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Epistaxis Explained Why Nosebleeds Happen | Dr. Busti · This Is Why with Dr. Busti

• 0:00
  Well, welcome to this episode on medical terminology where I'm going to make sure that we all understand the medical term epistaxis and use it appropriately as health care professionals. Yes, this is one of those terms where the more common word is much easier to use, right? Epistaxis essentially means nosebleed. But as always guys, the medical term matters because it should trigger a more precise way of thinking. And there is one type of nosebleed that is unique and you don't want to miss it. Okay. All right. Hey guys, I'm Anthony Busti, MD, PharmD, MSc, FAHA, FNLA and welcome to This Is Why, a show dedicated to helping health care professionals understand the why behind what we do and what we talk about every day in clinical practice. Okay. So, today we're talking about epistaxis. Not just what the word means, but why nosebleeds happen, who is at greater risk for it, when they may signal something more concerning underlying, and why the location of the bleeding in the nose matters in a very real way. Okay. Now, let's start with something that most people recognize from pop culture, right? In movies and TV, a nosebleed usually means something dramatic is happening, right? Think about it. The character is using psychic powers. They're under extreme amounts of stress. Something supernatural and weird is going on, right? Think about that movie Stranger Things where the character 11, played by Millie Bobby Brown, often develops a nosebleed, right? When she's using her telekinetic powers, it's one of the show's most recognizable visual signals that she is pushing herself, right?
• 1:47
  Something intense is happening. Well, that idea didn't start with Stranger Things, right? Stephen King's Fire Starter, which was published initially as a novel and later adapted to a film, right, also used nosebleeds in association with psychic strain, especially with Andy McGee's mind-controlling ability, right? So in pop culture guys, the nosebleed becomes this shorthand for some hidden power, hidden pressure or even danger that's going on, right? But in the real world clinical practice environment, epistaxis is not a sign of psychic powers, right? It is also not only a diagnosis, but it can be that clue to an underlying problem.
• 2:32
  And so the real questions that we should be asking ourselves are why did this patient have a nose bleed? Who is at greater risk and where in the nose is the bleeding actually coming from? Okay, that is the clinical framework for this episode.
• 2:54
  So let's first define the term. Epistaxis means bleeding from the nose, right? But more formally we can say epistaxis is bleeding from the nasal cavity. Usually from rupture of the blood vessels and that nasal mucosa. Okay. The word literally itself from Latin and Greek has roots connected to the idea of dripping. Right? So in a very literal sense clinically the word carried out this image of blood literally dripping from the nose. And anybody that's seen it knows that's true. Okay. Now, importantly, epistaxis is not also some random outdated word that only shows up in old medical textbooks. It's still actively used in modern clinical medicine, isn't it? Right. Even the American Academy of Otolaryngology Head and Neck Surgery Foundation has literally a clinical practice guideline titled nosebleleed paratheses epistaxis. Okay. The term is also used and can be found very easily in the emergency medicine literature, ENT literature, primary care and even some patient education. So when a patient says I have a nose bleed, we may document or discuss it clinically as epistaxis, right? But again naming it is only step one. The next question is why does epistaxis happen? Okay.
• 4:17
  And a good way to organize the causes is this, right? Nose bleeds can happen because something dries, irritates, injures, inflames, structurally disrupts, or prevents clotting in the nasal mucosa. Okay, so that's the big picture.
• 4:41
  But let's break that down. Okay, we're going to go through these individually. So the first and most common category is just basic dryness and mucosal irritation, isn't it? The inside of the nose is lined by that mucosa and that mucosa has a very rich blood supply because the nose isn't just an air tunnel, right? The nose is there to warm, humidify, filter the air as we breathe it in. And to do that, it needs blood vessels very close to the surface. Okay, that is useful physiologically, but it also makes that lining very vulnerable, doesn't it? Dry air, heated indoor air, winter weather air, high altitudes, or chronic use of nasal oxygen therapy can overdry that lining.
• 5:38
  Once that lining gets dry, crusted, it can crack just like chapped skin. Okay? And when it cracks over those superficial blood vessels, that's when you get epistaxis. All right? Now, that's category one. Let's talk about category two, right? Which is a major one, which is local trauma. That includes facial trauma, nasal injury, maybe nasal instrumentation that sometimes happens in the hospital environment, forceful nose blowing, right? And yes, yes, the most common trauma, nose picking.
