Nosebleeds are one of the most common emergencies in ENT. Can be unilateral bleeding, can also be bilateral bleeding, can be manifested as repeated intermittent bleeding, can also be persistent bleeding, light bleeding only in the nose with blood or blood nose, severe bleeding can reach hundreds of milliliters or more, according to statistics, the lifetime prevalence of epistaxis is about 60%.
Most nosebleeds stop spontaneously or with the nasal wings pinched, and 6% to 10% of patients require medical attention. Epistaxis mainly affects children between the ages of 2 and 10 years and adults between the ages of 45 and 65, and many statements are unconscious and self-limiting at presentation; Usually all we need is proper first aid.
Systemic causes include acute febrile infectious diseases, cardiovascular diseases, blood diseases, nutritional disorders or vitamin deficiencies, chronic diseases such as liver and kidneys, and rheumatic fever, as well as poisoning, hereditary hemorrhagic telangiectasia and endocrine disorders.
Nosebleeds have a significant effect in hypertensive patients with very low morbidity and mortality. Patients with epistaxis are usually frail older people and often have other complications. Epistaxis is clinically divided into posterior epistaxis, which is sometimes referred to as refractory epistaxis, because the bleeding originates in the posterior part of the nasal cavity, is insidious and often recurs.
pathogen
Risk factors for epistaxis include trauma, inflammation of the nasal mucosa, cold season, alcoholism, hemostasis abnormalities, and antithrombotic or antiplatelet therapy, and in patients with long-term hypertension, hypertension and diabetes are also associated with high recurrence rates of epistaxis, possibly because they are promoters of atherosclerotic cardiovascular disease.
Nosebleeds are associated with long-term high blood pressure and diabetes, and both can cause atherosclerotic changes in blood vessels. Although there is no direct link between epistaxis and cerebrovascular disease, these changes can lead to weak nasal vessels and therefore predispose to epistaxis. Whether there is an association or causation between nosebleeds and high blood pressure is a long-standing debate.
Although the pathophysiology of hypertension in patients with epistaxis is unclear, we must consider two important aspects highlighted in previous studies, first, chronic vascular diseases, such as end-vascular damage caused by hypertension, may play a role in the pathogenesis of epistaxis.
Some data suggest that patients with long-term hypertension may have an increased risk of nosebleeds, possibly due to its vascular effect. Enlargement of nasal arteries by nasal endoscopy in hypertensive patients with a history of epistaxis suggests that a history of epistaxis is caused by damage to the middle layer of the nasal artery, and that long-term hypertension may increase the risk of epistaxis.
5% to 10% of patients with epistaxis have deep nasal bleeding, which is less visible, and most patients with deep nosebleeds have a more difficult location to find, which is called refractory epistaxis or refractory epistaxis. Leeches are a rare nasal foreign body that can cause nosebleeds. It is a worm that lives in freshwater and is most commonly found in tropical regions.
Once it attaches to the nose, it secretes an antithrombin called hirudin, which causes more persistent bleeding. In the review by Kikidis et al., two-thirds of studies reported that arterial pressure was higher at epistaxis than in the control group or the general population, and epistaxis in hypertensive patients is usually posterior nosebleed, which is more difficult to control than anterior epistaxis.
In 2005, Bray Engen published a retrospective study of 1373 cases of primary spontaneous nosebleeds at the Third Referral Centre in London, UK, and they found no correlation between mean monthly temperature and the incidence of nosebleeds, and no seasonal variations.
Patients with unknown bleeding points have significantly higher rates of rebleeding and 30-day readmission and do not receive further treatment after removal of nasal tamponade because no bleeding point is found, and these patients are likely to have re-bleeding from the initial bleeding point rather than bleeding due to trauma to nasal tamponade.
examine
With the development of nasal endoscopic technology, the posterior nasal cavity is no longer a blind area. Orderly, thorough endoscopy with an appropriately angled endoscope improves the diagnosis of the source of bleeding and reduces blind tamponade. Moreover, with nasal endoscopic examination, the identification and direct burning of posterior nasal bleeding points becomes more accurate and easy.
Transnasal endoscopy is an ideal test in older patients because it has fewer adverse effects on cardiopulmonary function. Endoscopy must consider the risk of nosebleeds before and during endoscopy.
treat
According to statistics, most patients with nosebleeds present with primary medical staff present, and most cases are initially handled by less experienced medical staff. Only 10% of returning patients have received advice on nosebleeds, first aid and prevention, which could mean that the public lacks proper first aid and treatment for nosebleeds.
Most referrals for nosebleeds come from primary caregivers. Appropriate health interventions can improve, recognize, detect and manage nosebleeds. Treatment usually includes nasal tamponade, physical coagulation to stop bleeding, vascular ligation, vascular embolization, systemic therapy, and others.
1. Cauterization method
Cautery has been widely used in the treatment of epistaxis, and a large number of literature has discussed the advantages of cautery and its application in the treatment of acute epistaxis, the two main methods of nasal cautery are chemical cautery and bipolar diathermy equipment. Silver nitrate rods are the most common chemical cautery in the UK and electrocautery is more effective than chemical cautery therapy for active nosebleeds.
