Epistaxis

What is an anterior nosebleed?
Most nosebleeds or epistaxes begin in the lower part of the septum, the semi-rigid wall that separates the two nostrils of the nose. The septum contains blood vessels that can be broken by a blow to the nose or the edge of a sharp fingernail. Nosebleed coming from the front of the nose or anterior nosebleeds often begin with a flow of blood out one nostril when the patient is sitting or standing.

Anterior nosebleeds are common in dry climates or during the winter months when dry, heated indoor air dehydrates the nasal membranes. Dryness may result in crusting, cracking, and bleeding. This can be prevented by placing a light coating of petroleum jelly or an antibiotic ointment on the end of a fingertip and then rub it inside the nose, especially on the middle portion of the nose (the septum).

How do I stop an anterior nosebleed?

• Stay calm, or help a young child stay calm. A person who is agitated may bleed more profusely than someone who’s been reassured and supported.
• Keep head higher than the level of the heart. Sit up.
• Lean slightly forward so the blood won’t drain in the back of the throat.
• Using the thumb and index finger, pinch all the soft parts of the nose or place a cotton ball soaked with Afrin, Neo-Synephrine, or Dura-Vent spray into the nostril and apply pressure. The area where pressure should be applied is located between the end of the nose and the hard, bony ridge that forms the bridge of the nose. Do not pack the inside of the nose with gauze or cotton.
• Apply ice—crushed in a plastic bag or washcloth—to nose and cheeks.
• Hold the position for five minutes. If it’s still bleeding, hold it again for an additional 10 minutes.

What is a posterior nosebleed?
More rarely, a nosebleed can begin high and deep within the nose and flow down the back of the mouth and throat even if the patient is sitting or standing.

Obviously, when lying down, even anterior (front of nasal cavity) nosebleeds may seem to flow toward the back of the throat especially if coughing or blowing the nose. It is important to try to make the distinction between the anterior and posterior nosebleed, since posterior nosebleeds are often more severe and almost always require a physician’s care. Posterior nosebleeds are more likely to occur in older people, persons with high blood pressure, and in cases of injury to the nose or face.

What are the causes of recurring nosebleeds?

• Allergies, infections, or dryness that cause itching and lead to picking of the nose.
• Vigorous nose blowing that ruptures superficial blood vessels.
• Clotting disorders that run in families or are due to medications.
• Drugs (such as anticoagulants or anti-inflammatories).
• Fractures of the nose or the base of the skull. Head injuries that cause nosebleeds should be regarded seriously.
• Hereditary hemorrhagic telangiectasia, a disorder involving a blood vessel growth similar to a birthmark in the back of the nose.
• Tumors, both malignant and nonmalignant, have to be considered, particularly in the older patient or in smokers.

When should an otolaryngologist be consulted?
If frequent nosebleeds are a problem, it is important to consult an otolaryngologist. An ear, nose, and throat specialist will carefully examine the nose using an endoscope, a tube with a light for seeing inside the nose, prior to making a treatment recommendation. Two of the most common treatments are cautery and packing the nose. Cautery is a technique in which the blood vessel is burned with an electric current, silver nitrate, or a laser. Sometimes, a doctor may just pack the nose with a special gauze or an inflatable latex balloon to put pressure on the blood vessel.

Tips to prevent a nosebleed

• Keep the lining of the nose moist by gently applying a light coating of petroleum jelly or an antibiotic ointment with a cotton swab three times daily, including at bedtime. Commonly used products include Bacitracin, A and D Ointment, Eucerin, Polysporin, and Vaseline.
• Keep children’s fingernails short to discourage nose picking.
• Counteract the effects of dry air by using a humidifier.
• Use a saline nasal spray to moisten dry nasal membranes.
• Quit smoking. Smoking dries out the nose and irritates it.

Tips to prevent rebleeding after initial bleeding has stopped

• Do not pick or blow nose.
• Do not strain or bend down to lift anything heavy.
• Keep head higher than the heart.

If rebleeding occurs:

• Attempt to clear nose of all blood clots.
• Spray nose four times in the bleeding nostril(s) with a decongestant spray such as Afrin or Neo-Synephrine.
• Repeat the steps to stop an anterior nosebleed.
• Call a doctor if bleeding persists after 30 minutes or if nosebleed occurs after an injury to the head.

