Epistaxis

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

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

Laboratory Tests

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

• 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 ligation

  • Most common approach

  • Has reported efficacy of 73–100%

  • However, bleeds caused by ethmoid arterial supply may be missed

• Endovascular epistaxis control

  • Highly effective (75–92%)

  • Can address all potential sources of bleeding

  • However, risk of stroke is 1.1–1.5%

  • Therefore, may be reserved for cases in which surgery failed

Therapeutic Procedures

Anterior nasal bleeding

• Compress the nasal alae firmly for 5–15 min

• Venous pressure is reduced in the sitting position, and leaning forward lessens the swallowing of blood

• Cauterize the bleeding site with silver nitrate, diathermy, or electrocautery

• If the bleeding has not stopped, anterior nasal packing will usually suffice

  • Use several feet of lubricated iodoform packing systematically placed in the floor of the nose and then the vault of the nose

  • Alternatively, there are various manufactured products designed for nasal tamponade

Posterior nasal bleeding

• Placement of a pack to occlude the choana before placement of a pack anteriorly

• Opioid analgesics reduce the discomfort and elevated blood pressure caused by a posterior pack

• Apply nasal saline to keep packing moist

Follow-Up

• After control of the epistaxis, avoid vigorous exercise for several days

• Avoid hot or spicy foods and tobacco because they may cause vasodilation

• Once the acute episode has passed, carefully examine the nose and paranasal sinuses to rule out neoplasia

• Follow-up investigation of possible hypertension

Complications

• Sinusitis

• Aspiration or asphyxiation by blood

Prognosis

• Generally self-limited with a good prognosis

Prevention

• Avoid nasal trauma, eg, nose picking

• Lubrication with petroleum jelly or bacitracin ointment

• Increase home humidification

When to Refer

• Patients with recurrent epistaxis, large volume epistaxis, and episodic epistaxis with associated nasal obstruction should be referred to an otolaryngologist for endoscopic evaluation and possible imaging

• Patients with ongoing bleeding beyond 15 minutes should be taken to a local emergency department if the clinician is not prepared to manage acute epistaxis

When to Admit

• Hospitalization for several days is indicated when placing a nasal pack for posterior nasal bleeding because it is uncomfortable and may require opioid analgesics and generally requires oxygen supplementation to prevent hypoxia