Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 8-13: Epistaxis + Key Features Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ Laboratory Tests ++ Laboratory assessment of bleeding parameters (platelet count, coagulation studies) may be indicated, especially in recurrent cases + Treatment Download Section PDF Listen +++ ++ 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 + Outcome Download Section PDF Listen +++ +++ 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 + References Download Section PDF Listen +++ + +Khan M et al. Initial assessment in the management of adult epistaxis: systematic review. J Laryngol Otol. 2017 Dec;131(12):1035–55. [PubMed: 29280694] + +Krulewitz NA et al. Epistaxis. Emerg Med Clin North Am. 2019 Feb;37(1):29–39. [PubMed: 30454778] + +Min HJ et al. Association between hypertension and epistaxis: systematic review and meta-analysis. Otolaryngol Head Neck Surg. 2017 Dec;157(6):921–7. [PubMed: 28742425] + +Swords C et al. Surgical and interventional radiological management of adult epistaxis: systematic review. J Laryngol Otol. 2017 Dec;131(12):1108–30. [PubMed: 29280696] + +Williams A et al. Haematological factors in the management of adult epistaxis: systematic review. J Laryngol Otol. 2017 Dec;131(12):1093–107. [PubMed: 29280698]