Bleeding form nose (EPISTAXIS)

Bleeding from nose produces apprehension to the patient but more than that to the relatives. We doctors consider nose bleeding as a ‘safest’ way in many conditions. (We will discuss this later). From injury to disease, nose being the most prominent and exposed part of the face becomes the victim.

Nose is divided into two parts by the central bone. Either side opens separately outside. These openings are called Nostrils. Just 1cm inside this partition (Septum) lies the ‘Sangam’ of 4 blood vessels. This is a very delicate area. This Sangam gets affected in various conditions. Besides from nose proper, bleeding can occur from conditions in the back of the nose (portion that joins the back of the mouth) and sinuses.

CAUSES

* Injury to the nose, base of skull or sinuses

* Foreign body (like pearl, button,etc)

* Nose Diphtheria (Not common now)

* Infectitious diseases like Measles, Chicken Pox,

* Diseases like Typhoid, Mumps, Severe influenza or high fever

* Severe cold particularly with purulent nose discharge

* Very hot or very cold weather

* On a high mountain or valley

* Deep underwater swimming

* Bleeding conditions

* Hormonal imbalance in women (with menstrual irregularity)

* Liver damage due to excessive alcohol

* Blood containing swelling (Haemangioma) of nose

* Rheumatism

* T.B

* Kidney diseases

* High blood pressure

* Heart problem

* Certain drugs

* Generalised septic condition in the body

* During pregnancy

INJURY TO NOSE

Blow, vehicular accident, falling flat with face downwards can cause nose bleeding. Nose bleeding is very common among boxers, hockey and football players and cricketers. At times such an injury can result into fracture of the nose. Falling is a part of child’s growing. God is very kind. He has made the nose supple in growing child so that it does not fracture easily.

INVESTIGATIONS: X ray of nasal bone

X ray of sinuses to rule out any sinus infection

TREATMENT: If fracture of nasal bone shows that the bones are in line (aligned) it does not need fracture correction. But if it shows displacement then fracture reduction is required. It is usually done under general anaesthesia irrespective of age because without that manipulation is very painful. Fracture reduction should be done within 48 hours of fracture or one has to wait (nearly 7 to 8 days) till swelling of the nose subsides so that proper alignment can be achieved.

Tab. Suganril 3 times a day after food helps in reducing the swelling of nose. Antibiotics are not required unless gross sinus infection is seen on X ray.

FOREIGN BODY (F.B)

It is very common in children. Besides F.B is also common in mentally subnormal and jail inmates. Child while playing unknowingly puts the F.B in the nose or deliberately inserts in his nose to draw the attention of parents. This attention seeking may be due to his demand is not fulfilled or out of jealousy for other siblings who are pampered by parents. Any child who is bleeding off and on from ONE SIDE of nostril should arouse the suspicion of F.B in nose. The other condition was Diphtheria of nose that luckily we don’t see much. Poor hand- mouth coordination in mentally subnormal may result into F.B in the nose. Deliberate or accidental F.B by prisoners are for drawing the attention of the warden or shifting to hospital so that they can stay in better environment or get a chance to escape.

Parents should not make an attempt to remove the F.B. Child should be taken to a doctor and preferably to an ENT specialist. Most of the time removal by the specialist is done in his clinic without making him unconscious.

At times the F.B is detected by the doctor on routine examination or while looking for a cause in the nose. This missed F.B may require general anaesthesia.

INFECTITIOUS DISEASES

Chicken Pox like Measles can produce excessive nasal secretion, super added infection and bleeding. Unfortunately in our country we consider these diseases as ‘Godess’ even by many literates. Doctor’s treatment is not taken. Complication like this can set in (also nerve deafness-refer chapter ‘Deafness in Children’ ). I strongly suggest vaccination against Measles, Chicken pox and Typhoid to every child. (Detail in chapter on ‘Immunisation’)

SEVERE COLD

Nasal cold is mostly allergic in nature. This allergic cold can invite bacteria (germs) and produce purulent nasal discharge, headache, nose blocking, sneezing with feverish feeling. These germs can produce bleeding from ‘Sangam’ or sinuses.

INVESTIGATIONS: X ray of sinuses

TREATMENT: Detail in the chapter of ‘Cold’.

WEATHER

Extreme hot or cold weather can open up the blood vessels of ‘Sangam’. Similarly, high mountain where atmospheric pressure and the oxygen are low or valley where pressure is high can produce bleeding. Deep underwater swimming by scuba drivers and marines causes air trauma called as Barotrauma that leads to bleeding from Sangam

TREATMENT: General line of treatment as given at the end of this chapter

BLEEDING CONDITIONS

Person may be born with bleeding disorder like deficiency in clotting mechanism, Hemophilia, etc. This bleeding at times is so severe that patient requires hospitalisation and blood transfusions. Bleeding not coming under control or oozes for a long time even after the slightest cut or injury needs to be investigated for bleeding disorder. Razor cut while shaving, slight cut of knife while cutting vegetables or profuse bleeding after a slight injury should arouse the suspicion of such a disorder.

