What Is a Posterior Nose Bleed?

Nosebleeds (Epistaxis) is one of the common clinical symptoms, which can be caused by nasal diseases or by systemic diseases. Nosebleeds are mostly unilateral, and bilateral nosebleeds can occur in rare cases; the amount of bleeding varies, with light in the nasal discharge only, and severe cases can cause hemorrhagic shock, and repeated nosebleeds can lead to anemia.

Li Lijuan	(Attending physician)	Department of Otolaryngology, Peking University Third Hospital
Julie	(Chief physician)	Department of Otolaryngology, Peking University Third Hospital
Ma Furong	(Chief physician)	Department of Otolaryngology, Peking University Third Hospital

Western Medicine Name: Nosebleed
English name: Epistaxis
Affiliated Department: Faculty-

Disease site: nasal cavity
The main symptoms: Nosebleed
Contagious: Non-contagious

Causes of nosebleeds

There are many causes of nosebleeds, which can be caused by diseases of the nasal cavity itself, or induced by perinasal cavity or systemic diseases.

Local cause of nosebleeds

(1) Nasal injury Mechanical trauma: such as car accidents, falls, boxing injuries, and nose digging are common causes of nosebleeds. Barometric injuries: During high-altitude flight and diving, if the pressure difference between the inside and outside of the sinuses suddenly changes too much, the mucosal blood vessels in the nasal cavity and sinuses will rupture and rupture. Radiotherapy injury: during and after radiotherapy of the head and neck, congestion and edema of the nasal mucosa, or epithelial shedding may occur, and nosebleeds may also occur.

(2) Deflection of the nasal septum: It usually occurs near the epiphysis or spine (rectangular process) or the convex surface of the nasal septum, where the mucosa is thin, and the air flow direction changes here, so the mucosa becomes dry. Resulting in blood vessel rupture and bleeding. Patients with perforation of the nasal septum can cause repeated nosebleeds due to dryness, erosion and detachment of the mucous membrane at the edge of the perforation.

(3) Nasal inflammation: Non-specific inflammation of the nose: Acute rhinosinusitis, dry rhinitis, atrophic rhinitis, etc. are prone to cause nosebleeds, and the amount of bleeding is generally small. Nasal-specific infections: tuberculosis, lupus, syphilis, leprosy, and diphtheria. Specific infections can cause nosebleeds due to mucosal erosions, ulcers, granulation, and perforation of the nasal septum.

(4) Tumors of the nasal cavity, sinuses, and nasopharynx: the most prone to nosebleeds are nasal septum hemangioma, nasopharyngeal fibrohemangioma, hemorrhagic nasal polyps, and nasal sinus malignant tumors. A small amount of nosebleeds or blood in the nose is one of the main early symptoms of malignant tumors.

(5) Nasal foreign body: common in children, mostly unilateral nosebleeds, due to long-term retention of nasal foreign bodies in the nasal cavity, which can cause nasal mucosal erosion and bleeding. Animal nasal foreign bodies, such as Leeches, can cause repeated massive nosebleeds.

Nosebleed systemic causes

(1) Hemorrhagic diseases and blood diseases: Defective structure and function of blood vessel wall: such as hereditary hemorrhagic telangiectasia, vitamin C deficiency, allergic purpura, drug-induced vascular purpura, infectious vascular purpura , Vascular pseudohemophilia and so on. Platelet number or dysfunction diseases: such as primary thrombocytopenic purpura, secondary thrombocytopenia caused by various reasons, etc. clotting factor disorders: such as various types of hemophilia, vitamin K deficiency and so on. The blood's own anticoagulant effect is too strong: such as improper use of anticoagulants, antifibrinogen and other anticoagulant substances in the blood circulation, or excessive or accelerated dissolution of fibrin, such as diffuse intravascular coagulation.

(2) Acute febrile infectious diseases: such as flu, flu, hemorrhagic fever, scarlet fever, malaria, measles and typhoid fever. Mostly due to high fever, toxic vascular damage, nasal congestion, swelling and dryness, resulting in capillary rupture and bleeding. Under normal circumstances, the amount of bleeding is small, mostly occurs in the fever period, and the bleeding site is mostly located in the front of the nasal cavity.

