Definition

Epistaxis (nosebleed) is a common ear, throat and nose medical emergency. It occurs due to a rupture in a nasal blood vessel or a group of vessels. It can be classified as anterior or posterior nosebleed. Anterior nosebleed is more common but less significant, however posterior nosebleed is less common but more significant. Majority of anterior nosebleeds are identified within Kiesselbach's plexus (Little’s area) located on the anterior nasal septum.[1]

(Ayesha Tabassom & Julia J. Cho. StatPearls Publishing.2021)

Introduction to Epistaxis

The arterial vasculature of the nasal cavity arises from the terminal branches of five arteries [1].

The watershed of the five main arteries is located at the anterior nasal septum, including Kiesselbach's plexus (Figure 1.0). The Anterior nasal septum is located at the entrance of the nasal cavity, therefore is subject to environmental triggers such as heat, cold and moisture. This makes it more susceptible to trauma. In addition, the majority of nosebleed takes place at this site, due to the very thin mucosa that lines the septum. Anterior Epistaxis is more commonly reported compared to posterior epistaxis. In addition, anterior nosebleeds are usually caused by local trauma such as rupturing the nasal septum blood vessels by finger scratching or inserting a foreign object in the nostrils. However, if vessels in the posterior or superior nasal cavity bled, posterior epistaxis then occurs. Posterior epistaxis is usually due to systemic causes, such as hypertension or coagulopathies and is more reported by adults.[1][2][3]

(Ayesha Tabassom & Julia J. Cho. StatPearls Publishing.2021)

 

Pathophysiology

Epistaxis results from a rupture in a blood vessel in the nasal mucosa. This usually happens due to trauma. Since thin mucosa lines up the Anterior nasal septum, the blood vessel becomes highly susceptible to injury. The bleeding can be spontaneous, medication induced or secondary to a comorbidity such as hypertension or melanoma. Bleeding due to trauma is usually acute and resolves on its own. However, when a comorbidity is involved, the bleeding can be more serious. Specific medications can increase the chance of nosebleed. It is usually assumed that posterior nosebleeds take place at terminal branches of the sphenopalatine and posterior ethmoidal arteries named Woodruff's plexus. Blood can enter the nasopharynx, which is then swallowed and can be coughed. Posterior epistaxis is usually harder to control due to the high blood flow compared to anterior epistaxis. [1]

(Cho and Tabassom. StatPearls Publishing.2021)

 

Etiology

There are a plethora of causes to nosebleed. The causes include, but are not limited to systemic, local, medication-induced and environmental [1]. While the ones mentioned below are the most common causes of epistaxis, rarer etiologies such as neoplasms and malformations should be considered in the diagnosis. [4][5][6]

Local Causes

Inflammation

Systemic Causes

Environmental Factors

Medication Induced

Tumors and Aneurysms

 Juvenile angiofibromas

(Cho and Tabassom. StatPearls Publishing.2021)

 Visual Representations

EPISTAXIS - Figure 1.0

Figure 1.0: The five arteries that supply the anterior nasal septum. Kiesselbach plexus is a common site of anterior epistaxis. (S Bhimji MD, StatPearls Publishing LLC.) [1]

(Ayesha Tabassom & Julia J. Cho. StatPearls Publishing.2021)

EPISTAXIS - Figure 2.0

Figure 2.0: The main symptom of epistaxis is bleeding from the nostrils. The blood flow can range from drops to a stream of blood based on the severity and the location of the ruptured blood vessel. 90% of anterior epistaxis is due to trauma within Kiesselbach's plexus [1]. ( https://www.pexels.com/photo/2-men-boxing-on-ring-70567/ ) (License:https://www.pexels.com/creative-commons-images/ )

Differential Diagnosis

In the presence of nosebleed, it is necessary to perform a differential diagnosis by an accurate history, physical examination and diagnostic tests. If the bleeding is very significant, it is necessary to first stop the bleeding and stabilize the patient.