• 6:14
  We should not overcomplicate this, right? The anterior nasal septum, especially we'll see in a minute, has a very fragile superficial level of blood vessels that even with minor trauma can rupture them and cause them to bleed. And this is especially common obviously for anybody that's got kids or seen kids who have allergies, colds, dry mucosa, fingers or foreign bodies sometimes go in that nose, right? All right. So, that's category two. All right. Category three is related to inflammation and infection. Right?
• 6:53
  Think of viral upper respiratory tract infections, sinusitis, allergic rhinitis, non-allergic rhinitis. All of those things can contribute. Okay. The inflammation itself makes that mucosa more irritated and vascular, right?
• 7:06
  There's more flow and but that behavior around it also matters, doesn't it? All right. Think about the patient that is sneezing, rubbing, wiping, blowing their nose repeatedly, right? So the blood may not be from the virus or infection itself directly cutting open a vessel, right?
• 7:27
  It may be from inflamed mucosa plus repeated mechanical irritation. Okay. Now the fourth category and one that we should all keep in the back of our minds and we probably do see is medications and substances. Okay. Aspirin, other antiplatelet agents that are very well known to impair platelet aggregation and function.
• 7:55
  Anticoagulants such as warfarin or the DOACs, direct oral anticoagulants, can obviously make bleeding harder to stop once it starts. Think about NSAIDs.
• 8:02
  Very common over the counter can also contribute especially through that platelet effect depending on the agent and the context for which it's being used. How about intranasal steroid sprays and the way we administer them? So if you aim it towards the nasal septum all right and it's used in that way that will irritate the mucosa and actually contribute to bleeding. So the technique matters.
• 8:30
  Intranasal cocaine right is a major local irritant and vasoconstrictor that can over time damage the nasal tissue. Okay. So one of the useful teaching lines is this. Some medications make the vessel more likely to bleed. Others make the patient less able to stop bleeding once it starts.
• 8:53
  Right? All right. What about the fifth category?
• 9:00
  Systemic bleeding tendencies, things that we sometimes don't always think about, keep on the top of our mind, but that includes things like thrombocytopenia, platelet dysfunction, right?
• 9:11
  Especially like uremic platelet dysfunction, von Willebrand disease, hemophilia, underlying liver disease where the coagulopathy starts to occur. Obviously, patients who have heavy alcohol use who then get liver disease. How about hematologic malignancy such as leukemia? Okay, in those cases, the nose may be where the bleeding shows up. But listen guys, it's the identifier to an underlying systemic problem that could be missed if you just anchor on the nose bleed. So a tiny mucosal injury that would normally stop quickly may be prolonged, recurrent, and more dramatic because the patient's clotting system is impaired for some reason. And finally we have the structural or vascular causes.
• 9:57
  Right? Think about a deviated septum, nasal septal perforation, nasal polyps, nasal tumors, vascular malformations. How about hereditary hemorrhagic telangiectasia also known as HHT?
• 10:14
  All of those can be relevant, right? And the clinical warning here is that recurrent unilateral severe unexplained or unusual bleeding that should not should automatically be blamed by only dry irritated or even nose picking.
• 10:38
  Right? All right. Now let's separate some of those classic causes from the risk factors. Right? A cause is what starts the bleed. But we've already discussed patients that have causes and align with those risk factors. So it makes sense. But there's one I want to touch on a little bit further and that is hypertension. High blood pressure is often blamed for nose bleeds. But it's probably better to teach it this way, right? Hypertension may make the nose bleed more persistent and more difficult to control. But we should be careful about saying it is the sole or absolute cause for most nosebleeds. Okay, we still need to look for that local trigger, the medication effect or underlying bleeding risk. So, hypertension may certainly contribute to the persistence of bleeding that has already started, but it should not automatically stop your thinking. Okay. All right. So, now that we know why patients bleed, who is at risk, we can finally ask where is the bleeding actually coming from? Okay. This is where the anatomy and physiology becomes very practical and clinically relevant. Okay. So follow me here. The nasal cavity has a blood supply from both listen the internal and external carotid arteries. Okay. The major vessels we commonly emphasize coming off of those include the anterior ethmoid artery, the posterior ethmoid artery. Okay, that's one of the things that differentiates them from anterior versus posterior nose bleeds. Sphenopalatine artery and then the greater palatine artery and superior labial artery. All right. Now, those branches contribute to vascular networks in that nasal cavity, especially along the nasal septum. The most famous is Kiesselbach plexus.