(3) Cardiovascular diseases: hypertension and arteriosclerosis; hypertension and arteriosclerosis are important causes of nasal bleeding in the elderly, and vascular sclerosis is the pathological basis. Increased blood pressure, especially during constipation, excessive force, or emotional agitation, can cause nasal blood vessels to rupture and cause nosebleeds. In addition, sneezing, coughing hard, nasal breathing or nasal massage are also frequent and difficult to control nose bleeding. Increased venous pressure: Emphysema, pulmonary heart disease, mitral valve stenosis, neck or mediastinal space occupying diseases, etc., can cause superior vena cava hypertension. The nasal cavity and nasopharyngeal veins of these patients often have venous congestion When the patient has a severe cough or other causes, the blood vessels can rupture and bleed, and the bleeding site is mostly located in the nasopharyngeal vein at the posterior nostril from the distribution area.

(4) Other systemic diseases: pregnancy, premenopause, and menopause can cause nosebleeds, which may be related to increased capillary fragility. Patients with severe liver disease can cause nosebleeds due to liver coagulation factor disorders. Uremic disease can also cause nosebleeds. Nosebleeds can be one of the early manifestations of rheumatic fever.

Pathogenesis of nosebleeds

Vascular distribution in the nasal cavity is abundant, and the above-mentioned various causes can cause the occurrence of nosebleeds.

The arteries of the nasal cavity mainly come from the ophthalmic artery of the internal carotid artery and the maxillary artery of the external carotid artery. The main branches of the ophthalmic artery in the nasal cavity are the anterior ethmoidal artery and the posterior ethmoidal artery; Arteries and iliac arteries supply the nasal cavity. The anterior ethmoid artery mainly supplies the anterior upper part of the outer wall of the nasal cavity and the anterior upper part of the nasal septum. The branch of the sphenopalatine artery supplies the posterior, inferior and anterior inferior parts of the nasal septum. The branch of the infraorbital artery supplies the anterior part of the lateral wall of the nasal cavity. The iliac aorta supplies the anterior inferior part of the nasal septum. In addition, the upper carotid artery of the external carotid artery and the upper labial artery supply the nasal vestibule and the anterior lower part of the nasal septum. The branches of the sphenopalatine artery, the anterior ethmoidal artery, the posterior ethmoidal artery, and the superior labial artery are anastomosed with the iliac aorta before the nasal septum to form a reticular artery plexus, called the Little's area, which is the most common site of epistaxis.

Nasal vein anastomosis in the nasal cavity to form a reticular venous plexus. The Kiesselbach venous plexus located before and below the nasal septum and the Woodruff venous plexus located behind the outer wall of the lower nasal passage near the nasopharynx are both nasal Good sites for bleeding.

Clinical manifestations of nosebleeds

Nosebleeds have different performances due to different reasons. Most nosebleeds are unilateral or bilateral; they can be intermittently repeated, and they can also be persistent. The amount of bleeding varies, with light blood, a few drops or a few milliliters in the milder snot, which can reach tens of milliliters or even hundreds of milliliters or more, leading to hemorrhagic shock. Repeated bleeding can cause anemia. A small amount of bleeding can stop on its own or after self-compression.

Most bleeding sites occur in the easy-bleeding area (Little's area) of the lower part of the nasal septum. Sometimes jet or pulsatile arterial hemorrhage is seen. Nasal bleeding in children and young people occurs in this area. Nasal bleeding in middle-aged and elderly people is often related to hypertension and arteriosclerosis. The bleeding site is more common in the back of the nasal cavity. Wu's nasal ~ nasopharyngeal vein plexus (Woodruff venous plexus) and the arteries in the back of the nasal septum . Bleeding in this area is generally fierce, and it is not easy to stop bleeding. The bleeding often flows quickly into the pharynx and is spit out of the mouth. Nasal bleeding caused by local diseases mostly occurs on one side of the nasal cavity, while those caused by systemic diseases may have alternate or simultaneous bleeding on both sides of the nasal cavity.

Nosebleed diagnosis

1. Inquire about the history and bleeding in detail, confirm that the bleeding originates from the nasal cavity or adjacent tissues, and exclude hemoptysis and vomiting.

2. Determine the bleeding site, determine the location of the site by combining anterior nose, endoscope, and / or CT and MRI.

