Epistaxis

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shelley	(attending physician)	Department of Otolaryngology, Peking University Third Hospital
Julie	(Chief physician)	Department of Otolaryngology, Peking University Third Hospital
Ma Furong	(Chief physician)	Department of Otolaryngology, Peking University Third Hospital

Epistaxis is one of the common clinical symptoms, which can be caused by nasal diseases or systemic diseases. Most epistaxis are unilateral, and in a few cases, bilateral epistaxis may occur; The amount of bleeding varies. The light one is only blood in the nose, and the heavy one can cause Hemorrhagic shock , repeated epistaxis can cause anemia 。

Western medicine name: Epistaxis
Foreign name: Epistaxis
Department: Department of five sense organs-

Common location: nasal cavity
common symptom: Epistaxis
infectivity: Non infectious

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Pathogenesis

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cause Epistaxis There are many reasons for nasal cavity It is caused by its own disease, and can also be caused by diseases around the nose or systemic diseases.

Local cause

(1) Nose injury ① Mechanical injury: such as traffic accident, fall injury, boxing injury, nose digging, etc Epistaxis Common causes. ② Barometric injury: During high-altitude flight and diving, if the pressure difference inside and outside the nasal sinus suddenly changes too much nasal cavity Vascular dilation, rupture and bleeding of mucosa in nasal sinuses. ③ Radiation injury: nasal mucosa congestion occurs during and after radiotherapy of head and neck edema , or epithelial exfoliation, or Epistaxis 。

（2） Deviation of nasal septum : It usually occurs near bone crest or bone spine (rectangular process) or Deviation of nasal septum The mucous membrane is thin at the convex surface of, where the flow direction of air flow changes, so the mucous membrane becomes dry, resulting in blood vessel rupture and bleeding. existence Perforation of nasal septum The dry, erosive and dry shedding of mucosa at the edge of perforation can cause repeated Epistaxis 。

(3) Nasal inflammation: ① Nasal nonspecific inflammation: acute nose nasosinusitis , dryness rhinitis Atrophic rhinitis Etc Epistaxis The amount of bleeding is generally not much. ② Nose specific infection: tuberculosis, lupus Syphilis , leprosy and diphtheria Isospecific infection due to mucosal erosion, ulcer, granulation Perforation of nasal septum May cause Epistaxis 。

（4） nasal cavity Nasal sinus and nasopharynx tumors: most likely to occur Epistaxis Nasal septum Hemangioma Nasopharyngeal fiber Hemangioma Hemorrhagic nasal polyp And malignant tumors in nasal cavity and paranasal sinuses. a few Epistaxis Or bloody mucus is one of the early main symptoms of malignant tumors.

（5） Foreign body in nasal cavity : Common in children, mostly unilateral Epistaxis , because Foreign body in nasal cavity Long term retention in nasal cavity may cause erosion and bleeding of nasal mucosa. Animality Foreign body in nasal cavity , such as leeches, which can cause repeated Epistaxis 。

Systemic causes

（1） Hemorrhagic disease And blood diseases: ① vascular wall structural and functional defects: such as hereditary hemorrhagic telangiectasia, vitamin C deficiency allergic purpura Drug induced vascular purpura, infectious vascular purpura, vascular pseudopurpura hemophilia ② Platelet count or dysfunction disease: such as primary Thrombocytopenic purpura Secondary thrombocytopenia caused by various reasons. ③ Coagulation factor disorders: such as various types hemophilia 、 Vitamin K deficiency Etc. ④ The self anticoagulant effect of blood is too strong: such as improper use of anticoagulants, the presence of anti fibrinogen and other anticoagulant substances in the blood circulation, or excessive or accelerated fibrinolysis, such as disseminated intravascular coagulation.

(2) Acute febrile infectious diseases: such as flu, flu hemorrhagic fever 、 Scarlatina 、 malaria 、 measles and Typhoid fever Etc. Most of them are due to high fever, toxic damage to blood vessels, congestion, swelling and dryness of nasal mucosa, resulting in capillary rupture and bleeding. In general, the amount of bleeding is less, and it usually occurs in the fever period, and the bleeding site is mostly located in nasal cavity front.

