Pathophysiology

Bleeding typically occurs when the mucosa

is eroded and vessels become exposed and
subsequently break.
More than 90% of bleeds occur anteriorly
and arise from Littles area, where the
Kiesselbach plexus forms on the septum.[7,
8]
The Kiesselbach plexus is where vessels
from both the ICA (anterior and posterior
ethmoid arteries) and the ECA
(sphenopalatine and branches of the
internal maxillary arteries) converge. These
capillary or venous bleeds provide a
constant ooze, rather than the profuse
pumping of blood observed from an arterial
origin. Anterior bleeding may also originate
anterior to the inferior turbinate.
Posterior bleeds arise further back in the
nasal cavity, are usually more profuse, and
are often of arterial origin (eg, from
branches of the sphenopalatine artery in the
posterior nasal cavity or nasopharynx). A
posterior source presents a greater risk of
airway compromise, aspiration of blood, and
greater difficulty controlling bleeding.

Differential Diagnoses

Allergic Rhinitis

Barotrauma

Cocaine Toxicity

Coumarin Plant Poisoning

Disseminated Intravascular
Coagulation in Emergency Medicine

Emergent Treatment of
Endometriosis

Nasal Foreign Bodies

Nonsteroidal Anti-inflammatory
Agent Toxicity

Pediatric Osler-Weber-Rendu
Syndrome

Rodenticide Toxicity

Salicylate Toxicity

Sinusitis Imaging

Type A Hemophilia

Type B Hemophilia

von Willebrand Disease

Warfarin and Superwarfarin Toxicity

Diagnostic Considerations
Recurrent epistaxis in children could be
caused by a foreign body, especially if the
nosebleeds are accompanied by symptoms
of unilateral nasal congestion and purulent
rhinorrhea. Delayed epistaxis in a trauma
patient may signal the presence of a
traumatic aneurysm.
Other conditions to be considered include
the following:

Chemical irritants
Hepatic failure
Leukemia
Thrombocytopenia
Heparin toxicity
Ticlopidine toxicity
Dipyridamole toxicity
Trauma
Tumor

Physical Examination
Before evaluating a patient with epistaxis,
have sufficient illumination, adequate
suction, all the necessary topical
medications, and cauterization and packing
materials ready. Remove all packings, even
though bleeding may not be active. The
importance of obtaining adequate
anesthesia and vasoconstriction if time
permits cannot be overemphasized. A
comfortable patient tends to be more
cooperative, allowing for better examination
and more effective treatment.
Perform a thorough and methodical
examination of the nasal cavity. Blowing the

nose decreases the effects of local

fibrinolysis and removes clots, permitting a
better examination. Application of a
vasoconstrictor (eg, 0.05% oxymetazoline)
before the examination may reduce
hemorrhage and help to pinpoint the precise
bleeding site. A topical anesthetic (eg, 4%
aqueous lidocaine) reduces pain associated
with the examination and nasal packing.
Clots are then suctioned out to permit a
thorough examination.

endoscope is preferred because of its

superior optics and its ability to allow
endoscopic suction and cauterization.
Examine the skin for evidence of bruises or
petechiae that may indicate an underlying
hematologic abnormality.
Assess vital signs. Although high blood
pressure rarely, if ever, causes epistaxis on
its own, it may impede clotting. Check blood
pressure, and complete a workup if high
blood pressure is present. Persistent
tachycardia must be recognized as an early
indicator of significant blood loss requiring
intravenous (IV) fluid replacement and,
potentially, transfusion.

Gently insert a nasal speculum (see the

image below) and spread the naris
vertically. Begin the examination with
inspection, looking specifically for any
obvious bleeding site on the septum that
may be amenable to direct pressure or
cautery. This permits visualization of most
anterior bleeding sources. Anterior bleeds
from the nasal septum are most common
type, and the site can frequently be
identified if bleeding is active.