Key Differences between Anterior and Posterior Nosebleed

Anterior Epistaxis

Posterior Epistaxis

(Cho and Tabassom. StatPearls Publishing.2021)

Diagnosis

(Ayesha Tabassom & Julia J. Cho. StatPearls Publishing.2021)

Physical Examination

(Cho and Tabassom. StatPearls Publishing.2021)

Management and Treatment

Anterior Epistaxis

Posterior Epistaxis

(Cho and Tabassom. StatPearls Publishing.2021)

 

References:

1)Tabassom A, Cho JJ. Epistaxis. [Updated 2020 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK435997/-

The article is mainly adapted from the source above - by : Ayesha Tabassom; Julia J. Cho.

Including figure 1.

License: https://creativecommons.org/licenses/by/4.0/

 

Additional Resources and Clinical Studies

Introduction

The COVID-19 Pandemic has not only wrecked havoc upon the healthcare sector and has endangered the lives of millions, but has also almost equally affected businesses and economies. It has also affected each individual person differently. Everyone seems to be affected and stuck under the additional burdens and loads posed by the COVID-19 crisis, and it is almost evident that coming out of this crisis and burden would no doubt be a hard and time-consuming task. 

 

If we talk in particular about the people who are directly affected by it - that is, the healthcare personnel and the junior doctors and students, then they have undoubtedly had their fair share of loss and have faced a lot of troubles with regards to their studies and practice and clinical rotations. 

How Has COVID-19 Affected Medical Students and Junior Doctors?

As this is a well-established fact that a doctor is useless without any practical implementation of his skills, then this very fact could prove to be very disappointing and discouraging for all the aspiring medical students and junior doctors because they can no longer be exposed like before to the patients and try out their skills. 

With the advent of COVID-19, the entire educational sector was forced to move to virtual platforms. This seemed favorable at that time as keeping the health of both the tutor/facilitator and the student was the main priority.
For medical students, this was not that favorable. More than half of their studies is based on real-life patients and real-time clinical scenarios.
This sudden shift from live, hospital exposure to a screen-bound platform was not only limiting, but also caused an immediate rift to be created in their studies and clinical exposure.

When a group of Final Year Medical students from the UK was asked to give their opinions on how COVID-19 affected their studies and most importantly their clinical observerships, the majority of the students expressed their disappointment and reacted that they were reluctant to continue the upcoming academic year as they had to safeguard both - their lives as well as their future careers at a time as crucial as this.

The Bottom Line:

Medical students and junior doctors who are yet to start their training years feel confused about their next step - there has been a definite and visible education gap which has done no good but only created problems for everyone out there. There still exists an uncertainty about how long this pandemic will last and for how long it will continue to keep us restricted within our homes.
But one thing is evident - the students of today and the doctors of tomorrow would be more well-versed than us on how to deal with large-scale problems and disease outbreaks like the one that they are experiencing at a time like this. 

 

References

  1. Hilburg R, Patel N, Ambruso S, Biewald MA, Farouk SS. Medical Education During the Coronavirus Disease-2019 Pandemic: Learning From a Distance [published online ahead of print, 2020 Jun 23]. Adv Chronic Kidney Dis. 2020;doi:10.1053/j.ackd.2020.05.017
  2. Choi, B., Jegatheeswaran, L., Minocha, A. et al. The impact of the COVID-19 pandemic on final year medical students in the United Kingdom: a national survey. BMC Med Educ 20, 206 (2020). https://doi.org/10.1186/s12909-020-02117-1
  3. Yasmeen M. Byrnes, Alyssa M. Civantos, Beatrice C. Go, Tara L. McWilliams & Karthik Rajasekaran (2020) Effect of the COVID-19 pandemic on medical student career perceptions: a national survey study, Medical Education Online, 25:1, DOI: 10.1080/10872981.2020.1798088