(3) Cardiovascular system diseases: ① hypertension and Arteriosclerosis ； hypertension and Arteriosclerosis Middle aged and elderly people Epistaxis Angiosclerosis is the pathological basis of the disease. High blood pressure, especially in constipation . When exerting too much force or feeling excited, the nasal vessels may be broken, causing Epistaxis 。 In addition, sneeze, cough forcefully, breathe forcefully through the nose or nasal cavity Massage, too Epistaxis Repeated and uncontrollable factors. ② Increased venous pressure: emphysema Pulmonary origin heart disease 、 mitral stenosis , cervical or mediastinal space occupying STD It can cause superior vena cava hypertension nasal cavity And the nasopharyngeal vein is often distended and congested. When the patient has severe cough or other inducements, the blood vessels can rupture and bleed. The bleeding site is mostly located in the distribution area of the nasopharyngeal vein at the back nostril.

(4) Other systemic diseases: gestation 、 menopause Early stage menopause Can cause Epistaxis , which may be related to the increase of capillary fragility. Severe liver disease may be caused by the disorder of hepatic coagulation factor synthesis Epistaxis 。 uremia Can also cause Epistaxis 。 Epistaxis It can be wind Damp heat One of the early manifestations of.

Pathogenesis

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nasal cavity Abundant distribution of internal blood vessels can lead to Epistaxis Occurrence of.

nasal cavity The main branches of the ophthalmic artery in the nasal cavity are the anterior ethmoidal artery and the posterior ethmoidal artery; The maxillary artery in the pterygopalatine fossa successively divides into the sphenopalatine artery, the suborbital artery and the palatine artery to supply the nasal cavity. Main supply of anterior ethmoidal artery nasal cavity The anterior upper part of the lateral wall, the anterior upper part of the nasal septum, and the posterior ethmoidal artery supply the posterior upper part of the lateral wall of the nasal cavity and the posterior upper part of the nasal septum, and anastomose with the branches of the sphenoid mandibular artery. The branches of sphenopalatine artery supply the posterior, lower and anterior inferior nasal septum. Branch supply of infraorbital artery nasal cavity The front of the outer wall. The great palatine artery supplies the anterior and inferior part of the nasal septum. In addition, the upper lip artery, a branch of the facial artery of the external carotid artery, supplies the nasal vestibule and the anterior lower part of the nasal septum. The branches of the sphenopalatine artery, the anterior ethmoidal artery, the posterior ethmoidal artery, and the superior lip artery anastomose with the great palatine artery in the anterior and inferior nasal septum to form a reticular arterial plexus, called Little's area Epistaxis The most common part.

nasal cavity The veins anastomose in the nasal cavity to form a reticular vein plexus. The Kiesselbach venous plexus located at the lower front of the nasal septum and the Woodruff venous plexus located behind the lateral wall of the lower nasal meatus near the nasopharynx are both Epistaxis The predilection site of.

clinical manifestation

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Epistaxis Because of different reasons, their manifestations are different. Most epistaxis are unilateral or bilateral; It may be intermittent and repeated bleeding, or it may be continuous bleeding. The amount of bleeding varies from a few drops or milliliters of blood in the nose to tens or even hundreds of milliliters of blood in the heavy ones, resulting in Hemorrhagic shock 。 Repeated bleeding can cause anemia 。 A small amount of bleeding can stop by itself or stop after self compression.

Most of the bleeding sites occur in the lower anterior part of the nasal septum (Little's area), sometimes jet or pulsatile arteriolar bleeding can be seen, children, young people Epistaxis It mostly occurs in this area. Middle-aged and elderly Epistaxis , often with hypertension and Arteriosclerosis Relevant, the bleeding site is more common in nasal cavity The posterior part is the Woodruff venous plexus near the posterior end of the inferior turbinate and the artery behind the nasal septum. This part of the bleeding is generally fierce, not easy to stop bleeding, bleeding often quickly into the pharynx, spit out from the mouth. Caused by local diseases Epistaxis Most occur on one side nasal cavity , and those caused by systemic diseases may bleed alternately or simultaneously in both nasal cavities.

diagnosis

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1. Inquire the medical history and bleeding condition in detail to confirm the source of bleeding nasal cavity Or adjacent organizations, excluding hemoptysis And hematemesis.