By Texas Sinus Institute

DIZZINESS, VERTIGO & EAR BALANCE

Recently, during a small get together, a seventy year old relative of mine was sitting opposite me. She felt dizzy and suddenly her head fell back on to the chair. She was cut off for a few seconds. She also had repeated movements of her right forearm for a minute or so. Post recovery she had a couple of bouts of nausea and vomiting. Thereafter she went off to sleep and by morning far better.

I was witness to the entire episode as I was seated right opposite to her. She believed that she was fully conscious and never was cut off from the surrounding. Returning home the following day she visited a physician who labeled it as a possible case of labyrinthine vertigo and prescribed Tab Beta- histine.

This contradicted with my learning. What my teachers drilled into me was quite different. In my opinion this is a case of fits ?Jacksonian seizure, which needs to be investigated accordingly. Why was Beta-histine – a drug primarily meant for Meniere’s disease, prescribed?

To be sure I perused the various articles and definitions available and felt that Dizziness, Vertigo, Giddiness, Ear imbalance, Fits and Blackout are terms described differently in different areas of literatures and hence probably the confusion / misunderstanding by the public on this topic.

In the case of Dizziness, Cambridge dictionary [Noun] defines dizziness as a temporary feeling that your sense of balance is not good and that you may fall.

In Wikipedia dizziness is impairment in spatial perception and stability. Because the term dizziness is imprecise, it can refer to vertigo, presyncope, disequilibrium etc.

The oxford dictionary too gives a somewhat similar view.

When you read the above, you are given to understand that dizziness and vertigo is one and the same. Which is not what I believe?

My teachers three decades back, taught me something different. I find it to hold true even today. We were made to understand the differentiation in a simple and practical way. Once we understood the basic difference, management of a case of giddiness or dizziness becomes very simple. My patients have done well too. Through this blog I would like to share my experience in the process of diagnosing of a case giddiness.

 Dizziness, Vertigo, Giddiness are terms commonly used by people. In my clinical practice of over 40 years, I have found these terms are used loosely by friends and patients to describe something related to the head. A good reliable history of the episode is the most important guide to the doctor in diagnosis and management of these patients. It is hence of paramount importance that the patient and their well wishers understands this and in turn explains the event clearly to the doctor.

We were told to classify all these case under one of these four terms. The terms are: –

1. Dizziness,
2. Vertigo
3. Fits and
4. Black out.

 DIZZINESS:

1. Dizziness includes any feeling “When there are No movements”. It is all only feelings.
2. It include feelings like light headedness, faintness, Unsteadiness, Acrophobia [Fear of heights] etc. The point to be kept in mind is there is no movement of any sort.
3. Patient is fully conscious and never cuff of from the surroundings even for a split second.
4.  Most of these are non pathological. They do well with self-assurances.
5. Look at this picture carefully. This gives you a feeling of dizziness

VERTIGO OR GIDDINESS:

Vertigo and Giddiness is the same. Giddiness is layman term and Vertigo is technical term.

1. Vertigo is defined as the sensation of spinning or swaying while the body is stationary with respect to the earth.
2. In vertigo there are movements but these movements are virtual, not actual. I call it hallucination of movements.  In dizziness there are no movements only feeling and hence differentiation is easy.
3. The patient is fully conscious and in control. There is no dissociation from the surrounding even for a split second. That is because giddiness is due to input deficiency and the cerebrum [Brain proper] is not affected.
4. The commonest cause of vertigo is due to ear imbalance [Labyrinthine]. You can have central giddiness too which is seen in Cerebellar etiology.

 FITS OF SEIZURE:

Fits or seizures are the same. Usually occurs due to electric discharges in the cerebrum [Brain Proper].

1. In fits there are actual movements not just hallucination.  The movements may be localized like in Jacksonian or generalized like in Grandmal seizures.
2. Since there is cerebral involvement the patient tends to lose control. Usually there is at least a momentary cut off [dissociation] from the surrounding. If it is forthwith then it is an excellent indicator of brains involvement.

BLACK OUT:

Black out occurs due to momentary hypoxia [Lack of adequate oxygen] in the cerebrum [Brain proper].

1. Like in fits the movements are actual. Patient usually falls to the ground.
2. Since the brain is involved there is momentary  dissociation from the surrounding and loss of control.
3. The etiology is vascular.

Giddiness or Vertigo should be ideally investigated and manage by an ENT surgeon. But fit and black out needs to be managed by a neuro physician / vascular physician. A meticulous description of the episode goes a long way in the diagnosis and correct management of a case of dizziness, vertigo or ear imbalance

By  Shravan ENT