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

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

• 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

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 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 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 ...