Rhinorrhea is one of the common clinical symptoms, which can be caused by nasal diseases or systemic diseases. Rhinorrhea is mostly unilateral, but in a few cases, bilateral rhinorrhea may occur; the amount of bleeding varies, from blood in the snot in mild cases to hemorrhagic shock in severe cases, and repeated rhinorrhea may lead to anemia.
Causes
There are many causes of rhinorrhea, which can be caused by nasal cavity diseases, or induced by perinasal or systemic diseases.
Local causes
(1) Nasal injury
(1) Mechanical trauma: such as trauma and nose digging are common causes of nasal bleeding.
(② Pneumatic injury: during high altitude flight and diving.
③ Radiological injury: congestion and edema of the nasal mucosa occur, and nasal bleeding can also occur.
(2) Deviated nasal septum: It mostly occurs near the bone crest or bone spine (momentary eminence) or the convex surface of the deviated nasal septum, where the mucosa is thin and the flow direction of airflow changes here, so the mucosa becomes dry, so that the blood vessels rupture and bleed. In patients with nasal septal perforation, the dryness, erosion and dryness of the mucosa at the edge of the perforation can cause recurrent nasal bleeding.
(3) Nasal inflammation.
①Non-specific inflammation of the nose: acute rhinosinusitis, dry rhinitis, atrophic rhinitis, etc. are likely to cause rhinorrhea, and the amount of bleeding is usually not much.
(2) Specific nasal infections: tuberculosis, lupus, syphilis, leprosy, diphtheria and other specific infections can cause nasal bleeding due to mucosal erosion, ulceration, granulation and nasal septal perforation.
(4) Nasal cavity, sinus and nasopharynx tumors: the most likely to occur nasal bleeding are nasal septal hemangioma, nasopharyngeal fibrovascular tumor, hemorrhagic nasal polyp and malignant tumor of nasal cavity and sinus. Small amount of nasal bleeding or blood in the snot is one of the main early symptoms of malignant tumors.
(5) Nasal foreign body: it is common in children, mostly unilateral nasal bleeding, because the nasal foreign body stays in the nasal cavity for a long time, which may cause nasal mucosa erosion and bleeding.
Systemic causes
(1) Hemorrhagic diseases and blood disorders (relatively rare).
(1) Defective diseases of blood vessel wall structure and function: such as hereditary bleeding capillary dilation, vitamin C deficiency, allergic purpura, drug-related vascular purpura, infectious vascular purpura, vascular pseudohemophilia, etc.
② Platelet count or dysfunctional diseases: such as primary thrombocytopenic purpura, secondary thrombocytopenia caused by various reasons, etc.
(iii) Coagulation factor disorders: such as various types of hemophilia, vitamin K deficiency, etc.
(4) Blood’s own anticoagulation 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 diffuse intravascular coagulation.
(2) Acute febrile infectious diseases: such as epiglottitis, influenza, hemorrhagic fever, scarlet fever, malaria, measles and typhoid fever. Mostly due to high fever, toxic damage to blood vessels, congestion, swelling and dryness of the nasal mucosa, resulting in capillary rupture and bleeding. In general, the amount of bleeding is small, mostly occurs during the febrile period, and the bleeding site is mostly located in the anterior part of the nasal cavity.
(3) Cardiovascular system diseases.
① Hypertension and arteriosclerosis: Hypertension and arteriosclerosis are important causes of rhinorrhea in middle-aged and elderly people, and vascular sclerosis is its pathological basis. Increased blood pressure, especially when constipation, excessive force or emotional excitement, can cause rupture of nasal blood vessels, resulting in nasal bleeding. In addition, sneezing, coughing, violent nasal breathing or nasal massage are also factors that make nasal bleeding recurrent and difficult to control.
(2) Increased venous pressure: emphysema, pulmonary heart disease, mitral stenosis, neck or mediastinal occupying lesions and other diseases can cause superior vena cava hypertension, the nasal cavity and nasopharyngeal veins of these patients are often angry stasis, when patients cough violently or other triggers, the blood vessels can rupture and bleed, the bleeding site is mostly located in the posterior nostril nasopharyngeal veins from the distribution area.
