ear, nose, and throat disorders
Epistaxis
Evaluation of Epistaxis
History of present illnessshould try to determine which side began bleeding first; although major epistaxis quickly involves both nares, most patients can localize the initial flow to one side, which focuses the physical examination. Also, the duration of bleeding should be established, as well as any triggers (eg, sneezing, nose blowing, picking) and attempts by the patient to stop the bleeding. Melena may occur, and swallowed blood is a gastric irritant, so patients may also report vomiting blood. Important associated symptoms before onset include symptoms of an upper respiratory infection (URI), sensation of nasal obstruction, and nasal or facial pain. The time and number of previous nosebleeds and their resolution should be identified. Review of systemsshould ask about excessive bleeding (particularly related to toothbrushing, phlebotomy, or minor trauma), easy bruising; bloody or tarry stools, hemoptysis, and blood in urine.. Past medical historyshould note presence of known bleeding disorders (including a family history) and conditions associated with defects in platelets or coagulation, particularly cancer, cirrhosis, HIV, and pregnancy. Drug history (prescription, over-the-counter, recreational) should specifically include use of medications that may promote bleeding, such asaspirinand other nonsteroidal anti-inflammatory drugs (NSAIDs), other antiplatelet medications (eg,clopidogrel),heparin, andwarfarin. Vital signs should be reviewed for indications of intravascular volume depletion (tachycardia, hypotension) and marked hypertension. With active bleeding, treatment takes place simultaneously with evaluation. During active bleeding, inspection is difficult, so attempts are first made to stop the bleeding as described below. The nose is then examined using a nasal speculum and a bright head lamp or head mirror, which leaves one hand free to manipulate suction or an instrument. Anterior bleeding sites are usually apparent on direct examination. If no site is apparent and there have been only 1 or 2 minor nosebleeds, further examination is not needed. If bleeding is severe or recurrent and no site is seen, fiberoptic endoscopy may be necessary. The general examination should look for signs of bleeding disorders, including petechiae, purpura, and perioral and oral mucosal telangiectasias as well as any intranasal masses. In patients with epistaxis, the following findings are of particular concern: Signs of hypovolemia or hemorrhagic shock Anticoagulant use Cutaneous signs of a bleeding disorder Bleeding not stopped by direct pressure or vasoconstrictor-soaked pledgets Multiple recurrences of epistasis, particularly with no clear cause Many cases of epistaxis have a clear-cut trigger (particularly nose blowing or picking), as suggested by findings (see table). To diagnose epistaxis, routine laboratory testing is not required. If patients have symptoms or signs of a bleeding disorder and severe or recurrent epistaxis, a complete blood count (CBC), prothrombin time (PT), and partial thromboplastin time (PTT) should be done. CT may be done if a foreign body, a tumor, or sinusitis is suspected. 