Epistaxis

[bí nǜ]

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

Epistaxis is one of the common clinical symptoms, commonly known as Epistaxis 。 May be determined by Nasal diseases It can also be caused by systemic diseases. Most epistaxis Unilateral 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 。

Foreign name: epistaxis
Alias: Epistaxis
Visiting department: Otolaryngology

Multiple population: Hematopathy patient
Common causes: Caused by nasal diseases or systemic diseases
common symptom: Unilateral or bilateral nostril bleeding

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pathogeny

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There are many reasons for epistaxis, which can be caused by diseases of the nasal cavity itself, or by diseases around the nasal cavity or systemic diseases.

1. Local causes

（1） Nasal injury ：

① Mechanical trauma For example, traffic accidents, falls, boxing injuries and nose gouging are common causes of epistaxis.

② Barotrauma During high-altitude flight and diving, if the pressure difference between the inside and outside of the sinuses suddenly changes too much, it will make the mucosa in the nasal cavity and sinuses Vasodilation Rupture and bleeding.

③ Radiation injury During and after radiotherapy of head and neck, Nasal mucosa Congestion and edema, or epithelial shedding, may also occur epistaxis.

(2) Deviation of nasal septum: It usually occurs near the bone ridge or bone spine (rectangular process) or the convex surface of the deviated nasal septum, where the mucosa is thin, and the flow direction of air flow changes here, so the mucosa becomes dry, resulting in blood vessel rupture and bleeding. existence Perforation of nasal septum As the mucosa at the edge of perforation is dry, erosive and dry, it can cause repeated epistaxis.

(3) Nasal inflammation:

① Nasal nonspecific inflammation: Acute rhinosinusitis, dry rhinitis Atrophic rhinitis It is easy to cause epistaxis, and the amount of bleeding is generally small.

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) Tumors in nasal cavity, sinuses and nasopharynx: Among them, epistaxis is most likely to occur nasal septum Hemangioma 、 Nasopharyngeal angiofibroma 、 Hemorrhagic nasal polyps And nasal cavity and sinuses Malignant tumor 。 A small amount of epistaxis or bloody mucus is one of the early main symptoms of malignant tumors.

(5) Nasal foreign body: It is common in children, mostly unilateral epistaxis. Because the foreign body in the nasal cavity has remained in the nasal cavity for a long time, it can cause erosion and bleeding of nasal mucosa. Animal nasal foreign body, such as Leech It can cause repeated massive epistaxis.

2. Systemic causes:

（1） Hemorrhagic disease and Hematopathy ：

① Vascular wall Structural and functional defects: such as hereditary hemorrhagic telangiectasia Vitamin C deficiency 、 allergic purpura , Drug Vascular purpura 、 Infectivity Vascular purpura Vascular pseudohemophilia Etc.

② platelet Quantitative or dysfunctional diseases: such as primary thrombocytopenic purpura, caused by various reasons secondary Thrombocytopenia, etc. ③ Coagulation factor disorder Such as various types of hemophilia, vitamin K deficiency, etc.

④ The self anticoagulation of blood is too strong: If anticoagulant is used improperly, anti coagulation exists in blood circulation Fibrinogen And other anticoagulant substances, or Fibrinolysis Excessive or accelerated, such as Diffuse intravascular coagulation Etc.

(2) Acute febrile infectious disease: Such as flu, flu, hemorrhagic fever Scarlatina 、 malaria 、 measles and Typhoid fever Etc. Polygenic High fever 、 Angiogenesis Toxic damage, nasal mucosa congestion, swelling and dryness, resulting in Capillary rupture Bleeding. In general, the amount of bleeding is less, which mostly occurs in the fever period, and the bleeding site is mostly in the front of the nasal cavity.

（3） cardiovascular system Disease:

① hypertension and Arteriosclerosis Hypertension and arteriosclerosis are important causes of epistaxis in middle-aged and elderly people, Angiosclerosis It is the pathological basis. The increase of blood pressure, especially in constipation, overexertion or emotional excitement, can rupture the nasal vessels and cause epistaxis. In addition, sneeze and force cough The forceful nasal breathing or nasal massage is also a recurrent and uncontrollable factor of epistaxis.