3. Routine blood tests are essential for patients with heavy bleeding and suspected hematological diseases. For patients with anticoagulant drugs and suspected coagulation disorders, coagulation needs to be checked.

4. Estimate the amount of bleeding, assess the patient's current circulatory system status, and whether there is hemorrhagic shock. Necessary fashion must consult with relevant departments. Comprehensively determine the amount of bleeding according to each bleeding situation and number of episodes, the patient's blood pressure, pulse, general conditions and laboratory tests. When the blood loss reaches 500ml, dizziness, thirst, fatigue, paleness and other symptoms may occur; when the blood loss reaches 500-1000ml, sweating, blood pressure drop, and pulse speed may occur; if the systolic blood pressure is lower than 80mmHg, blood is indicated. Capacity has been lost by about 1/4.

5. Troubleshoot systemic disorders. ^[1]

Differential diagnosis of nosebleeds

Nosebleed hemoptysis

After bleeding from the throat, trachea, bronchi, and lungs, the blood leaks out through the mouth. It is common in tuberculosis, bronchiectasis, lung cancer, lung abscess, and pulmonary congestion caused by heart disease. Can be identified based on the patient's previous medical history, signs and auxiliary examination.

Nosebleeds and vomiting

Hematemesis is one of the main manifestations of upper gastrointestinal bleeding. When a large amount of hematemesis occurs, blood can flow out of the mouth and nasal cavity, often accompanied by other symptoms of gastrointestinal diseases. A general physical examination may have positive signs and can be identified.

Nose Bleeding Treatment

Nosebleed is an emergency, and you should first maintain vital signs, stop bleeding as quickly as possible, and treat the cause.

General management of nosebleeds

First, comfort the nervous and feared patients and their relatives to calm them down, so as to prevent the patients from increasing their blood pressure due to mental factors and exacerbating the bleeding. The blood pressure and pulse should be measured in time, and fluid should be replenished if necessary to keep the vital signs stable. If the patient is in shock, first aid should be given to the shock. When inquiring about the medical history, ask the following: which side of the nasal cavity or which side of the nasal cavity first bleeds, the rate and amount of bleeding, whether there have been repeated nosebleeds in the past, whether the bleeding was induced, and whether there were other accompanying symptoms.

Nosebleed looking for bleeding point

Depending on the situation, local and systemic nasal examinations are performed. When examining the nasal cavity, clear the clot in the nasal cavity, apply 1% ephedrine and dicaine to fully contract and anesthetize the nasal mucosa, find the bleeding site as much as possible in order to stop bleeding accurately. If possible, it is best to find the bleeding point under the nasal endoscope and implement hemostatic treatment.

Hemorrhage of nose and nose

According to the severity of the bleeding, the bleeding site, the amount of bleeding and the etiology, choose different hemostatic methods.

(1) Shiatsu method:

Patients can pinch the bilateral wing with their fingers or press the bleeding wing to the nasal septum for about 10 to 15 minutes. They can also press the upper lip with the fingers horizontally, while applying cold forehead and back neck. This method is suitable for patients with a small amount of bleeding and bleeding in the front of the nasal cavity. Patients with nose bleeding at home can take this method.

(2) Local hemostatic drugs: suitable for lighter anterior nasal bleeding, this method is simple and easy, and the patient is less painful. For bleeding areas, cotton pads can be dipped in 1% ephedrine, 1 adrenaline, 3% hydrogen peroxide solution, or thrombin, and the nasal cavity can be tightly closed for several minutes to several hours to achieve the purpose of hemostasis.

(3) Cauterization method: chemical cauterization and physical cauterization are commonly used (including electric cauterization, laser cauterization, and microwave cauterization). The bleeding located before and after the nasal septum is clearly visible after fully contracting and anesthetizing the nasal mucosa. You can use a cotton swab dipped in 30 ~ 50% silver nitrate or 30% trichloroacetic acid to burn the bleeding point, and press it on the bleeding point until White film is formed locally.

(4) Anterior nostril tamponade: it can be applied when the anterior nasal active bleeding is severe or the bleeding site is not clear.

