Excessive painkiller use may trigger nosebleed –Physician

24 OCTOBER 2021

Godfrey George

In this interview, Dr. Ogunbiyi Agboola, a senior registrar at the Department of Otorhinolaryngology, Lagos University Teaching Hospital, Idi-Araba, speaks to GODFREY GEORGE about the causes and management of epistaxis (nose bleeding)

How best can epistaxis be defined?  

Epistaxis simply means bleeding from the nasal cavities. It can either be anterior or posterior, in terms of its location. For the former, the bleeding point is before the bony inlet of the nasal cavity while the latter refers to bleeding beyond the bony inlet, in which case the blood is expelled from the mouth. The anterior bleeding is commoner. Epistaxis can also be spontaneous or induced, following trauma, sneezing, etc.

What would result in a person having a bleeding nose?

Bleeding from the nose can be caused by local and systemic factors. Local causes include trauma to the face and/or head, foreign body insertion to the nose, inflammatory and infective conditions of the nose and paranasal sinuses e.g. allergic rhinitis and fungal sinusitis. Neoplasms of the nose and the sinuses (sinonasal tumour, nasopharyngeal tumour, inverted papilloma, juvenile agiofibroma) are known causes of epistaxis. Frequent nose picking and dry air, during harmattan period, are also local factors. Systemic causes are not necessarily due to factors within the nasal cavity but occur as a result of disorders affecting other organs in the body. This includes chronic kidney disease, chronic liver disease, haematological disorders like clotting factor deficiencies or derangement. Chronic use of anticoagulants and non-steroidal anti-inflammatory drugs like diclofenac are also risk factors. Poorly-controlled hypertension and artherosclerosis are frequent systemic causes. In a good proportion of people, the cause is unknown (idiopathic).

If the cause is external, say from a fight, what is the best approach to work on it?

This simply means how a nose bleed from a local trauma can be addressed. The first thing to do after the trauma is to gently pinch the nose with the fingers while the patient breathes with an open mouth. This action will reduce blood loss, while the patient is gently conveyed to the hospital for definitive management of the epistaxis and also treatment of other possible structural issues occurring as a result of the trauma.

What if the bleeding was internally-induced?

Epistaxis, just like bleeding in other parts of the body, is an emergency. The patient also holds the nose to avoid bleeding, while the mouth is opened to breathe and also expel the bleeding. This is called Trotter’s Maneouvre. If the bleeding persists, a more definitive approach to control the bleeding can be implemented. This ranges from cauterisation to the application of anterior or posterior nasal packing. In addition to these, medications that can facilitate clotting and cause constriction of the blood vessels are administered. If these fail, then more extensive surgical techniques can be used to identify the bleeding vessel and then control the bleeding. It is important to state that if epistaxis is due to other systemic conditions e.g. poorly controlled blood pressure, chronic liver disease, chronic kidney disease etc, a multidisciplinary approach, involving the other medical teams, is the way to go.

The location of the nose in relation to the blood vessel can be a factor. Could you please shed more light on this?

The nasal cavity is a well vascularised structure as it has connections of blood vessels (plexuses) within it – Kiesselbach and the Woodruff plexuses. As a result of this, trauma/irritation to the mucosa lining of the nose easily causes bleeding.

What does nose bleeding in a pregnant woman symbolise?

Nose bleeding in pregnancy is attributed to increased blood volume during this physiological state. This increased vascular state makes the blood vessels liable to rupture, hence epistaxis. The hormonal changes in pregnancy has a major role in this.

At what age is the condition seen as life-threatening

Epistaxis can be dangerous at any age. The amount of blood loss and the body’s compensatory mechanisms are important factors that determine how dangerous it is. These compensatory mechanisms (neural, hormonal and biochemical), may not be optimal at the extremes of age, especially in the elderly, however, the danger is more with the quantity of blood loss and not age-dependent.

Since this condition leads to blood loss, if it continues over time, what is the expected outcome?

With continuous bleeding from the nose, especially of large quantities, the next sequence of events is the development of hypovolemic shock, which if not managed, may result in cardiac arrest and death. I’d love to add that epistaxis is not a disease but a symptom, which may be a pointer to an underlying disease.

Some people when they have flu release blood particles together with their sputum. Is this normal?

