Nose bleeding is a common reason for ENT patients to visit the clinic. Many patients visit the emergency room because nosebleeds are aggressive and unstoppable, and they tend to recur, causing great inconvenience to their lives. Many patients are always in a state of panic because they do not know when the next bleeding will occur. Especially for patients who work as leaders, they speak a lot in meetings and feel very embarrassed if they have nosebleeds in important occasions. Children who go to school can also suffer from bleeding in class that affects the effectiveness of listening. The proportion of children with nosebleeds is relatively high, so you need to have a proper understanding and knowledge of nosebleeds, and never delay to seek treatment if you should. Sometimes nosebleeds are a sign of some serious diseases and must be taken seriously.
So what are the common causes of nosebleeds? According to the classification in textbooks, there are two major types of causes.
I. Local causes
1, trauma: the most common. Nasal sinus trauma or surgery damage to the nasal mucosa, blood vessels; digging nose too deep, forceful nose blowing, air pressure injury or nasal cannula can also be caused.
2, anatomical abnormalities: nasal septal deviation causes changes in nasal airflow and bleeding can occur on or near the convex side of the deviation. If the bleeding point is located behind the deviation, it is not easy to find and difficult to control, so it is often necessary to resort to nasal endoscopy. Nasal septal perforation caused by various reasons is prone to nasal bleeding because of its edge erosion and dry crust formation.
3.Inflammatory diseases: Various specific or non-specific infections of the nasal cavity and sinuses can cause bleeding due to congestion, dryness, erosion and crusting of the nasal mucosa, resulting in bacterial multiplication, granulation tissue formation, increased vascularity and increased fragility.
4.Foreign body : Commonly found in children and mentally challenged people, bleeding can be caused by sharp edges of foreign bodies or chemical substances, etc. It can also cause bleeding due to inflammatory changes and granulation tissue formation around the foreign body.
5.Tumor: Benign and malignant tumors in the nasal cavity, sinuses or nasopharynx can cause nasal bleeding. Malignant tumors in the early stage mostly manifest as repeated small amount of bleeding.
6.Aneurysm: The rupture of aneurysm in the epidural or cavernous sinus of the internal carotid artery can cause fatal rhinorrhea. This situation is relatively rare.
Systemic causes
1.Cardiovascular disease: hypertension, atherosclerosis, congestive heart failure, pulmonary heart disease, etc.
2. Blood component abnormalities: abnormalities in the quality and quantity of coagulation factors and/or platelets, such as leukemia, reocclusion, hemophilia, hypersplenism, post-prosthetic heart valve surgery, DIC, uremia, liver disease, vitamin deficiency and the use of heparin, aspirin, warfarin, poliovir or coumarin, etc.
3. Hereditary hemorrhagic capillary dilation. Due to the lack of contractile components in the blood vessel wall, it is difficult to stop bleeding on its own after bleeding.
4.Other: alcohol abuse, febrile infectious diseases such as typhoid fever, hemorrhagic fever, whooping cough, scarlet fever, nasal diphtheria, malaria, measles, influenza and rheumatic fever, toxic drugs (such as heavy metals), endocrine disorders (such as nasal bleeding during menstruation in women during puberty, and also during menopause or the last trimester of pregnancy).
Treatment of rhinorrhea
First of all, the cause and the site of bleeding should be determined, and the site of bleeding should be found as much as possible when the cause is difficult to determine at once. However, it is often difficult to stop the bleeding when the bleeding volume is large, and an emergency plug is needed to stop the bleeding first. Rhinorrhea is an ENT emergency, and the patient and accompanying family members are often very nervous at the time of consultation. As a doctor, you should be calm and unruffled, comforting the patient and family members with psychological treatment while examining the nasal cavity to determine the bleeding point for treatment. The consultation can be done after the bleeding is basically controlled, and should ask about the frequency and duration of bleeding, whether there is a history of nasal bleeding in the past, whether there are any precipitating factors, how much bleeding is present, whether the bleeding comes out of the nose first or is spit out through the mouth, whether there is liver disease, hypertension, diabetes, heart and lung disease, history of nasal and head and face trauma surgery, whether there is a family history, whether there is long-term use of anticoagulant drugs and whether there is a history of long-term exposure to toxic substances, etc. According to clinical observation, 90% of nasal bleeding comes from the anterior side of the nasal cavity, especially the lower end of the nasal septum, which is also called the plough area, where many blood vessels gather to form a network. The other 10% comes from the posterior end of the nasal septum and the middle and lower nasal passages, which often requires the use of a nasal endoscope or fiberoptic nasopharyngoscope.