INVESTIGATIONS: Blood routine

Coagulation study

TREATMENT: General line of treatment as given at the end of this chapter

Always carry the card indicating type of bleeding disorder one is suffering from

HORMONAL IMBALANCE

This problem pertains to women who have irregular periods, taking contraceptive tablets because of its sensitivity or side reaction from using for a long time.

TREATMENT: Take the advise of the Gynecologist for investigations and treatment.

ALCOHOLISM

Excessive consumption of alcohol for many years can lead to Cirrhosis of liver. Liver is detoxifying organ. Alcohol addiction affects the detoxifying function of liver resulting into damage to the Sangam.

Rheumatism, T.B, Leprosy and Kidney diseases affect the blood vessels in general.

TREATMENT: Take the opinion of General Physician or Rheumatologist for suspected Rheumatism, Chest or TB specialist for suspected TB, Skin specialist for suspected Leprosy and Kidney specialist (Urologist) for suspected kidney disease.

HIGH BLOOD PRESSURE

This is one of the commonest causes in adults who are also having high cholesterol and Diabetes. High cholesterol affects all the blood vessels of the body more so of smaller blood vessels like that of heart, inner ear and Sangam, reducing its lumen and increasing its rigidity. High blood pressure does not allow the blood vessels to contract to stop bleeding. We doctor consider bleeding from nose in such conditions as ‘Safest’ lest patient may develop internal bleeding in heart, kidney or brain. Bleeding from nose is frightening because it is ‘seen’ but it helps in reducing blood pressure. Certain heart conditions like heart attack, heart valve dysfunction (may be due to Rheumatism) can produce nose bleeding.

INVESTIGATIONS: Frequent check up of BP

Fasting and after lunch blood sugar

Blood – Lipid profile particularly for Cholesterol and Triglycerides

Cardiogram

Further investigations depending on above reports and consultation of Physician or Cardiologist

TREATMENT:

* Antihypertensive drug as advised by Physician or Cardiologis

* Drug to control Diabetes, Cholesterol and Triglycerides, if any

* General line of treatment given at the end of this chapter With high blood pressure, attempts to control bleeding may fail or patient may bleed again after the bleeding has come under control till the BP reasonably comes to normal. This is no cause for panic. One cannot bring down the high blood pressure because it might precipitate heart attack.

DRUGS

Patient may be sensitive to any drug which then produces nose bleeding besides other allergic symptoms like body rash, severe itching all over the body, asthma like breathlessness or fainting. Drugs such as Aspirin, Dispirin, and any painkillers like Salicylates, Anticoagulants used after heart attacks to prevent clotting can cause nose bleeding.

TREATMENT: Discontinue the drug.

Orally cortisone Tab Prednisolone 10 mgms 3 times a day for   3   days

then reduce to 5 mgms 4 times a day

then 5 mgms 3 times a day

then 5 mgms twice a day

then 5 mgms once a day.

In severe cases we give even injection of cortisone.

Patient SHOULD TAKE Cortisones only under medical supervision. Idea of writing the medicine and dose is to tide over the acute crisis arising out of drug allergyand not self medications.

Patient with heart conditions and diabetes should avoid taking cortisones.

Alternately, patient can take: Antihistamine tablets like Avil (25mgms), Foristal longtab, Allegra 180, Incid L, Cetzine, etc.

SEPTICEMIA

Generalised septic condition in the body due to various severe infection of any organ can lead to nose bleeding

TREATMENT: This requires Physician opinion and suitable antibiotics depending upon the condition. It may also need hospitalisation.

PREGNANCY

Any woman who had bleeding in first 3 months of pregnancy should be kept under weekly observations in last 3 months of pregnancy. Bleeding during last 3 months in that woman may be the first sign of Foetal Distress and if not detected and treated immediately it can lead to death of the baby in mother’s womb.

GENERAL TREATMENT:

EVERY PERSON SHOULD KNOW HIS BLOOD GROUP

* Press both nostrils tightly with index finger and thumb for at least 5 minutes. During which patient should breath through his mouth

* Apply ice over nose

* Apply coconut oil (not hot), Vaseline, glycerin or paraffin inside the nose

* Consult your family doctor or go to the nearest clinic or hospital

* Replacement of blood loss may require intravenous fluid or blood (Blood group card helps)

* Control of bleeding may require nose packing for 48 to 72 hours. One cannot remove nasal packing before that even when it is soaked with blood as it happens in hypertensive patient, lest he will bleed more.

* Further procedure may require cauterisation (burning) of bleeding area by an ENT specialist. In rare case surgery is required to clamp (ligate the bleeder).

*

LET’S SMILE

I had gone for an emergencyafter mid-night for bleeding from nose when one lady patient phoned my residence. My wife informed her that I had gone for some emergency. On hearing that she said, “ Emergency and that too in ENT? Madam, I tell you your husband is like SUN, exactly like my husband”. My wife did not understand the simile. She clarified, “ He disappears at night and reurns back in morning like SUN”