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For further information, see CMDT Part 8-13: Epistaxis

Key Features

Essentials of Diagnosis

  • Bleeding from a unilateral anterior nasal cavity most common

  • Most cases can be successfully treated by direct pressure on the bleeding site for 5–15 minutes

  • When this is unsuccessful, topical sympathomimetics or 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

General Considerations

  • Anterior nasal cavity bleeding originates from Kiesselbach plexus, a vascular plexus on the anterior nasal septum

  • Posterior nasal cavity bleeding

    • Originates from the posterior half of the inferior turbinate or the top of the nasal cavity

    • More commonly associated with atherosclerotic disease and hypertension

  • Predisposing factors

    • Nasal trauma (eg, nose picking, forceful nose blowing, foreign body)

    • Nasal mucosa drying from low humidity or supplemental nasal oxygen

    • Allergic or viral rhinitis

    • Deviation of the nasal septum

    • Inhaled corticosteroids

    • Inhaled cocaine use

    • Excessive alcohol intake

    • Anticoagulation or antiplatelet medications (eg, aspirin, clopidogrel)

    • Atherosclerotic disease

    • Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)

  • Poorly controlled hypertension is associated with epistaxis

    • However, confounding factors during bleeding episodes make further predictions about the degree of hypertension and its management impossible

Demographics

  • Only 5% of nasal bleeding originates in the posterior nasal cavity

  • Less than 10% of nasal bleeding is caused by coagulopathy or tumor

Clinical Findings

Symptoms and Signs

  • Bleeding from nostril or nasopharynx

  • Posterior bleeding may present with hemoptysis or hematemesis

Differential Diagnosis

  • Thrombocytopenia

  • Immune thrombocytopenia

  • Thrombotic thrombocytopenic purpura

  • Hemophilia

  • Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)

  • Polycythemia vera

  • Leukemia

  • Granulomatosis with polyangiitis

  • Nasal tumor

Diagnosis

Laboratory Tests

  • Laboratory assessment of bleeding parameters (platelet count, coagulation studies) may be indicated, especially in recurrent cases

Treatment

  • Most cases of anterior epistaxis may be successfully treated by direct pressure on the bleeding site

Medications

  • Short-acting topical nasal decongestants (eg, phenylephrine, 0.125–1% solution, one or two sprays), which act as vasoconstrictors, may help

  • When the bleeding does not readily subside, the nose should be examined to locate the bleeding site: topical 4% cocaine (or a topical decongestant [eg, oxymetazoline] and a topical anesthetic [eg, tetracaine or lidocaine]) applied either as a spray or on a cotton strip serves as an anesthetic and a vasoconstrictor

  • If a posterior pack is required for > 5 days, administer antistaphylococcal antibiotics to limit possibility of toxic shock syndrome

    • Cephalexin, 500 mg orally four times daily

    • Clindamycin, 150 mg orally four times daily

Surgery

  • Ligation of the nasal arterial supply (internal maxillary artery and ethmoid arteries) is indicated when direct pressure and nasal packing fail

  • Endoscopic sphenopalatine artery ...

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