The next step after finding the site of bleeding is how to avoid further bleeding. For the first bleeding, the problem is usually solved by filling the anterior nostril with a hemostatic gauze. It does not take much force for an experienced surgeon to get the gauze into the nasal cavity and hold the bleeding spot down. Inexperienced patients are in pain with rough movements and may not be able to stop the bleeding well in the end. However, for recurrent bleeding, this method is often not a complete cure and requires minor surgery to stop the bleeding. Commonly used methods are cautery. This includes chemical cautery, electric cautery, laser cautery, radiofrequency cautery and microwave cautery. Preoperative mucosal surface anesthesia with 2% bupivacaine is required. Commonly used chemical drugs are 30-50% silver nitrate or 30% trichloroacetic acid. Cauterize the periphery of the bleeding site before cauterizing the bleeding site, otherwise cautery alone may cause bleeding. This method is hardly effective for active bleeding. Electric cautery is not easy to control the depth of cautery, and the incidence of mucosal ulceration and nasal septal perforation is high and painful, so it is now used sparingly. Microwave and laser are easy to control and have better results, and have been widely used in many hospitals in recent years. The latest method is still the new technology in recent years — low-temperature plasma radiofrequency cautery hemostasis method, which has a complete hemostatic effect, is convenient to operate, and can be performed in the outpatient clinic. This includes nosebleeds from long-term anticoagulant medications and abnormal blood components. Radiofrequency technology is the preferred treatment for rhinorrhea because of its relatively small trauma to the mucosa and quick recovery. The procedure often requires nasal filling with hemostatic sponges to compress the wound and the appropriate use of antibiotics and antibiotic ointment. I have treated more than 100 cases of nasal bleeding from various causes by this method, and all of them have been completely cured without recurrence.
A few patients with nasal bleeding may not be completely resolved even with the above methods, such as bleeding from the posterior segment of the inferior nasal tract and bleeding from the posterior end of the middle nasal tract, and other methods of hemostasis should be considered. For those who continue to bleed even after proper anterior nostril plugging, posterior nostril plugging should be considered if the bleeding site may be from the posterior end of the nasal cavity. Posterior nostril tamponade is more painful for the patient than anterior nostril tamponade. This is because a gauze ball is introduced in the nasopharynx to fill the nasopharynx while the anterior nostril is filled. For general posterior nasal bleeding hemostasis is more complete. Patients may feel a significant foreign body sensation in the nasopharynx after surgery and uncomfortable eating. Generally, the filling should last more than 48 hours.
In rare cases, if all the above methods of occlusion fail and the bleeding does not stop, vascular ligation or arterial embolization can be considered. However, the source of bleeding must be accurately determined before surgery. With the widespread development of nasal endoscopic surgery, electrocoagulation of the pterygopalatine artery under nasal endoscopy can also be very effective in some patients with bleeding. Complications are also relatively rare. Arterial embolization is generally not recommended, and although it is highly effective, the serious complications such as hemiplegia, aphasia, and tissue necrosis in the blood supply area often outweigh the costs. Vascular ligation, on the other hand, is associated with a higher number of comorbidities. Therefore, embolization or ligation is now rarely used in clinical practice. For rhinorrhea caused by systemic diseases, systemic diseases must be treated at the same time to solve the problem at root. For nasal bleeding caused by tumor, the tumor must be removed. In addition, for adults over 40 years old with blood in the nose, nasopharyngeal cancer must be excluded, especially in areas with a high incidence of nasopharyngeal cancer such as Guangdong. Early detection can lead to good treatment effect.
In conclusion, nasal bleeding should still be examined meticulously in hospitals to rule out major diseases if it occurs repeatedly, especially in adult patients. In pediatric patients, nasal bleeding from the Plough’s area is predominant, and parents mostly do not need to be overly nervous. Most rhinorrhea can be treated with simple surgery or conservative treatment with more satisfactory results.