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Vincent’s S.C.A.N.S 
Ear, Nose and Throat (ENT), Head and Neck Surgery
Specialist Clinic
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Last update:  10/5/14 
EDUCATION Nose Bleeding  Epistaxis
This patient education is provided in good faith to help patients and their families learn more about their medical conditions, the options available to them and the possible consequences of their decisions. This information is not intended to be used for diagnosis, or treatment of any specific individual. Please consult with your ENT doctor regarding your particular circumstances.
MY BLOODY NOSE !
(image from http://en.wikipedia.org/wiki/Nosebleed)
© Vincent Tan ENT
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Bleeding from the nose, also called 'Epistaxis' in medical terminology is a common complaint. While in most cases, the bleeding is of small volume (though enough to 'shock' unfamiliar parents), spontaneous and self-limiting, some can be recurrent and in rare cases, may even be torrential! The sight of fresh blood oozing from the nostrils can be extremely distressing for the parents and even adults, not to mention the inconvenience. While nose bleed can happen in any age, medical studies demonstrated that the age distribution peaks in young children (2-10 y) and older individuals (50-80 y). Despite its small size compared to other organs, the nose receives a rich blood supply from the two major arterial supply in the head and neck region, namely the internal carotid artery (ICA) and the external carotid artery (ECA). Hence, epistaxis can be divided into 2 categories, anterior bleeds and posterior bleeds, on the basis of the site where the bleeding originates. This can affect how your doctor treats your nose bleed. What are the causes ? Causes are commonly local i.e arising from the nose itself causes (eg, trauma, mucosal irritation, septal abnormality, inflammatory diseases, tumors) and less commonly systemic i.e influenced by factors outside the nose or generalised body disorders. In some cases, the exact cause is also not even known. Anterior bleed commonly arise from the most front part ('anterior' in medical terminology) of the nasal septum known as the Little's area. Here the confluence of small vessels or capillaries can break easily, made worse by any trauma (eg. rubbing the nose, picking the nose) or even spontaneously as a result of dry air/weather exposure. LOCAL CAUSES Trauma Self-induced trauma from rubbing the nose in allergic rhinitis or habitual repeated nasal picking can cause anterior septal vessels to tear and subsequently bleed. This scenario is frequently observed in young children. If the bleeding is from minor mucosal laceration, it is usually limited. Thankfully, most bleeding can be controlled easily with some simple first aid knowledge as outlined here. Nasal foreign bodies or nasogastric tubes in the nose (required for feeding in patients who have swallowing problems) can also cause local trauma. Of course, any accidental trauma to the nose and face can lead to nose bleeds. Patients who have undergone any nasal surgery can likely bleed as well. Any local infection in the nose due to poor postoperative care can increase the risk of potential bleeding. Dry weather Occasionally, nose bleeding happens in the middle of the night with some patients waking up to find their clothes soaked in blood. This can sometimes be attributed to the cold drying effect of the air-conditioned room. Low humidity may lead to mucosal irritation. It is a fact that epistaxis is more prevalent in dry climates and during cold weather due to the dehumidification of the nasal mucosa. Septal abnormality Septal deviations also known as deviated nasal septum (DNS) and spurs may disrupt the physics of the normal nasal airflow through the nasal passageway, leading to dryness and subsequent epistaxis. The bleeding sites are usually located anterior to the spurs in most patients. Similarly, holes or perforation in the nasal septum can alter the airflow in the nose, encourage crusting and become common sources of epistaxis although nasal septal perforations on its own are rare. Common causes of septal perforation include previous septal surgery, infection and trauma. Inflammation Bacterial, viral, and allergic rhinosinusitis or adenoidal gland infection can cause generalised mucosal inflammation and may lead to blood-streaked nasal discharge rather than a full-blown epistaxis. Atrophic rhinitis causes generalised inflammation and infection of the nose and can present with bleeding. Other rarer infection include granulomatosis diseases such as leprosy,  Wegener granulomatosis, tuberculosis, among others often lead to crusting and friable mucosa and may be a cause of recurrent epistaxis. Tumors Any tumour or growth in the nasal cavity is likely to bleed. These tumours can be both benign or cancerous/malignant. The patients may present with other ENT and neck symptoms as well. In our