EPISTAXIS, FOREIGN BODIES AND PARASITES
Bleeding from the nose is common and may occur at any age and from many
causes. It is frequently met with in children in whom the most common
precipitating factors are picking the nose and acute rhinitis, usually of the
epidemic influenzal type. Epistaxis in children nearly always arises from the
'bleeding area* of the nose which is situated on the nasal septum low down
near the mucocutaneous junction (Plate 1,2). Following an epistaxis the blood
clots and as the clot hardens it becomes irritable and is picked loose with
further bleeding. During influenzal epidemics vascular engorgement may
cause epistaxis and the chance of this is increased by nose blowing. After the
infection settles there may be residual crusting in the nasal cavities and this
may promote picking of the nose with further haemorrhage. Such an event
may occur during light sleep, or may take place when the child is in bed and
away from the reproving eye of the parents. Trauma js a common cause
epistaxis in children, and blood diseases such as haemophilia, leukaemia and
purpura predispose to nose bleeding.
In the adult epistaxis may occur from the same causes as in children, and it
is also met with in diseases of the heart, liver and kidney, or from intranasal
crusting and tumours. It occurs most commonly in hypertension from
whatever cause, and this is especially so in the elderly. "IfTs very rarely
vicarious, replacing menstruation.
Epistaxis may be slight in amount, there merely being a streaking of blood
in the nasal catarrh, or it may occur in any quantity up to the point at which a
great deal of blood is lost rapidly. In general, parents and patients tend to
exaggerate any estimate of blood loss, but the haemorrhage may be so severe,
so persistent or so frequently repeated as to require blood transfusion. Such
severe cases should be treated in hospital.
Bleeding generally arises from the 'bleeding area' of the nasal septum, but
in a proportion of cases the source is from the anterior ethmoidal vessels in the
region of the middle concha. In the presence of actual bleeding the exact
location may not be determined on inspection. If the haemorrhage has
recently ceased the nasal cavity may be full of blood clot, and this may have to
be douched out before one can discover the source. In patients who are first
examined some time after bleeding has stopped the dilated vessel or raw area
may be seen on anterior rhinoscopy. Apart from determining the site of the
bleeding, a full blood investigation should be carried out in severe epistaxis.
This not only gives the haemoglobin level but analysis of the blood may point
to some haemorrhagic disease as the cause.