② Increased venous pressure: Emphysema, pulmonary heart disease mitral stenosis , neck or mediastinum Space occupying lesion And other diseases may cause Superior vena cava High pressure, the nasal cavity and nasopharynx Constant distension of veins Congestion When the patient coughs violently or other inducements, the blood vessels may burst and bleed. The bleeding part is mostly located in the nasopharyngeal vein at the back nostril range 。

(4) Other systemic diseases : Pregnancy, premenopausal period and menopause can cause epistaxis, which may be related to blood capillary Increase in brittleness. serious hepatopathy Patients may suffer from epistaxis due to the disorder of coagulation factor synthesis in the liver. uremia It can also cause epistaxis. A nosebleed can be Rheumatic fever One of the early manifestations of.

clinical manifestation

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The symptoms of epistaxis are different due to different reasons. 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 occurs in the anterior and lower part of the nasal septum Bleeding prone area , sometimes it can be seen that the ejection or pulsatility is small Arterial hemorrhage The epistaxis of children and young people mostly occurred in this area. The epistaxis of middle-aged and elderly people is often associated with hypertension and Arteriosclerosis Related, the bleeding site is mostly found in the back of the nasal cavity, located in Inferior turbinate Wu's nose nasopharynx near the back end Venous plexus And the arteries 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. The epistaxis caused by local diseases mostly occur in one side of the nasal cavity, while those caused by systemic diseases may alternate or bleed at the same time on both sides of the nasal cavity.

diagnosis

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1. Inquire the medical history and bleeding situation in detail, confirm that the bleeding originates from the nasal cavity or adjacent tissues, and exclude hemoptysis and haematemesis 。

2. Determine the bleeding site before combining Nasal speculum , nasal endoscopy and/or CT MRI Check and determine the location.

three routine blood test Examination, for large amount of bleeding and suspected Hematopathy Of patients. Apply to Anticoagulants And doubt Coagulation function Abnormal patients need to check the coagulation function.

4. Estimate the amount of bleeding, and evaluate the patient's current circulatory system Condition, yes or no Hemorrhagic shock If necessary, consult with relevant departments. According to the bleeding condition and the number of attacks each time, the patient's blood pressure, pulse, general condition and laboratory examination come Comprehensive judgment Bleeding volume. When the blood loss reaches 500ml dizzy , thirst, fatigue Pale Isosymptom; When the blood loss reaches 500ml~1000ml, sweating, decreased blood pressure, and weak pulse speed may occur; if systolic pressure Below 80mmHg, prompt Blood volume About 1/4 has been lost.

5. Troubleshoot systemic diseases.

differential diagnosis

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one hemoptysis : throat, trachea a bronchial tube And pulmonary hemorrhage, blood oozes out through the mouth, usually pulmonary tuberculosis 、 bronchiectasia 、 lung cancer 、 pulmonary abscess and heart disease Resulting Pulmonary congestion Etc. Depending on the patient Past medical history , signs and Supplementary Examination identify.

two haematemesis : hematemesis is Upper gastrointestinal bleeding It is one of the main manifestations of the disease. When a large amount of hematemesis occurs, blood can flow out of the mouth and nasal cavity, often accompanied by other symptoms of digestive tract disease, which can be found in a general physical examination Positive signs And can be identified.

treatment

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Nosebleeding is an emergency and should be maintained first during treatment Vital signs , stop bleeding as quickly as possible, and Causative treatment 。

1. 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, first aid should be given for the shock. When asking the medical history, ask the following: which side of the nasal cavity is bleeding or which side of the nasal cavity is bleeding first, the speed and amount of bleeding, and whether there was any bleeding in the past Repeated epistaxis Is there any inducement and other accompanying symptoms for this bleeding.

2. Search Bleeding spot : According to the specific situation, the local nasal cavity and general physical checkup 。 Clear the nasal condensation when checking the nasal cavity clot , application 1% ephedrine Dicaine fully shrinks and anaesthesia Nasal mucosa , try to find the bleeding site to stop bleeding accurately. If possible, it is better to find the bleeding point under nasal endoscope and implement hemostasis treatment.

