Epistaxis 2

Take a history from this 15 year old boy’s father about his recurrent epistaxis. He tends to bleed heavily and has needed hospitalisation on two occasions during which he required blood transfusions.

History

  • Onset

  • Duration

  • Timing – episodic or constant

  • Severity – quantify blood loss

  • Unilateral or bilateral

  • Exacerbating and relieving factors 

  • Previous treatments e.g.  first aid measures, cautery or hospital admissions

  • Associated symptoms – crusting, nasal obstruction, rhinorrhoea, post-nasal drip, headaches, visual disturbance

  • Predisposing events – nasal trauma, digital trauma

  • Constitutional symptoms – weight loss, malaise, anorexia, night sweats

  • Past Medical History – recent sinonasal surgery

  • Drug History – anticoagulants, antiplatelets, direct oral anticoagulants (DOACs), steroid nasal sprays, St John’s Wort, antibiotics

  • Social History – smoking, alcohol, occupation (wood work, nickel, chromium, leather, formaldehyde, cloth fibres), Southeast Asian ethnic origin, cocaine use

  • Family History – Family history of cancer, bleeding disorders

  • Systems review

  • Elicit the patient’s ideas, concerns and expectations 


Conclusion

  • Summarise consultation

  • Thank patient

  • Offer appropriate differential diagnosis

Differential diagnoses to consider*

Trauma

  • Nasal trauma

  • Nose picking

Vascular abnormalities

  • Hereditary haemorrhagic telangiectasia

Infective

  • URTI

  • Rhinitis

Malignancy

  • Primary nasal tumour

  • Juvenile nasoangiofibroma

Other

  • Dry weather

  • Idiopathic

  • Chemical irritants

  • Cocaine abuse

  • Foreign body

  • Septal deformity 

Medication induced

  • Warfarin

  • DOACs

  • Antiplatelets

  • Steroid nasal sprays

*Table not exhaustive


Management


You will be asked to suggest an appropriate management plan based on your presumed diagnosis. Ensure that you offer a complete ENT examination, including nasendoscopy using a three-pass technique, prior to further investigations. 


Bloods should be ordered for full blood count at the minimum, along with a clotting screen especially if the patient is on warfarin. Further investigations will depend on the history and your examination findings. Some examples are below:-

Suspected diagnosis

The following investigations/management strategies may be indicated however you must offer based on the clinical scenario you are given

Sinonasal tumour

CT + MRI (depending on local guidance)

Juvenile Nasoangiofibroma

CT + MRI + angiography

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