2. Determine the location of bleeding, and judge the location of bleeding in combination with anterior nasal endoscopy, nasal endoscopy and/or CT, MRI examination.

3. Blood routine examination is essential for patients with large amount of bleeding and suspected blood disease. For patients who use anticoagulants and suspect abnormal coagulation function, it is necessary to check the coagulation function.

4. Estimate the amount of bleeding, evaluate the patient's current circulatory system status, and check whether there is bleeding shock If necessary, consult with relevant departments. Comprehensively judge the amount of bleeding according to each bleeding and the number of attacks, the patient's blood pressure, pulse, general conditions and laboratory tests. When the blood loss reaches 500ml, dizziness, thirst, fatigue, pale face and other symptoms may occur; When the blood loss reaches 500~1000ml, sweating, decreased blood pressure, and weak pulse speed may occur; If systolic blood pressure is lower than 80mmHg, it indicates that about 1/4 of blood volume has been lost.

5. Troubleshoot systemic diseases.^[1]

differential diagnosis

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hemoptysis

It refers to the bleeding of the throat, trachea, bronchus and lungs, and the blood oozes out through the mouth pulmonary tuberculosis 、 bronchiectasia 、 lung cancer 、 pulmonary abscess and heart disease Pulmonary congestion caused. It can be differentiated according to the patient's previous medical history, physical signs and auxiliary examinations.

haematemesis

Hematemesis is Upper gastrointestinal bleeding One of the main manifestations of nasal cavity Exudation is often accompanied by other symptoms of digestive tract diseases. There can be positive signs in the body examination, which can be identified.

treatment

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Epistaxis It is an emergency, and the vital signs should be maintained first during treatment, the bleeding should be stopped as quickly as possible, and the cause should be treated.

General treatment

First, comfort the nervous and frightened patients and their families to calm them, so as to prevent the patients' blood pressure from rising due to mental factors, which will aggravate the bleeding, and measure the blood pressure and pulse in time. If necessary, give fluids to maintain the stability of vital signs. If the patient has shock , you should first target shock Give first aid. When asking about the medical history, ask the following: which side nasal cavity Bleeding or which side of the nasal cavity bleeding first, bleeding speed and amount, whether repeated in the past Epistaxis Is there any inducement and other accompanying symptoms for this bleeding.

Look for bleeding spots

According to the specific situation nasal cavity Local and general examinations. inspect nasal cavity Clear the clot in nasal cavity, apply 1% ephedrine and dicaine to fully shrink and anaesthesia The nasal mucosa should be located as far as possible to stop bleeding accurately. If possible, it is better to find the bleeding point under nasal endoscope and implement hemostasis treatment.

Hemostasis of nasal cavity

Different hemostasis methods are selected according to the priority, location, volume and cause of bleeding.

(1) Finger pressing:

The patient can pinch the bilateral nasal wings with fingers or press the bleeding side nasal wings to the nasal septum for about 10-15 minutes, or press the upper lip with fingers horizontally, while applying cold compress to the forehead and back neck. This method is applicable to small amount of bleeding and bleeding in nasal cavity Front patient, patient occurs at home Epistaxis This method can be adopted.

(2) Local hemostatic drugs: applicable to lighter ones nasal cavity This method is simple and easy for patients with anterior hemorrhage. For the bleeding area, cotton piece can be soaked with 1% ephedrine, 1 ‰ adrenaline, 3% hydrogen peroxide solution or thrombin, and tightly plugged nasal cavity It can stop bleeding for several minutes to several hours.

(3) Cauterization: chemical cauterization and physical cauterization (including electric cauterization, laser cauterization and microwave cauterization) are commonly used. The bleeding located at the front and lower part of the nasal septum anaesthesia After the nasal mucosa, the bleeding site is clearly visible. You can use a cotton roll dipped in a little 30-50% silver nitrate or 30% trichloroacetic acid to cauterize the bleeding point, and press it on the bleeding point for a while until a white film is formed locally.

(4) Anterior nostril packing: It can be used when the active bleeding of the anterior nose is severe or the bleeding site is not clear.