region, NPC ranks high in the list of nose cancers. In teenage boys, it is also important to exclude juvenile angiofibroma (JNA) if nose bleeding increases in volume and  frequency. SYSTEMIC CAUSES Drugs Blood thinners like aspirin and warfarin, function to prevent blood clotting as a treatment in patients with previous stroke, defective heart valves can contribute to nasal bleeding. Trivial trauma to the nasal mucosa can trigger more-than-usual nose bleed in this group of patients. Wrong usage of topical nasal sprays can also cause mucosal trauma especially when applied directly to the nasal septum instead of the lateral walls. While topical nasal spray on its own are generally very safe, it is important to ensure proper usage technique to avoid this complication. That said, intranasal spray has much more advantages than this trivial issue. Blood clotting disorders/Coagulopathy Coagulopathy refers to an impaired blood clotting mechanism that is so necessary to stop even bleeding from some trivial minor trauma. While we never often give a second thoughts to simple cut and bruises, people with coagulopathy do face potentially serious life-threatening complications is the cuts do not stop bleeding. Congenital coagulopathies including hemophilia and von Willebrand disease should be suspected in individuals with a positive family history (especially first-degree relatives i.e parents and siblings, easy bruising, or prolonged bleeding from minor trauma or surgery. At times, clotting disorders can be a result of other systemic conditions, i.e acquired coagulopathies like liver disease in chronic liver failure, acute shortage of platelets in dengue fever or as a result of certain medication like aspirin as described above. Vascular abnormalities Arteriosclerotic vascular disease is considered a reason for the higher prevalence of epistaxis in elderly individuals. Here the vessels which would normally spontaneously constrict to prevent further blood loss has lost its contractile properties. Ocasionally dilated capillaries in the form of telangiectasia can be found in the nose. Telangiectasia bleeds easily and contribute to recurrent nasal bleeds if not treated. Hereditary hemorrhagic telangiectasia (HHT; also known as Osler-Weber-Rendu syndrome) is a genetic condition where vessels ranging from capillaries to arteries, leading to the formation of telangiectasias and arteriovenous malformations with a significant risk of bleeding. Other organs such as the respiratory, gastrointestinal, and genitourinary systems may also be involved. Any tumours of the blood vessels, not only in the nose, but elsewhere are definitely at a higher risk of spontaneous bleeding. Hypertension Hypertensive patients are also at a higher risk of nasal bleeding, though rarely a direct cause. 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, the old age commonly associated with this disease, not to mention the anxiety which further elevates the already higher blood pressure ! Frequent sneezing, nose blowing or coughing especially in an allergic rhinitis patient also raises the blood pressure within the vessels and causes the vessel to rupture. Idiopathic causes The cause of epistaxis is not always readily identifiable in a small group of patients even after a thorough evaluation. The offending bleeding cause could have spontaneously resolved
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© Vincent Tan ENT
Figure A showing a foreign body in the shape of a button battery in the nose seen on the X-ray. Figure B showing the button battery up close and personal. Figure C showing an endoscopic view of a rhinolith in the nose and Figure D showing the rhinolith up close and personal. A B C D © Vincent Tan ENT
Nasogastric tube in the nose (arrow)
Prominent vessels on Little’s area (Mouse over to zoom in)
Nose picking -a common cause
© Vincent Tan ENT
© Vincent Tan ENT
Prominent vessels just in front of a DNS (Mouse over to zoom in)
Nasopharyngeal Cancer (NPC) Nasopharyngeal Cancer (NPC) is a very common cancer in this region (Malaysia, Singapore, Indonesia). It arises from the back (posterior) portion of the nose. Early detection is crucial in the successful treatment of this cancer...
© Vincent Tan ENT
© Vincent Tan ENT
© Vincent Tan ENT
Multiple telangiesctasia in a HHT patient’s tongue (Mouse over to zoom in)
© Vincent Tan ENT “When was the last time you checked your blood pressure ?”
A single telangiesctasia in he nose
Part 1 - What ? How? Who ? Am I the One ?
Continue to Nose Bleeding Part 2 -Diagnosis & Treatment
Nose blowing, more so in an alllergic nose -a common cause
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ENT
D R. V INCENT T AN Consultant Ear, Nose and Throat, Head and Neck Surgeon, MD (UKM), MS ORL-HNS (UKM), DOHNS RCS Edinburgh (UK), MRCS Edinburgh (UK), Postgrad. Cert.in Allergy (UK), A.M. (Mal), Fellowship in Rhinology (Singapore) Fellowship in Head and Neck Oncology & Surgery (Amsterdam)
+603-3377 7864  +6012-3760 728
ENTdrvincenttan@gmail.com