Nose bleeding or Epistaxis is a common condition that many children and adults will encounter. In fact, it is estimated that up to 60% of people will experience at least one episode of nose bleeding in their lifetime, and of these, about 6% will seek medical treatment with a doctor.
Patients that seek medical treatment for nose bleeding typically fall into 2 categories: (1) those who have multiple minor episodes; and
(2) those who have a single severe and/or prolonged episode that will not stop.
In the first group, the patient is usually a child or young adult, and many of them may also have accompanied symptoms of nose allergies, or what a lay person would commonly called “sinus” symptoms such as frequent sneezing, nose itchiness and nasal congestion resulting in nose block.
Fortunately, in this group of younger patients, the nose bleeding usually comes from the front or the anterior aspect of the nose we would call the ‘Little’s Area’. This ‘Little’s Area’ lies in the front part of the nasal septum where terminal or small branches of the arteries supplying the nose comes together in this location to form the Kiesselbach plexus. This confluence of small terminal arteries makes the Little’s Area rich in blood supply, but it also makes it susceptible to bleeding and any form of trauma, such as nose-picking, blunt injuries, or inflammation of the nasal mucosa such as allergies or infection will trigger bleeding from this area.
Blood Supply of the Nose
The treatment usually entails simple first aid measure such as sitting up the patient, bending slightly forward and pinching the soft cartilaginous part of the nose for a few minutes. In addition, we also have to treat the underlying cause of the infection, inflammation or stop the nose-picking, whichever we think triggers the bleeding.
While the majority of nose bleeding can be attributed to the Little’s area, there is a group of patients that may have conditions which are more serious. These would include infections like sinusitis, nasopharyngeal cancers, or other tumour growth in the nose. So, besides having recurrent episodes of nose bleeding, these patients would have other presenting symptoms as well, such as abnormal nasal discharge, blood stained mucus, persistent blocked ear, numbness, pain or swelling in areas of the face or enlarged lymph nodes in the neck. The treatment for these patients would depend on the actual diagnosis, and we would advise patients with these additional symptoms to seek medical attention promptly.
Nose Cancer Diagnosis
The second group of patients tend to be older adults and usually have underlying medical conditions, such as hypertension or heart conditions, and some of them may even be on blood-thinning medications. When evaluating these patients, we have to look out for infections, cancers or tumour growth in the nose.
Other less common causes would include blooding clotting disorder, autoimmune conditions, or bleeding which can be attributed to patient’s medications. The management for these patients is mainly directed at treating the underlying condition.
However, sometimes, we may not be able to find an apparent cause even after investigations. In this instance, especially if significant nose bleeding keeps recurring, which requires nose packing and hospitalization, we will have to discuss with the patient regarding the various treatment options.
One can opt for more conservative management which consist of nose packing and observation/monitoring in the hospital ward. However, the bleeding can recur after the nose packs are remove and the whole treatment cycle would repeat again, causing much frustration and anxiety to the patient. The other option would be to undergo minimally invasive surgery through the nose whereby the sphenopalatine artery (which is one of the main arteries supplying the nose) is ligated or cauterized. Our experience and studies have shown that the success rate for this treatment is very good, and patient’s hospital stay is also reduced considerably.
Sphenopalatine artery (which is one of the main arteries supplying the nose) is ligated or cauterized
In summation, while we know most cases (especially in the younger population) are self-limiting, and generally do not have serious diseases, there are some additional symptoms and red flags (which I have highlighted above) that may indicate the presence of more serious conditions. And certainly, in the older adults, if there are recurrent epistaxis or episode of significant bleeding, it will be prudent to seek medical attention to find out the cause of your nose bleed and to get the appropriate treatment.
Dr Kang Wee Lee - ENT (Visiting Consultant)
· MBBS(NUS), MMed(ORL), MRCSEd, FAMS(ORL), DFD(CAW)
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