3. Hemostasis method 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 both sides with fingers nosewing Or press the nasal wing on the bleeding side nasal septum For 10-15 minutes, you can also press the upper lip horizontally with your fingers, and apply cold compress on the forehead and back neck at the same time. This method is applicable to patients with small amount of bleeding and bleeding in the front of the nasal cavity. This method can be used for patients with epistaxis at home.

(2) Local hemostatic drugs: It is suitable for mild anterior nasal bleeding. This method is simple and easy, and patients suffer less. The bleeding area can be soaked with 1% ephedrine and 1 ‰ cotton flakes adrenaline 、3% Hydrogen peroxide solution or thrombin The purpose of hemostasis can be achieved by tamping the nasal cavity for several minutes to several hours.

(3) Cauterization: Commonly used are chemical cauterization and physical cauterization (including electric cauterization, laser cauterization and microwave cauterization). The bleeding located at the front and lower part of the nasal septum can be seen clearly after the nasal mucosa is fully contracted and anesthetized. A little 30%~50% of the bleeding can be dipped in a cotton roll silver nitrate Or 30% Trichloroacetic acid Burn the bleeding point and press it for a while until it forms locally albuginea 。

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

Vaseline Oil gauze front nostril packing is a traditional method of hemostasis. Most patients with epistaxis can stop bleeding after packing, and a few patients need repeated packing or further packing Posterior nostril Packing. Vaseline gauze strips can be folded from the top of the nasal cavity to the top of the nasal cavity and filled layer by layer. They can also be filled from the bottom of the nose to the top of the nasal cavity. When filling, they should have 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 the nasal cavity as appropriate Stuffing Take out time. For patients with severe bleeding or blood disease, the tamping time should be appropriately extended. During the tamping process, antibiotics should be given to patients to prevent infection of nasal cavity and sinuses.

Vaseline gauze front nostril packing is widely used in the treatment of epistaxis, but patients suffer greatly and are prone to relapse. There are many improved methods, such as:

① Hemostatic packing: Put the finger sleeve coated with oil or ointment into the nasal cavity, and then use the gauze strip to fill the sleeve. This method is less painful when filling and removing the gauze strip.

② Hemostasis by air bag or water bag compression: The rubber membrane is used to make various shapes of hemostatic air bags, which are placed at the bleeding part of the nasal cavity, and the cuff is inflated or filled with water to compress hemostasis. ③ Others Other hemostatic materials, such as expansion sponge Alginic acid Calcium fiber, etc., is suitable for nasal mucosa diffuse, small amount of bleeding, with good hemostatic effect and less pain.

(5) Posterior nostril packing: If the bleeding continues after the front nostril is filled, and it flows backward into the pharynx or flows out from the opposite nasal cavity, the posterior nostril filling operation should be selected.

① Classic posterior nostril packing: Put a thin urinary catheter into the nasal floor on the bleeding side Oropharynx And pull out the oral cavity, tie the silk thread of the posterior nasal embolization ball to the tip of the urinary catheter, put the posterior nasal embolization ball into the oral cavity with one hand, and gradually pull the urinary catheter with the other hand to make the posterior nasal embolization ball enter the posterior nostril, and then apply gauze Anterior nose After tamping, the silk thread is tied to a gauze roll and fixed to the patient's front nostril. The operation of posterior nostril tamponade is complicated, and the patient is in great pain. Generally, the patient needs to stay in hospital for observation, and give sufficient antibiotics to prevent infection. Daily inspection is required soft palate And whether there is redness and swelling at the front nostril, and observe the patient's breathing and eating conditions, which can generally be filled for 3 to 7 days.

② Air bag or water bag packing method: Using the air bag (Foley tube) with trachea as the rear nostril packing can not only significantly reduce the pain of patients, but also greatly reduce the complication Occurrence of. 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 development 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 Efficiency It can reach more than 90%. The advantage is that it can stop bleeding in the deep and narrow areas of the nasal cavity, especially the upper part, the rear part and the nasopharynx that are not easy to be observed by the front nose mirror. It is accurate and reliable. Compared with vaseline gauze packing, it greatly reduces the damage to the nasal mucosa, and patients suffer less. Not required after hemostasis Special care There is no need for hospitalization, and there are few complications. The disadvantage is that the cost is high.

