe bleeding.
  • Management of underlying causes if identified.

Uganda-specific notes

Common, often due to trauma/dryness. First aid measures usually effective. Anterior packing with lubricated gauze standard at HC3/4. Access to cautery/posterior packing/specialist care limited.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 21, Section 21.2.2

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