(4) Other systemic diseases: pregnancy, premenopause and menopause can cause rhinorrhea, which may be related to the increase of capillary fragility. Patients with severe liver disease can cause nasal bleeding due to impaired synthesis of coagulation factors by the liver. Uremia can also cause rhinorrhea. Rhinorrhea can be one of the early manifestations of rheumatic fever.
Pathogenesis
The nasal cavity is richly vascularized, and rhinorrhea can occur due to all of the above mentioned etiologies. The branches of the pterygopalatine artery, anterior septal artery, posterior septal artery, branches of the superior labial artery and the palatine aorta anastomose under the anterior nasal septum to form a reticular arterial plexus called Little’s area, which is the most common site of nasal bleeding. The nasal veins anastomose in the nasal cavity to form the reticular venous plexus, and the Kirschner’s plexus, which is located under the anterior nasal septum, and the Wu’s plexus, which is located behind the lateral wall of the inferior nasal tract near the nasopharynx, are both good sites for rhinorrhea.
Clinical manifestations
Most nasal bleeding is unilateral, but it can be bilateral; it can be intermittent and repeated, or continuous. The amount of bleeding varies, from a few drops or a few milliliters of blood in the snot in light cases to tens or even hundreds of milliliters in heavy cases, leading to hemorrhagic shock. Repeated bleeding may lead to anemia. A small amount of bleeding may stop on its own or after self-compression.
Most of the bleeding occurs in the bleeding-prone area (Little’s area) in the lower part of the nasal septum, and sometimes it can be seen as jet or pulsating small arterial bleeding. Nasal bleeding in middle-aged and elderly people is often related to hypertension and arteriosclerosis, and the bleeding site is mostly found in the posterior part of the nasal cavity, located near the posterior end of the inferior turbinate in the Wu’s nasal to nasopharyngeal venous plexus and the arteries in the posterior part of the nasal septum. Bleeding from this area is generally more violent and not easy to stop, and bleeding often flows rapidly into the pharynx and is spit out from the mouth.
Rhinorrhea caused by local disorders mostly occurs in one nasal cavity, while those caused by systemic diseases may bleed alternately or simultaneously in both nasal cavities.
Diagnosis
1.Inquire into the detailed medical history and bleeding situation to confirm that the bleeding originates from the nasal cavity or adjacent tissues and exclude hemoptysis and vomiting.
2.Determine the site of bleeding, combine with anterior rhinoscopy, nasal endoscopy and/or CT, MRI examination to determine the site of appearance.
3.Blood routine examination is essential for patients with large bleeding volume and suspected hematological disease. Checking of coagulation function is required for patients applying anticoagulant drugs and those suspected of abnormal coagulation function.
4.Estimate the amount of bleeding, assess the patient’s current circulatory system condition and the presence of hemorrhagic shock, and consult with relevant departments if necessary. The amount of bleeding is judged comprehensively according to each bleeding situation and the number of episodes, the patient’s blood pressure, pulse rate, general condition and laboratory tests. When the blood loss reaches 500ml, symptoms such as dizziness, thirst, weakness and pallor may appear; when the blood loss reaches 500~1000ml, sweating, blood pressure drops, pulse is fast and weak; if the systolic blood pressure is lower than 80mmHg, it indicates that the blood volume has been lost about 1/4.
5. Examine systemic disorders.
Differential diagnosis
Hemoptysis: blood is hemoptysis through the mouth after bleeding from the larynx, trachea, bronchus and lungs, commonly caused by pulmonary tuberculosis, bronchiectasis, lung cancer, lung abscess and pulmonary stasis due to heart disease. It can be identified based on the patient’s past medical history, physical signs and ancillary tests.
Vomiting blood: Vomiting blood is one of the main manifestations of upper gastrointestinal bleeding. When a large amount of blood is vomited, blood may gush out from the mouth and nasal cavity, often accompanied by other symptoms of gastrointestinal diseases, and there may be positive signs on general examination, which can be identified.
Treatment
Rhinorrhea is an emergency, and treatment should first maintain vital signs, stop the bleeding as quickly as possible, and treat the cause.
General treatment: firstly, comfort the patient and family members who are nervous and fearful to calm them down, so that the patient’s blood pressure will not rise due to mental factors, which will aggravate the bleeding, and take blood pressure and pulse rate in time, and rehydrate if necessary to maintain stable vital signs. If the patient is in shock, first aid should be given for shock. When taking medical history, ask about the following: which side of the nasal cavity bleeds or which side bleeds first, the speed and amount of bleeding, whether there is recurrent nasal bleeding in the past, whether there is any trigger for this bleeding, whether there are other accompanying symptoms, etc.
