ESSENTIALS OF DIAGNOSIS
Bleeding from a unilateral anterior nasal cavity most common.
Most cases may be successfully treated by direct pressure on the bleeding site for 15 minutes. When this is inadequate, topical sympathomimetics and various nasal tamponade methods are usually effective.
Posterior, bilateral, or large-volume epistaxis should be triaged immediately to a specialist in a critical care setting.
Epistaxis is an extremely common problem in the primary care setting. Bleeding is most common in the anterior septum where a confluence of veins creates a superficial venous plexus (Kiesselbach plexus). Predisposing factors include nasal trauma (nose picking, foreign bodies, forceful nose blowing), rhinitis, nasal mucosal drying from low humidity or supplemental nasal oxygen, deviation of the nasal septum, atherosclerotic disease, hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome), inhaled nasal cocaine (or other illicit drug), and alcohol abuse. Poorly controlled hypertension is associated with epistaxis, although confounding factors during bleeding events make further predictions about the degree of hypertension and its management impossible. Anticoagulation or antiplatelet medications may be associated with a higher incidence, more frequent recurrence, and greater difficulty in control of epistaxis, but they do not cause it.
Laboratory assessment of bleeding parameters may be indicated, especially in recurrent epistaxis. Once the acute episode has passed, careful examination of the nose and paranasal sinuses is indicated to rule out neoplasia and hereditary hemorrhagic telangiectasia.
Patients presenting with epistaxis often have higher blood pressures than control patients, but in many cases, blood pressure returns to normal following treatment of acute bleeding. Repeated evaluation for diagnosis and treatment of clinically significant hypertension should be performed following control of epistaxis and removal of any packing.
Most cases of anterior epistaxis may be successfully treated by direct pressure on the site by compression of the nares continuously for 15 minutes (eFigure 8–4). Venous pressure is reduced in the sitting position, and slight leaning forward lessens the swallowing of blood. Short-acting topical nasal decongestants (eg, phenylephrine, 0.125–1% solution, one or two sprays), which act as vasoconstrictors, may also help. When the bleeding does not readily subside, the nose should be examined, using good illumination and suction, in an attempt to locate the bleeding site. Topical 4% cocaine applied either as a spray or on a cotton strip serves both as an anesthetic and a vasoconstrictor. If cocaine is unavailable, a topical decongestant (eg, oxymetazoline) and a topical anesthetic (eg, tetracaine or lidocaine) provide similar results. When visible, the bleeding site may be cauterized with silver nitrate, diathermy, or electrocautery. A supplemental patch of Surgicel or Gelfoam may be helpful with a moisture barrier, such as petroleum-based ointment, to prevent drying and crusting. Warfarin may be continued in the setting of controlled epistaxis, although resorbable packing may be preferable in these patients.