Blood-stained nasal discharge may occur following irritation to the nose as a result of the force of sneezing. However, in some cases, it may be an indicator of some serious disease condition of the nose. Hence, a visit to an ENT doctor is necessary in such a case.

Are there genetic explanations as to why people develop epistaxis?

Epistaxis can be genetic in conditions like Hereditary Haemorrhagic Telangiectasia also called Osler-Weber-Rendu Syndrome. This is a condition in which there are punctate bleeding points on the mucosa of the nose, tongue and lips. Haemophilia and Von-Willebrand disease are also hereditary diseases that can cause epistaxis

What are the things to avoid so that one does not develop this condition?

It is not all causes of epistaxis that can be prevented. However, adequate treatment of rhinitis, avoidance of nasal trauma, avoidance of nose picking and foreign body insertion into the nose, optimisation of blood pressure are some of the ways we can prevent epistaxis.

Are there lifestyle modifications you’d advice for people who have the condition?

There are no lifestyle modifications per se. However, sneezing should be done gently and with an open mouth. In addition, nose-picking should be discouraged. Frequent use of over-the-counter medications like NSAIDs may cause nose bleeding, so should be used with caution.

What is the management of epistaxis like?

The management of epistaxis involves stoppage of bleeding, a quick history taking and fast examination are done alongside, resuscitation of patient, investigation and treatment of the primary disease causing the nose bleed. All of these are carried out almost at the same time. The Trotter’s technique, which was earlier explained, is used to stop the nose bleed. If this fails, cauterisation of the bleeding spots with chemical or electrocautery can be done. Failure of this procedure would lead to nasal packing. Nasal packing achieves bleeding control in about 90 per cent of cases. Extensive surgical techniques are used for bleeding that is not stopped by nasal packing. In addition to the aforementioned techniques, intravenous fluids and medications that can encourage blood clotting are administered. At the same, blood samples are taken so as to check for different analytes in the body that can suggest the amount of blood loss, check the state of the liver enzymes, electrolytes (for the kidney function), blood clotting mechanism and grouping/cross-matching (for blood transfusion, if necessary). Further treatment now depends on what the primary cause of the nose bleeding is. Epistaxis usually presents as an acute, recurrent, chronic (usually blood-stained discharge) depending on the primary disease causing this. I’d love to reiterate that nose bleeding may be a one-off symptom when conditions like foreign body in the nose, trauma to the nose, excessive use of anticoagulants are properly managed. However, it may be difficult to control in people with HHT. Once the primary disease has been adequately managed, then epistaxis should be fully controlled.

Are there complications that may occur in the treatment of epistaxis?

Sure. This includes perforation of the nasal septum, alae necrosis, toxic shock syndrome, dislodgement of the nasal pack, otitis media with effusion

Do antibiotics cure the condition?

No. However, it can be given prophylactically during nasal packing to prevent complications like Toxic Shock Syndrome

How is one diagnosed with epistaxis when one presents at the hospital?

Epistaxis is a symptom that is usually straightforward in terms of description. However, if there is no epistaxis as at the point of the presentation, making a diagnosis entails taking a detailed history, asking if the bleeding is from one or both sides of the nose, how the bleeding started, the frequency of the bleeding, quantity of blood loss, if there is bleeding from other parts of the body etc. All these questions will point out the severity and likely cause. Examination of the nose with a headlight (anterior rhinoscopy) is done, followed by endoscopic examination. These will help to locate the possible bleeding spots or pathology responsible for the bleeding. Blood investigations and Imaging – Computerised Tomography scan of the nose and sinuses can be done for further assessment.

What should one not do during a nosebleed?

During a nosebleed, the person should try not to swallow the blood, so as not to provoke vomiting. It is also important for the person to remain calm while the bleeding is controlled.

What would happen when bleeding refuses to cease?

The control of nose bleed follows a step-wise approach. If epistaxis is not adequately controlled at the accident and emergency ward, then this may involve deploying the armamentarium of surgical procedures in the theatre to achieve control. A nose bleed is an emergency that may be a pointer to a serious medical condition involving the nose or other organs in the body. Hence, patients with this symptom should present to the hospital as quickly as possible.

SOURCE: THE PUNCH

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