What is the cause of epistaxis (nosebleed)?

From the Guidelines

Epistaxis can be effectively managed with simple first aid measures, including sitting upright, leaning slightly forward, and pinching the soft part of the nose firmly for 10-15 minutes, as recommended by the clinical practice guideline published in 2020 1. When managing epistaxis, it is essential to consider the severity and duration of the bleeding, as well as the impact on the patient's quality of life. According to the guideline, interventions for nosebleeds range from self-treatment and home remedies to more intensive medical interventions, and the setting for treatment can include ambulatory medical sites, emergency departments, inpatient hospitals, and remote outpatient encounters 1.

Some key points to consider when managing epistaxis include:

• Applying an ice pack to the bridge of the nose to constrict blood vessels
• Using nasal saline sprays and water-based lubricants like petroleum jelly to prevent dryness
• Avoiding nose picking, forceful nose blowing, and hot showers immediately after a nosebleed
• Evaluating underlying conditions like hypertension, blood thinning medications, or clotting disorders that may contribute to severe or recurrent epistaxis

It is also important to note that while most epistaxis occurs from the anterior nasal septum (Kiesselbach's plexus) due to trauma, dryness, or irritation, posterior nosebleeds, which are less common but more serious, often require medical intervention with nasal packing or cauterization. If bleeding persists beyond 20-30 minutes, it is recommended to seek medical attention 1.

From the Research

Definition and Treatment of Epistaxis

• Epistaxis refers to bleeding from the nostrils, nasal cavity, or nasopharynx 2
• It can be treated with first aid measures such as external pressure and ice packing, and applying topical agents like oxymetazoline, which stops 65-75% of nosebleeds in emergency departments 2

Treatment Options

• Electrocautery is more effective and has fewer recurrences (14.5% vs. 35.1%) than chemical cauterization 2
• Tranexamic acid promotes hemostasis in 78% of patients, versus 35% and 31% respectively in patients treated with oxymetazoline and nasal packing 2
• Nasal packing can be applied with non-absorbable materials, absorbable materials, and newer hemostatic materials, which are more effective and have fewer complications 2
• Endoscopic ligation of arteries, mainly SPA, is more effective than conventional nasal packing (97% vs. 62%) 2
• Endoscopic cauterization is more effective than ligation 2
• Embolization can be applied using gelatin sponge, foam, PVA, and coils with an 80% success rate and comparable efficacy and complications to surgical methods 2

Outpatient Management

• Up to 60% of the general population experience epistaxis, and 6% seek medical attention for it 3
• More than 90% of cases arise from the anterior nasal circulation, and most treatments can be easily performed in the outpatient setting 3
• Compressive therapy is the first step to controlling anterior epistaxis, and oxymetazoline nasal spray or application of cotton soaked in oxymetazoline or epinephrine 1:1,000 may be useful adjuncts 3
• Directive nasal cautery, most commonly using silver nitrate, can be used to control localized continued bleeding or prominent vessels that are the suspected bleeding source 3

Efficacy of Topical Tranexamic Acid

• Topical intranasal tranexamic acid is no more effective than placebo at controlling bleeding and reducing the need for anterior nasal packing in patients presenting to the emergency department with atraumatic epistaxis that is uncontrolled with simple first aid measures 4
• There were no statistically significant differences between tranexamic acid and placebo for any of the secondary outcome measures, including hospital admission, need for blood transfusion, recurrent epistaxis, and any thrombotic events requiring hospital reattendance within 1 week 4

Comparison of Treatment Efficacy

• Oxymetazoline is superior to tranexamic acid and epinephrine-lidocaine in achieving rapid hemostasis and reducing recurrence in epistaxis 5
• Significant differences were found among the three drug groups regarding hemostasis success, with oxymetazoline showing superior efficacy (p = 0.007) 5
• Oxymetazoline achieved hemostasis in 71% of patients, tranexamic acid in 55%, and epinephrine-lidocaine in 49% 5

Use of Oxymetazoline in Epistaxis Management

• Sixty-five percent of patients with epistaxis were successfully managed with oxymetazoline as their sole therapy 6
• An additional 18% were managed successfully with silver nitrate cautery in combination with oxymetazoline 6
• In only 17% of patients was it necessary to use nasal packing as treatment for epistaxis after an initial attempt with oxymetazoline alone or in combination with silver nitrate failed 6