Vaseline gauze front nostril packing is a traditional method of hemostasis Epistaxis The patients can stop bleeding after tamping, and a few patients need repeated tamping or further posterior nostril tamping. Vaseline gauze can be filled from nasal cavity The top is folded down and filled layer by layer, or it can be filled from the bottom of the nose to the top of the nasal cavity with a certain depth and strength. Do not stack all the gauze strips at the front nostril. After packing, check whether there is still blood flowing into the oropharynx through the back nostril. Decide as the case may be nasal cavity The time for taking out the packing material shall be appropriately extended for patients with severe bleeding or hematopathy. During the packing process, patients shall be given antibiotic treatment to prevent nasal cavity and sinuses from concurrent infection.

Vaseline gauze front nostril packing is widely used at present Epistaxis Treatment, but patients suffer a lot and are easy to relapse. At present, there are many improved methods, such as:

① Hemostatic sleeve packing: put the finger cover coated with oil or ointment nasal cavity , and then use the yarn to fill the sleeve. This method is less painful when filling and taking out the yarn.

② Air bag or water bag compression hemostasis: use rubber membrane to make various shapes of hemostatic air bags and place them nasal cavity The bleeding part shall be compressed with air or water to stop bleeding.

③ In addition, other hemostatic materials can be selected, such as expansion sponge, calcium alginate fiber, etc., which are suitable for nasal mucosa diffuse and small amount of bleeding, and have the advantages of good hemostatic effect and less pain.

(5) Posterior nostril tamponade: bleeding still continues after anterior nostril tamponade, flowing backward into the pharynx or from the opposite side nasal cavity For gushing out, the choanal tamponade should be selected.

① Classic posterior nostril packing: put a thin catheter into the oropharynx from the bottom of the bleeding side nose and pull it out of the mouth, tie the silk thread of the posterior nasal embolism ball to the tip of the catheter, put the posterior nasal embolism ball into the mouth with one hand, and gradually pull the catheter with the other hand to make the posterior nasal embolism ball enter the posterior nostril, then fill the front nose with gauze strips, and tie the silk thread to a gauze roll, And fixed in the patient's front nostril. The operation of posterior nostril packing is complicated, and the patient is in great pain. Generally, the patient needs to stay in the hospital for observation, and sufficient antibiotics are given to prevent infection. Every day, it is necessary to check whether there is redness and swelling in the soft palate and anterior nostril, and observe the patient's breathing and eating. Generally, it can be packed for 3 to 7 days.

② Air bag or water bag packing method: The air bag with trachea (Foley tube) is used to fill the back nostril, which can not only significantly reduce the pain of patients, but also greatly reduce the occurrence of complications. Most scholars believe that the application of Foley tube makes the posterior nostril embolization simple and feasible, and has obvious advantages in emergency treatment. The patient can take any position, which is easy to operate, quick to stop bleeding, with little body damage and good treatment effect. The pressure of the air bag can be controlled by the injected liquid, and can be adjusted at will. It has little irritation to the nasal mucosa, slight damage, and is easy to master and apply.

(6) Transnasal endoscopic hemostasis: With the progress of ear, nose and throat instruments, the method of probing the bleeding site under nasal endoscope and electrocoagulation hemostasis has achieved remarkable results in recent years, and has been widely used, with an effective rate of more than 90%. The advantage is that nasal cavity Each part, especially the upper part, rear part and nasopharynx that are not easy to be observed by the front nose mirror, can stop bleeding in the deep and narrow areas under the bright vision, which is accurate and reliable. Compared with the packing of vaseline gauze, it greatly reduces the damage to the nasal mucosa, and patients suffer less. There is no need for special care and hospitalization after hemostasis, with fewer complications. The disadvantage is that the cost is high.

（7） Arterial embolism : The rapid development of imaging examination technology is critical Epistaxis The digital subtraction angiography (DSA) technology can be used to locate the bleeding site and embolize the blood vessels at that site. The method is to place a catheter through femoral artery puncture, selectively place it on the main artery, perform angiography and observe the branches of the external carotid artery. After determining the branches of the bleeding vessels, inject embolic agent into the catheter to stop bleeding. Arterial embolism Can be applied to: uncontrollable primacy Epistaxis Traumatic epistaxis, internal carotid cavernous fistula, internal carotid artery rupture and nasopharyngeal fibers Hemangioma Bleeding, etc. This method can directly show the location and cause of bleeding. The hemostasis effect is rapid and effective, and the treatment time is shortened. Digital subtraction angiography (DSA) embolization is an effective rescue measure in critical situations with large amount of bleeding. but Arterial embolism treatment Epistaxis Certain equipment and conditions are required, technical requirements are high, and patients' costs are also high. For allergic constitution, serious atherosclerosis The patients with liver and kidney insufficiency are contraindicated, so the indications should be strictly controlled.

