Epistaxis (鼻出血)

Aetiology:
Most cases of epistaxis are idiopathic, although bleeding can also result from a number of specific conditions.

• Local conditions – include nasal trauma, nasal and paranasal sinus tumours and nasal septal perforations.
• General conditions – include systemic bleeding diathesis such as leukemia, anticoagulant therapy and thrombocytopenia, and systemic vascular disorders. In hereditary hemorrhagic telangiectasia (Rendu-Oster-Weber syndrome), epistaxis is a prominent feature and usually arises from abnormal vessels on the nasal septum.

Systemic hypertension, although not a cause of epistaxis, is often associated with an increased severity of bleeding.

Clinical features:

In most cases of epistaxis bleeding originates from the nasal septum, particularly Little’s area just behind the mucocutaneous junction where there is a rich anastomosis of vessels (Kiesselbach’s plexus). Bleeding from a posterosuperior site in the nasal cavity can occur, especially in the elderly. 

Haemorrhage can present via the anterior nares or pass backwards via the nasopharynx where it is spat out or swallowed. In severe cases with profuse blood loss, hypotension and tachycardia may occur.

Management:

Initial measures to stop bleeding consist of exerting pressure on Little’s area by pinching the nose, with the patient leaning forward and spitting any blood into a bowl. If a bleeding vessel is seen, it may be coagulated with chemical or electric cautery following topical application of local anaesthetic, but this is rarely successful in the acute stage. 

Epistaxis not responding to pressure necessitates nasal packing either with gauze impregnated with an antiseptic such as bismuth, iodoform and paraffin paste or with nasal balloons. Patients requiring nasal packing also require hospitalization.

In severe cases arterial ligation may be required. Endoscopic ligation or diathermy of the sphenopalatine artery in the nasal cavity is the commonest method. Other available arteries are the external carotid via the neck and the anterior ethmoidal via an inner canthal incision.

An alternative to arterial ligation in severe cases is arterial embolization performed with angiographic control by a radiologist. Intravenous resuscitation with blood or plasma substitute is necessary in cases where hypotension and tachycardia are present.