Epistaxis

Essentials of Diagnosis

Bleeding from the unilateral anterior nasal cavity most commonly.

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.
General Considerations

Epistaxis is an extremely common problem in the primary care setting.

Predisposing factors include nasal trauma (nose picking, foreign bodies, forceful
nose blowing), rhinitis, drying of the nasal mucosa from low humidity or
supplemental nasal oxygen, deviation of the nasal septum, hypertension,
atherosclerotic disease, hereditary hemorrhagic telangiectasia (Osler-WeberRendu syndrome), inhaled nasal cocaine or other drug use, and alcohol use.
Anticoagulation or antiplatelet medications may be associated with a higher
incidence of epistaxis, more frequent recurrence of epistaxis, and greater
difficulty controlling bleeding, but they do not cause epistaxis. Bleeding is most
common in the anterior septum where a confluence of veins creates a superficial
venous plexus (Kisselbach plexus).

Clinical Findings

It is important in all patients with epistaxis to consider underlying causes of the

bleeding. Laboratory assessment of bleeding parameters may be indicated,
especially in recurrent cases. Once the acute episode has passed, careful
examination of the nose and paranasal sinuses to rule out neoplasia and
hereditary hemorrhagic telangiectasia is wise.

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. Repeat evaluation for clinically significant
hypertension and treatment should be performed following control of epistaxis
and removal of any packing.

Treatment

Most cases of anterior epistaxis may be successfully treated by direct pressure

on the site by compression of the nares continuously for 15 min (see illustration).
Venous pressure is reduced in the sitting position, and slight leaning forward
lessens the swallowing of blood. Short-acting topical nasal decongestants (eg,
phenylephrine, 0.1251% solution, one or two sprays), which act as
vasoconstrictors, may also be helpful. 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 as a vasoconstricting agent.
If cocaine is unavailable, a topical decongestant (eg, oxymetazoline) and a
topical anesthetic (eg, tetracaine or lidocaine) provide equivalent 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.
Occasionally, a site of bleeding may be inaccessible to direct control, or attempts
at direct control may be unsuccessful. In such cases there are a number of
alternatives. When the site of bleeding is anterior, a hemostatic sealant,
pneumatic nasal tamponade, or anterior packing may suffice. There are a
number of ways to do this, such as with several feet of lubricated iodoform
packing systematically placed in the floor of the nose and then the vault of the
nose, or with various manufactured products designed for nasal tamponade.

About 5% of nasal bleeding originates in the posterior nasal cavity. Such bleeds
are more commonly associated with atherosclerotic disease and hypertension. If
an anteriorly placed pneumatic nasal tamponade is unsuccessful, it may be
necessary to consult an otolaryngologist for a pack to occlude the choana before
placing a pack anteriorly (see illustration). In emergency settings, new double
balloon packs (Epistat) may facilitate rapid control of bleeding with little or no
mucosal trauma. Because such packing is uncomfortable, bleeding may persist,
and vasovagal syncope is quite possible, hospitalization for monitoring and
stabilization is indicated. Opioid analgesics are needed to reduce the
considerable discomfort and elevated blood pressure caused by a posterior pack.
Surgical management of epistaxis, through ligation of the nasal arterial supply
(internal maxillary artery and ethmoid arteries) is an alternative to posterior
nasal packing. Endovascular embolization of the internal maxillary artery or
facial artery is also quite effective and can allow very specific control of
hemorrhage. Such alternatives are necessary when packing fails to control life-

threatening hemorrhage. On very rare occasions, ligation of the external carotid

artery may be necessary.

After control of epistaxis, the patient is advised to avoid straining and vigorous
exercise for several days. Nasal saline should be applied to the packing
frequently to keep the packing moist. Avoidance of hot or spicy foods and
tobacco is also advisable, since these may cause nasal vasodilation. Avoiding
nasal trauma, including nose picking, is an obvious necessity. Lubrication with
petroleum jelly or bacitracin ointment and increased home humidity may also be
useful ancillary measures. Finally, antistaphylococcal antibiotics are indicated to
reduce the risk of toxic shock syndrome developing while the packing remains in
place (at least 5 days).

When to Refer

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