Find the bleeding point (important step): according to the specific situation, perform local and general examination of the nasal cavity. Remove the clot in the nasal cavity when examining the nasal cavity, apply 1% ephedrine and dicaine to fully contract and anesthetize the nasal mucosa to find the bleeding site as much as possible in order to stop the bleeding accurately. If available, it is best to find the bleeding site under nasal endoscopy and implement hemostatic treatment.
Methods of nasal hemostasis
According to the priority of bleeding, bleeding site, bleeding volume and etiology, different methods of hemostasis are selected.
(1) Acupressure method: Patients can insert a fava bean-sized cotton ball into the bleeding nasal cavity with a depth of about 1-37.5px, pinch the nasal flanks bilaterally with fingers or press the bleeding side of the nose toward the nasal septum for about 10-15 minutes, or use fingers to press the upper lip transversely while applying cold compresses to the forehead and back of the neck. This method is suitable for patients with a small amount of bleeding and bleeding in the anterior part of the nasal cavity, and patients with nasal bleeding at home can take this method.
(2) Local hemostatic drugs: Applicable to lighter bleeding in the anterior part of the nasal cavity, this method is simple and easy to use and less painful for the patient. For the bleeding area, cotton tablets can be used to stop the bleeding by dipping in 1% ephedrine, 1‰ epinephrine, thrombin or Yunnan Baiyao powder and plugging into the nasal cavity at a depth of about 1-37.5px for several minutes to several hours.
(3) cautery method: commonly used are chemical cautery and physical cautery (including electric cautery, laser cautery and microwave cautery, etc.). The bleeding located in the anterior and inferior part of the nasal septum, after adequate contraction and anesthesia of the nasal mucosa, the bleeding site is clearly visible, and the bleeding point can be cauterized with a roll of cotton dipped in a little 30 to 50% silver nitrate or 30% trichloroacetic acid, and pressed at the bleeding point for a few moments until a white film is formed locally.
(4) anterior nostril filling: anterior nasal active bleeding intense or bleeding site is not clear can be applied. Vaseline oil gauze plugging of anterior nostril is the traditional method to stop bleeding, most patients with nasal bleeding can stop bleeding after plugging, a few patients need repeated plugging or further posterior nostril plugging. Vaseline oil gauze anterior nostril tamponade is more painful and easy to recur, there are many improved methods, such as.
①Hemostatic sleeve filling: a finger sleeve coated with oil or ointment is placed into the nasal cavity, and then the sleeve is filled with gauze strips, this method is less painful when filling and removing the gauze strips.
②Air sac or water sac compression hemostasis method: various shapes of hemostatic air sacs made of rubber membrane are placed at the site of nasal bleeding, and the sleeve is inflated or filled with water to compress the bleeding.
③Other filling materials can be used to stop bleeding: such as expansion sponge, hemostatic sponge, gelatin sponge, calcium alginate fiber, etc., which are suitable for diffuse and smaller amount of bleeding in the nasal mucosa and have the advantages of good hemostatic effect and less pain.
(5) Transnasal endoscopic hemostasis method: In recent years, the method of nasal endoscopic exploration of bleeding sites and electrocoagulation hemostasis has achieved remarkable results and has been widely used, with an efficiency of up to 90% or more. Compared with petroleum jelly gauze filling, the damage to nasal mucosa is greatly reduced and the patient suffers less pain.
No special care is needed after hemostasis, and hospitalization is not required, and there are few complications. At present, our department has been carrying out transnasal endoscopic nasal hemostasis for many years, and the effect of hemostasis is remarkable and the patient suffers little pain.
(6) Posterior nostril plugging: If the bleeding does not stop after the front nostril plugging and flows backward into the pharynx or gushes out from the contralateral nasal cavity, posterior nostril plugging should be chosen.
①Posterior nostril filling: the operation is more complicated and the patient suffers more, usually need to stay in hospital for observation and give sufficient antibiotics to prevent infection, daily need to check the soft palate and anterior nostril for redness and swelling, and observe the patient’s breathing and eating, usually can be filled for 3-7 days.