(8) Vascular ligation: at present, it is generally used less, but more for severe cases Epistaxis Those who still cannot stop bleeding after the above treatment methods. Before ligation, the source of bleeding should be correctly judged as far as possible before deciding which artery to ligate. commonly nasal cavity Ligation of anterior ethmoidal artery is feasible for upper hemorrhage; Patients with bleeding in the posterior lower part of nasal cavity should be ligated with maxillary artery or external carotid artery [3].

(9) Nasal septum surgery: Nasal septum mucosa scratch surgery, suitable for repeated dilation of small vessels in the front and lower part of the nasal septum Epistaxis 。 In local anaesthesia Next, scratch the nasal septum mucosa to destroy the expanded small vascular network, so as to prevent repeated Epistaxis The effect of. The expanded small vascular network can also be destroyed by laser, radio frequency and other methods. Deviation of nasal septum Caused by Epistaxis , nasal septum correction is feasible.

(10) Other surgery: for nasal cavity Or sinus tumor Epistaxis According to the specific situation and the nature of the tumor, stop bleeding first, or remove the tumor surgically, or use radiotherapy, or ligate the neck blood vessels to stop bleeding.

Systemic treatment

cause Epistaxis There are many causes of bleeding and different degrees of bleeding. Epistaxis The treatment and treatment of nasal cavity For hemostasis, necessary basic and special treatment of the whole body shall be taken according to the condition of the patient, that is, the primary disease shall be actively treated during hemostasis.

(1) Find the cause of bleeding and treat it.

(2) Yes Epistaxis The amount of bleeding should be evaluated for all patients, especially for patients who are still active bleeding at the time of treatment.

(3) For elderly patients or patients with more bleeding, pay attention to whether there is bleeding anemia 、 shock And heart damage, and deal with them in time. For patients with large amount of blood loss, blood type should also be detected and blood should be prepared at the same time. According to the amount of blood loss, fluid should be supplemented blood transfusion treatment. yes hypertension Active antihypertensive treatment should be taken, and the blood pressure of elderly patients should not be lowered too fast to avoid thrombosis.

（4） nasal cavity Packing and back nostril packing can reduce the partial pressure of blood oxygen and increase the partial pressure of carbon dioxide. Therefore, elderly patients should pay attention to the function of heart, lung and brain, and if necessary, give oxygen, pay attention to the nutrition of patients, and give them high calorie and digestible diet.

(5) Appropriate use of systemic hemostatic drugs, such as thrombin, aminocaproic acid, etamsylate, etc.

(6) For patients with nervous mood, sedatives can be used appropriately, psychotherapy It also plays a very important role in reducing patients' tension and anxiety, and preventing bleeding again.^[2-3]

prevention

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Precautions should be taken at ordinary times Epistaxis The measures include:

1. Keep the room quiet and clean with proper temperature. Keep the indoor air fresh, open windows properly for ventilation, and keep the temperature at 18~20 ℃. Can be induced by too dry air nasal cavity Bleeding, so the air humidity should be ≥ 60%.

2. The elderly should move slowly during daily activities. Do not blow your nose forcefully to stop coughing.

3. Eat soft food that is easy to digest, eat more fruits and vegetables, avoid spicy and stimulating food, and keep your stool smooth, constipation Give laxative.

4. Senility Epistaxis Most patients are accompanied by hypertension , coronary heart disease bronchitis The primary disease should be prevented and treated regularly. In particular, hypertension patients must control their blood pressure to a normal or near normal level as soon as possible, observe the changes in their condition, and go to the hospital in time.

5. For children Epistaxis Patients should correct the bad habits of children, such as digging the nose, rubbing the nose, and curiously placing foreign bodies, which can easily lead to mucosal damage.

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