Vaseline oil gauze anterior nostril tamponade is a traditional method of hemostasis. Most patients with nosebleeds can stop bleeding after tamponade. A few patients need repeated tamponade or further posterior nostril tamponade. Vaseline oil gauze strips can be folded from the top of the nasal cavity from top to bottom and packed tightly, or they can be stuffed from the bottom of the nose to the top of the nasal cavity. There must be a certain depth and strength when stuffing. Do not stack the gauze strips at the front nostril. After stuffing, check if there is still blood flowing into the pharynx from the nostril. The time for removing the nasal stuffing should be determined according to the situation. For patients with severe bleeding or hematological diseases, the packing time should be appropriately extended. During the stuffing process, patients should be given antibiotics to prevent nasal cavity and sinus infection.

Vaseline oil gauze anterior nostril tamponade is currently widely used in the treatment of nosebleeds, but patients have greater pain and are prone to relapse. There are currently many improved methods, such as:

Hemostasis tamponade: Put fingertips coated with oil or ointment into the nasal cavity, and then use gauze to do stuffing in the sleeve. This method is less painful when filling and removing the gauze.

Compression hemostasis by airbag or water sac: Hemostatic airbags of various shapes are made of rubber film and placed in the nasal bleeding site. The sleeve is inflated or filled with water to compress the hemostasis.

In addition, other stuffing hemostatic materials can be used, such as swelling sponge, calcium alginate fiber, etc., which is suitable for diffuse nasal mucosa and small amount of bleeding, and has the advantages of good hemostatic effect and less pain.

(5) Posterior nostril tamponade: After anterior nostril tamponade, the bleeding still does not stop. It flows back into the pharynx or flows out from the contralateral nasal cavity. Posterior nostril tamponade should be selected.

Classic posterior nostril stuffing: Place a thin urinary catheter from the bleeding side of the nasal floor into the pharynx and pull it out of the mouth, tie the silk of the posterior nasal embolization ball to the tip of the catheter, and hold the posterior nasal embolization ball with one hand Send it to the mouth cavity, and gradually pull the urethral catheter with the other hand to make the posterior nasal embolization ball enter the posterior nostril, then perform anterior nasal stuffing with oil gauze strips, and then tie the silk thread to a gauze roll and fix it to the patient's anterior nostril. The operation of posterior nostril stuffing is more complicated, and the patient is more painful. Generally, the patient needs to be hospitalized for observation and given sufficient antibiotics to prevent infection. The soft palate and the anterior nostril should be checked daily for redness and swelling, and the patient's breathing and eating conditions should be observed. Can be stuffed for 3 to 7 days.

Airbag or sac tamponade method: using a tracheal balloon (Foley tube) for posterior nostril filling can not only significantly reduce the pain of patients, but also greatly reduce the occurrence of complications. Most scholars believe that the application of Foley tube makes posterior nostril embolization simple and feasible, and has obvious advantages in emergency treatment. The patient can take any position, the operation is simple, the hemostasis is rapid, the patient's physical damage is small, and the treatment effect is good. The pressure of the balloon can be controlled by the injected fluid, which can be adjusted freely. It has little irritation to the nasal mucosa, light damage, and easy to grasp the application.

(6) Transnasal endoscopic hemostasis: With the advancement of ENT equipment, in recent years, the method of electrocoagulation and hemostasis by detecting the blood site under nasal endoscopy has achieved significant results and has been widely used. Its effective efficiency is up to More than 90%, the advantage is that the hemostasis can be accurately and reliably stopped in the deep and narrow areas such as the upper part, the rear part and the nasopharynx, which are not easy to observe with the front nose, in the nasal cavity. Damage to the nasal mucosa is reduced, and the patient suffers less. No special care is needed after hemostasis, no hospitalization is required, and fewer complications. The disadvantage is the higher cost.

(7) Arterial embolization: The rapid development of imaging technology has helped the diagnosis and treatment of severe nosebleeds. Through digital silhouette angiography (DSA) technology, the bleeding site can be located and the blood vessels in this area can be embolized. The method is to insert a catheter through a femoral artery puncture, selectively place it on the arterial trunk, perform an angiogram and observe the external carotid artery branch. After determining the bleeding vessel branch, inject an embolizer from the catheter to stop bleeding. Arterial embolism can be applied to: difficult to control primary nosebleeds, traumatic nosebleeds, internal carotid artery-cavernous sinus fistula, internal carotid artery rupture, and nasopharyngeal fibrohemangioma bleeding. The method can directly display the bleeding site and cause, and the hemostatic effect is rapid and quick, and the treatment time is shortened. In the critical situation of heavy bleeding, digital silhouette angiography embolization is an effective rescue measure. However, arterial embolization requires certain equipment and conditions for the treatment of epistaxis. The technical requirements are high and the cost of the patient is also large. Allergies, severe atherosclerosis, and liver and kidney dysfunction are contraindicated, so the indications must be strictly controlled.