• 12:38
  Okay, it's also known as Little's area. It's in the anterior portion of the nasal septum. Okay, this is where the anterior posterior vascular meeting point and where those vessels are most superficial. Okay. And close to the surface. That is why many anterior nose bleeds come from this region. So why so we divide epistaxis remember into two broad categories anterior and posterior.
• 13:11
  Anterior epistaxis is more common. It's usually coming from that front part of the nasal septum often in that Kiesselbach plexus near the surface.
• 13:26
  The blood supply usually for comes out forward from the nostril right in a dripping manner and and the source may be easier for you to visually see. Treatment is often also more straightforward. It's the posterior epistaxis that is less common but usually more clinically concerning. It comes from deeper in that nasal cavity. may involve those larger vessels literally coming from more of an arterial supply and it may drain in backward into the throat. It's obviously also a little bit harder to visualize since it's not dripping out of the front. That means it's also harder to control. Now posterior bleeds are more common in older patients and may require more aggressive management and even involve our colleagues otolaryngologists or ENTs to be involved. Okay. And this is why the location matters. If the bleed is anterior, we can often compress it. we can access it, visualize it, apply topical vasoconstrictors, cauterize a visible bleeding site, or even pack it with anterior packing. If the bleed is posterior, the source may be deeper, larger, and less accessible.
• 14:41
  And that may require posterior packing, nasal endoscopy, ENT consultation, as I just mentioned, arterial ligation and even potentially interventional radiology to embolize selected cases. Now, that is not a procedural lecture, right? But let's summarize the basic treatment concept here, right? First assess severity. Is the patient stable? Are they protecting their airway? Is the bleeding heavy? Okay. Are they on anticoagulants or antiplatelets? Do they have anemia, bleeding disorders or other risk factors that you need to consider? So for a typical nose bleed, all right, the basic first step is to sit upright. Help let gravity help you. Lean forward, right? and then apply firm sustained pressure to that lower part of the nose. Okay, not the obviously hard bony bridge. Okay, leaning forward matters because it also prevents that blood from running down the back of the throat. Okay, if bleeding does continue, we they can use topical vasoconstrictors, remove clots to visualize the source, cauterize that visible anterior bleeding site, or even institute nasal packing. If the bleeding is severe, posterior recurrent, or difficult to control, some sort of associated disease, that's when our escalation needs to become more important and initiated. So here's the takeaway guys. Epistaxis means nosebleed.
• 16:20
  It's a simple word common problem right? But clinically it should trigger a disciplined thought process by you. Why did that vessel bleed? Okay.
• 16:35
  Is this a local issue like dryness, trauma, inflammation or nasal irritation? Or is this a medication issue like anticoagulants, antiplatelet drugs, NSAIDs, intranasal steroid drug exposure?
• 16:49
  Are you being used wrong? Right? Is this a part of a systemic disease or a structural lesion? And finally, where is that blood coming from? Anterior versus posterior. All right? Because because once you understand that anatomy, the treatment plan really actually starts to make sense. That's the how we talk about. So anterior bleeds are often usually accessible and often easier to control.
• 17:12
  Posterior bleeds are deeper, harder to visualize, more likely to need that escalation. All right.
• 17:17
  So Hollywood may use nose bleeds to show a psychic level of strain or something concerning, but clinicians use epistaxis as a vascular clue. And that is why the term matters. I hope that this episode was helpful, interesting, but also clinically relevant in bringing back some of the old things of even anatomy and physiology. Okay, if it was, please consider subscribing to the channel. Share this with your colleagues, students, residents, anyone that's interested just learning the language of medicine, right? I'm Dr. Busti and remember, never stop learning the why because that is what helps us to master the how. how we take care of patients and maximize the benefits of our care and improve outcomes. Take care.