② Air sac or water sac filling method: using air sac (Foley tube) with ventilation tube for posterior nostril filling can not only significantly reduce the patient’s pain, but also greatly reduce the occurrence of complications. Patients can be taken in any position, easy to operate, rapid hemostasis, little damage to the patient’s body, and good therapeutic effect.
(7) Arterial embolization: Through digital silhouette angiography (DSA) technique, the bleeding site can be localized and the vessels in the site can be embolized. The method is to insert a catheter through the femoral artery puncture, selectively place it in the arterial trunk, perform imaging and observe the branches of the external carotid artery.
Arterial embolization can be used for: uncontrollable primary rhinorrhea, traumatic rhinorrhea, internal carotid artery-cavernous sinus fistula, internal carotid artery rupture and nasopharyngeal fibrovascular hemorrhage. The method can directly show the site and cause of bleeding, and the hemostatic effect is rapid and effective, which shortens the treatment time. In critical cases of heavy bleeding, digital silhouette angiography embolization is an effective rescue measure. However, arterial embolization for nosebleeds requires certain equipment and conditions, high technical requirements, and higher costs for patients. It is contraindicated for those with allergies, severe atherosclerosis, and hepatic and renal insufficiency, so the indications should be strictly controlled.
(8) Vascular ligation: At present, it is generally used less frequently and is mostly used for severe rhinorrhea.
(9) Nasal septal surgery: nasal septal mucosal scratching is applied to recurrent nasal bleeding caused by dilated small blood vessels in the lower anterior part of the nasal septum. Under local anesthesia, the mucosa of the nasal septum is scratched to destroy the dilated small blood vessel network to achieve the effect of preventing recurrent nasal bleeding. Laser and radiofrequency can also be used to destroy the dilated small vascular network. Nasal septum correction is feasible for nasal bleeding caused by deviated septum.
(10) Other surgery: For nasal bleeding caused by nasal cavity or sinus tumor, depending on the specific situation and the nature of the tumor or first stop the bleeding, or surgically remove the tumor, or use radiotherapy, or ligate the neck blood vessels to stop the bleeding.
Systemic treatment
There are many causes of rhinorrhea, and the degree of bleeding varies. The treatment and management of nasal bleeding should not only stop the bleeding in the nose, but also take the necessary systemic basic and special treatment according to the condition, i.e., actively treat the original disease during the period of hemostasis.
(1) Find the cause of bleeding and carry out etiological treatment.
(2) All patients with rhinorrhea should be evaluated for bleeding, and it is especially important for patients who are still bleeding actively at the time of consultation.
(3) In elderly patients or those with more bleeding, attention should be paid to the presence of hemorrhagic anemia, shock and cardiac damage, and prompt treatment. Patients with large bleeding should also be tested for blood type and blood preparation, and treated with rehydration and blood transfusion according to the amount of blood loss. For elderly patients, blood pressure should not be lowered too fast to avoid thrombosis.
(4) Nasal and posterior nostril occlusion can lower the partial pressure of oxygen and increase the partial pressure of carbon dioxide, so the elderly patients should pay attention to the function of the heart, lungs and brain, and give oxygen if necessary.
(5) Appropriate application of systemic hemostatic drugs, such as thrombin, aminoglycolic acid, phenolsulfonamide, etc.
(6) For patients with emotional tension, appropriate sedative drugs can be applied.
Prevention
The following measures should be taken to prevent rhinorrhea
1. Keep the room quiet and clean, and the temperature should be appropriate. Keep the air in the room fresh, open the windows properly for ventilation, and keep the temperature at 18-20℃. Because the air is too dry can induce nasal bleeding, so the air humidity should be ≥ 60%.
2.The elderly should move slowly and not blow their noses to stop coughing.
3, the diet should be easy to digest soft food, eat more fruits and vegetables, avoid spicy and stimulating diet, and keep the bowel movement smooth, constipation can be given laxatives.
4.Patients with senile rhinorrhea are mostly accompanied by hypertension, coronary heart disease, bronchitis, etc. They should regularly prevent and control the original disease, and must carry out corresponding treatment for the cause, especially for patients with hypertension.
5, for children with rhinorrhea should correct the child digging nose, rubbing nose, curious placement of foreign objects and other bad habits that may lead to mucosal damage.