(7) Arterial Embolism: The rapid development of imaging examination technology has helped the diagnosis and treatment of severe epistaxis Angiography （ DSA ）The technique can locate the bleeding site and embolize the blood vessels at that site. The method is Femoral artery Puncture and place the catheter, selectively place it on the main artery, perform angiography and observe Branch of external carotid artery After determining the branch of the bleeding vessel, inject it into the catheter Embolic agent It can stop bleeding. Arterial embolization can be applied to: difficult to control Primary Epistaxis, traumatic epistaxis Internal carotid artery -Cavernous sinus fistula, internal carotid artery rupture and Nasopharyngeal angiofibroma 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. In critical situations with large amount of bleeding, digital subtraction angiography Embolization It is an effective rescue measure. However, arterial embolization for epistaxis requires certain equipment and conditions, technical requirement Higher, the cost of patients is also higher. about Allergic constitution , serious atherosclerosis , Liver Renal insufficiency Those are taboos, so they should be strictly controlled Indications 。

(8) Vascular ligation: Generally, it is seldom used, but it is mostly used for patients with severe epistaxis who cannot stop bleeding after the above treatments. Before ligation, the source of bleeding should be correctly judged as far as possible before deciding which artery to ligate. General upper nasal bleeding is feasible Anterior ethmoidal artery Ligation; Patients with bleeding in the posterior lower part of nasal cavity should Maxillary artery or External carotid artery Ligation.

(9) Nasal septum surgery: Scratch of nasal septum mucosa, suitable for small anterior and lower nasal septum Vasodilation Repeated epistaxis. Under local anesthesia, the nasal septum mucosa is scratched to destroy the dilated small vascular network, so as to prevent repeated epistaxis. The expanded small vascular network can also be destroyed by laser, radio frequency and other methods. Deviation of nasal septum Nasal bleeding caused, feasible Correction of nasal septum 。

(10) Other operations: For epistaxis caused by tumors in the nasal cavity or paranasal sinuses, depending on 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.

4. Systemic treatment:

There are many causes of epistaxis, and the degree of bleeding varies. The treatment and treatment of epistaxis should not only stop the bleeding in the nasal cavity, but also take necessary general and Special treatment That is, the primary disease should be actively treated during hemostasis.

(1) Find the cause of bleeding and carry out Etiological treatment 。

(2) The bleeding volume of patients with epistaxis should be evaluated Active bleeding Of patients are particularly important.

(3) For Elderly patients Or patients with more bleeding, pay attention to whether there is Hemorrhagic 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 fluid infusion 、 Blood transfusion treatment 。 Patients with hypertension should be actively treated for lowering blood pressure Patient's blood pressure Do not descend too fast to avoid Thrombosis 。

(4) Nasal packing and posterior nostril packing may cause Partial pressure of blood oxygen Reduce and Partial pressure of carbon dioxide Therefore, the elderly patients should pay attention to the cardiopulmonary and brain functions, take oxygen when necessary, pay attention to the nutrition of the patients, and give them high calorie easy digestion diet.

(5) Appropriate use of systemic hemostatic drugs, such as thrombin amino Hexanoic acid Ethamsylate Etc.

(6) For Emotional tension The patients can use sedative drugs properly, and psychotherapy can reduce the patients' tension Anxiety It is also very useful to prevent bleeding again.

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 ℃. Because the air is too dry to induce nasal bleeding air humidity It should be ≥ 60%.

2. The elderly should move slowly during daily activities, and do not use force Blow one's nose , symptomatic cough relief.

3. Eat soft food that is easy to digest, eat more fruits and vegetables, avoid spicy and stimulating food, and keep Smooth stool , can be given to those with constipation Laxative 。

4. Elderly epistaxis patients are often 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 Epistaxis in children 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.^[1-3]

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