The Nosebleeds ‘Epistaxis’

                    

Most often, bleeding from the nose is a minor problem, usually following the seemingly insignificant trauma of nose-picking. The habit of picking the nose is, I could say, almost universal and of course gross. Children usually admit it truthfully and can then be easily trained to break the habit. Adults more often deny it and for them, accepting the problem is the halfway mark to cure. The common excuse is that they were only indulging in a gentle cleansing of the nostrils!

Frankly, the nose needs no cleaning. Crusting in the nose is usually the result of the injury to the delicate skin caused by the cleaning. Wounds heal by scab formation and the removal of these scabs, lead to the refreshing of the wound. This vicious cycle in the nose is the most common cause of bleeding. If left alone for a week or so, the crusts fall off with healing. If the crusts are persistent and irritating, medical attention should be sought. Another downside of the nose-picking is the possibility of infections by the microorganisms on infected hands. These infections may, in turn, be a cause for bleeding too. The habit is best avoided, especially, in these COVID times.

Other trivial causes of bleeding include the drying of the nasal lining (mucosa) due to extremes of weather and the injuries to the nose following a fall or a blow. Often people panic on seeing blood and are tempted to check whether the bleeding has stopped. They blow the nose or hawk up the phlegm to check and this in effect exacerbates the bleeding. The panic also raises blood pressure only to worsen the condition. There is a myth among some people that the bleeding from the nose is somehow connected to the brain causing much fear. Most of these minor bleeds can be managed by bed rest, local compression by pinching the nose or by ice packs applied on the nose. It is important to remain calm and avoid panic

Rarely, bleeding from the nose may be serious. Profuse, recurrent or persistent bleeding from the nose, may even be life-threatening and early hospitalisation is warranted. The otorhinologist examines the nose to ascertain the severity of the bleeding. He conducts blood tests to measure the extent of blood loss or for defects in the blood clotting mechanism like haemophilia. He looks out for other contributory factors like raised blood pressure or the intake of certain medications like Aspirin, that may prevent the effective clotting of the blood. He may administer some drugs to calm you or to reduce the blood pressure. He may also give medications to facilitate the clotting mechanism. Sometimes, he may use nasal dressings to pack the nose, to stop further blood loss. Severe blood loss may require blood transfusions to make up for the loss. Endoscopic examinations may also be conducted by the doctor to visualise and to cauterise any bleeding points.

Cauterisation is the sealing of the bleeding points and this is done, usually by using certain chemicals or by an electric current or by other more sophisticated techniques. Occasionally, there may be recurrent nasal bleeds associated with fragile capillaries in the nose despite repeated cauterisation. This is common in the elderly and may necessitate blocking the main artery to the nose after an angiography of the blood vessels of the nose.

 In addition to the local treatment in the nose, it is essential to treat the underlying cause of the bleeding. These may include infections in the nose, raised blood pressures, defects in the clotting mechanism, disorders in the blood cells itself and sometimes tumours in the nose. Some medications like Aspirin, taken for other diseases, may precipitate bleeding. They may then have to be temporarily discontinued, of course, with the consent of the prescribing physician.   

 Just the other day, I had two cases of nasal bleeds following raised blood pressure. One of them was due to the inadvertent discontinuation of the medicine for the raised blood pressure and the other due to the hitherto undetected problem of hypertension. These examples highlight the importance of maintaining general health and also portray the significance of taking prescription medications regularly, as advised.

 Cancerous and noncancerous tumours of the nose, the sinuses or the nasopharynx may present with bleeding from the nose. Of note is the Juvenile Angiofibroma, which is more common in the male child around puberty. These present with profuse bleeding. The management of such cases usually involves endoscopies, scans, biopsies or excisions. These, fortunately, are the rare causes of epistaxis.