(8) Vascular ligation: At present, it is rarely used, and it is mostly used for severe nosebleeds, who still cannot stop bleeding through the above-mentioned various treatment methods. Before ligating, you should try to determine the source of the bleeding as accurately as possible before deciding which artery to ligate. Generally, anterior ethmoid artery ligation can be used for bleeding in the upper nasal cavity; patients with hemorrhage in the lower part of the nasal cavity should undergo maxillary or external carotid artery ligation [3].

(9) Nasal Septum Surgery: Nasal septum mucosal scratches are suitable for repeated nosebleeds caused by dilated small blood vessels before and after the nasal septum. Under local anesthesia, the mucosa of the nasal septum is scratched to destroy the expanded small blood vessel network, and the effect of preventing repeated nosebleeds is achieved. Laser, radio frequency and other methods can also be used to destroy the expanded small blood vessel network. Nasal bleeding caused by deviated nasal septum, nasal septum correction is feasible.

(10) Other operations: For nosebleeds caused by tumors in the nasal cavity or sinuses, hemostasis should be stopped first, or the tumor should be removed surgically, or radiotherapy, or ligature of the neck vessels should be used to stop bleeding, depending on the specific conditions and the nature of the tumor.

Nosebleed Systemic Treatment

There are many causes of nosebleeds, and the degree of bleeding varies. The treatment and treatment of nosebleeds cannot be just hemostasis in the nasal cavity. Necessary systemic and special treatments must be taken according to the condition, that is, the primary disease should be actively treated during hemostasis.

(1) Find the cause of bleeding and treat it.

(2) The amount of bleeding should be evaluated for patients with nosebleeds, especially for patients with active bleeding at the time of consultation.

(3) For elderly patients or patients with more bleeding, pay attention to the situation such as hemorrhagic anemia, shock, and heart damage, and deal with it in a timely manner. Patients with a large amount of bleeding should also test their blood type and prepare blood at the same time, according to the amount of blood loss to rehydration, blood transfusion treatment. Those with high blood pressure should be actively treated with antihypertensive therapy, and the blood pressure of elderly patients should not be reduced too quickly to avoid thrombosis.

(4) Nasal packing and posterior nostril packing can cause lower blood oxygen partial pressure and elevated carbon dioxide partial pressure. Therefore, elderly patients should pay attention to cardiopulmonary and cerebral functions, give oxygen inhalation if necessary, pay attention to the nutrition of patients, and give them high-calorie digestibility diet.

(5) Appropriate application of systemic hemostatic drugs, such as thrombin, aminocaproic acid, phenothelamine, etc.

(6) For patients with emotional stress, sedative drugs can be appropriately applied. Psychological treatment can also reduce the patient's nervousness and anxiety and prevent re-bleeding. ^[2-3]

Nose Bleeding Prevention

Usually pay attention to prevent the occurrence of nosebleeds, measures include:

1. Keep the room quiet, clean and at an appropriate temperature. Keep the air fresh in the room. Open the windows appropriately for ventilation. The temperature should be kept at 18 20 . Because the air is too dry, it can induce nasal bleeding, so the air humidity should be 60%.

2. The elderly should move slowly during weekday activities. Don't blow your nose hard.

3. Eat some digestible soft foods in your diet, eat more fruits and vegetables, avoid spicy food to stimulate your diet, and keep your stools open. Laxatives can be given for constipation.

4. Elderly patients with epistaxis are often accompanied by hypertension, coronary heart disease, bronchitis, etc. The primary disease should be regularly prevented and treated accordingly, especially for patients with hypertension, and blood pressure must be controlled to normal or as soon as possible. Close to normal level, observe the change of condition, and go to the hospital in time.

5. For children with nosebleeds, the bad habits such as digging the nose, rubbing the nose, and placing foreign objects with curiosity may be corrected.