Bleeding nasal polyposis

Why can bleeding occur?

1. Trauma or inflammation
   • Nose picking, vigorous blowing, infection, allergic inflammation, dry air, or prior nasal surgery can make adjacent mucosa bleed.
   • Intranasal steroid sprays may cause minor bleeding when directed at the nasal septum rather than outward toward the ear.
2. A lesion mistaken for an ordinary polyp
   • Antrochoanal polyp: benign, usually unilateral, arising from the maxillary sinus.
   • Inverted papilloma: benign but locally aggressive tumour, often unilateral; needs excision and histology because of recurrence and association with malignancy.
   • Sinonasal malignancy: less common, but must be excluded in a unilateral, friable, bleeding mass.
3. Other causes of nosebleeds
   • Anticoagulants or antiplatelet drugs, platelet/coagulation disorders, liver disease, vascular lesions, foreign body, cocaine or other nasal irritants. Nasal polyps and neoplasms are both included in the differential diagnosis of epistaxis. Rosen's Emergency Medicine, Box 58.6.

Red flags for urgent ENT evaluation

• Unilateral polyp, blockage, or bloody discharge
• Recurrent or unexplained nosebleeds
• A visible red, irregular, ulcerated, or easily bleeding nasal mass
• Facial pain, numbness of cheek/upper teeth, swelling, or persistent foul smell
• Double vision, eye swelling, reduced vision, severe headache, or neurologic symptoms
• Neck lump, weight loss, or persistent symptoms despite treatment

Assessment

• History of laterality, duration, bleeding severity, obstruction, smell loss, facial/eye symptoms, medicines, and occupational exposure such as wood dust
• Nasal examination and nasal endoscopy
• CT scan of nose and paranasal sinuses if a unilateral mass or surgery is considered
• Biopsy or surgical histopathology if a suspicious mass is present. Do not repeatedly manipulate or try to remove a bleeding lesion yourself.

What to do during active bleeding

1. Sit upright and lean forward.
2. Pinch the soft part of both nostrils continuously for 15-20 minutes.
3. Spit out blood rather than swallowing it.
4. Avoid blowing, picking, heavy lifting, and hot drinks for 24 hours once controlled.
5. Seek emergency care if bleeding is heavy, you feel faint or short of breath, blood keeps flowing into the throat, or it does not stop after 20 minutes of firm pressure.