For some nasal endoscopic bleeding points are not found, and the patient has a large amount of bleeding, bipolar electrocoagulation can be used to electrocoagulate the sphenopalatine artery under the premise of excluding bleeding from the anterior ethmoidal artery. This can block the blood supply in the nasal cavity and achieve good results.
2. Tranexamic acid
Topical tranexamic acid allows clinicians to treat epistaxis with a relatively low-cost drug that is less painful while avoiding discomfort and the need for follow-up associated with nasal tamponade. Due to the potential risk of accelerated thrombosis following tranexamic acid exposure, topical tranexamic acid is not recommended in patients with a history of thrombometabolic disease or a high thrombotic risk.
3. Physical solidification
Laser hemostasis treatment is an ideal method for rapid hemostasis at this stage, Zhang Jianhua in the nasal endoscopic phosphopeptide potassium laser treatment of epistaxis, realized that the use of phosphopeptide potassium laser in nasal endoscopic hemostasis hemostasis has a clear vision, accurate hemostasis, safe and simple, no pain, few complications and other advantages.
4. Microwave therapy
Microwave therapy is also a more commonly used hemostatic method, its principle is endogenous heat and thermal external effect, high-frequency electromagnetic waves into the tissue can make the tissue instantly produce high temperature, so that the bleeding site and surrounding protein coagulation, tissue degeneration, improve the local mucosal anti-infection ability. Promote early repair of wounds, so as to achieve good hemostatic effect.
5. Vascular ligation
With the development of nasal endoscopic electrocoagulation hemostasis and minimally invasive intervention, vascular ligation has been less used, and patients with nasal bleeding consider vascular ligation after the failure of traditional nasal tamponade and physical coagulation to stop bleeding.
Clinically, arterial ligation is more demanding, such as maxillary artery ligation, which usually causes complications such as maxillofacial pain and numbness, facial paralysis, infraorbital nerve injury and blindness, maxillary sinusitis, tearing, and upper lip numbness. Compared with surgical arterial ligation, the use of intravascular artery embolization therapy for refractory nosebleeds is increasing in China.
Even in the case of elderly epidemics with a higher incidence of congestive heart failure, compared with embolization therapy refractory epistaxis; Current research also supports surgical ligation as a safe and more cost-effective intervention, and current trends seem to indicate a shift from ligation to embolization.
6. Vascular embolism
Digital subtraction angiography and superselective thrombosis technology are new developments and breakthroughs in endovascular contrast diagnostic technology, and this method is suitable for patients with severe nosebleeds. Under digital subtraction angiography, the bleeding location can be directly displayed, which has the advantages of rapid hemostatic effect, obvious effect, and short treatment time.
Patients with hypertension, myocardial infarction, coronary heart disease, arteriosclerosis, and prior cardiovascular and cerebrovascular disease, as well as those treated with anticoagulants, both require an experienced surgeon or neuroradiologist specialist. A better understanding of the anatomical origin of nosebleeds helps to choose between these techniques.
7. Nasal tamponade
In patients with epistaxis, when simple measures such as direct pressure and cautery are not enough, intranasal tamponade is recognized as the main treatment modality for nosebleeds, and the ideal nasal tamponade material should have a variety of functions when used for nasal tamponade, including stopping bleeding, promoting wound healing, and maximizing patient comfort.
Optional iodoform yarn, petroleum jelly oil yarn, expansion sponge, absorbable hemostatic materials, etc. Stuffing material: iodoform yarn in the process of tamponade is more likely to cause erosion of nasal mucosa, and can cause local compressive necrosis, iodoform yarn has the advantage of antiseptic, anti-infection effect, can stay in the nasal cavity for 5-7 days.
It is particularly suitable for patients with nosebleeds who require prolonged compression to stop bleeding and are not effective in the short term. Vaseline oil tamponade method is more suitable for patients with nosebleeds who do not have much bleeding, and the bleeding site is not clear, and the nasal mucosa is torn due to trauma and other hemostatic methods are ineffective.
According to the bleeding site and the size of the bleeding range, the polymer expansion sponge can be cut into different shapes, and the principle of rapid water absorption and expansion can be used to compress and stop bleeding. Polymer expansion sponge has better air permeability than iodoform yarn and petroleum jelly oil yarn, soft material, relatively good nasal ventilation, easy tolerance for patients, and good hemostatic effect.
summary
At present, the common treatment methods of epistaxis are: nasal tamponade, cautery, physical coagulation to stop bleeding, vascular ligation, vascular embolization, systemic treatment, etc. When dealing with patients with epistaxis, always pay attention to the patient's mental state and vital signs to relieve the patient's nervousness. In general, patients with epistaxis with hypertension bleed heavily.
And some people have a history of aspirin taking, and if they can find bleeding points, electrocoagulation is performed. Bleeding points that are located at the back of the nasal cavity are difficult to distinguish, and nasal tamponade therapy is usually used, commonly used in gelatin sponges and oil yarns. At present, the most commonly used method is electrocoagulation cautery treatment, which has the advantages of high one-time cure rate, less pain for patients, and not easy to recur.