Complications
Complications of epistaxis may include the
following:

Sinusitis
Septal hematoma/perforation
External nasal deformity
Mucosal pressure necrosis
Vasovagal episode
Balloon migration
Aspiration

Terapi
Approach Considerations
When medical attention is needed for
epistaxis, it is usually because of the
problem is either recurrent or severe.
Treatment depends on the clinical picture,
the experience of the treating physician, and
the availability of ancillary services.

Nasal speculum.

If an anterior source cannot be visualized, if

the hemorrhage is from both nares, or if
constant dripping of blood is seen in the
posterior pharynx, the bleeding may be from
a posterior site. After placement of an
anterior pack, and, if bleeding is noted in the
pharynx with the anterior pack in place,
strongly consider a posterior bleed.

In most patients with epistaxis, the bleeding

responds to cauterization, nasal packing, or
both. For those who have recurrent or
severe bleeding for which medical therapy
has failed, various surgical options are
available. After surgery or embolization,
patients should be closely observed for any
complications or signs of rebleeding.

Massive epistaxis may be confused with

hemoptysis or hematemesis. Blood dripping
from the posterior nasopharynx confirms a
nasal source. Approximately 90% of
nosebleeds can be visualized in the anterior
portion of the nasal cavity.
Fiberoptic endoscopy may be performed
with a flexible or (preferably) rigid
endoscope to inspect the entire nasal cavity,
including the nasopharynx. The rigid

Medical approaches to the treatment of

epistaxis may include the following:

Adequate pain control in patients

with nasal packing, especially in those
with posterior packing (However, the need
of adequate pain control has to be

balanced with the concern over

hypoventilation in the patient with
posterior pack.)
Oral and topical antibiotics to
prevent rhinosinusitis and possibly toxic
shock syndrome
Avoidance of aspirin and other
nonsteroidal anti-inflammatory drugs
(NSAIDs)
Medications to control underlying
medical problems (eg, hypertension,
vitamin K deficiency) in consultation with
other specialists

Manual Hemostasis
Initial treatment begins with direct pressure.
The nostrils are squeezed together for 5-30
minutes straight, without frequent peeking to
see if the bleeding is controlled. Usually, 510 minutes is sufficient.
Patients should keep their heads elevated
but not hyperextended because
hyperextension may cause bleeding into the
pharynx and possible aspiration. This
maneuver works more than 90% of the time.
If direct pressure is not sufficient, gauze
moistened with epinephrine at a ratio of
1:10,000 or phenylephrine (NeoSynephrine) may be placed in the affected
nostril to help vasoconstrict and achieve
hemostasis.

Humidification and
Moisturization
If bleeding is caused by excessive dryness
in the home (eg, from radiator heating),
patients may benefit from humidifying the air
with a cool mist vaporizer in the bedroom or,
as a simpler alternative, placing a metal
basin of water on top of a radiator to
humidify the ambient air.
Nasal saline sprays are useful.
Oxymetazoline may also be used, with
fewer cardiac adverse effects. To minimize
the risk of rhinitis medicamentosa and
tachyphylaxis, these agents should be used
for no more than 3-5 days at a time.
The physician may consider local
application of bacitracin or petrolatum

ointment directly to the Kiesselbach area

with a cotton applicator to prevent further
drying (studies recommend 2 wk).

Cauterization
Bleeding from the Kiesselbach plexus
(Littles area) is frequently treated with silver
nitrate cauterization.[13] Manage the vessels
leading to the site before managing the
actual bleeding site. Avoid random and
aggressive cauterization and cautery on
opposing surfaces of the septum.
Electrocauterization with an insulated
suction cautery unit can also be used. This
method is usually reserved for more severe
bleeding and for bleeding in more
posteriorly located sites, and it often
requires local anesthesia. The effectiveness
of both cauterization methods can be
enhanced by using rigid endoscopy,
especially in the case of more posteriorly
located bleeding sites (see the image below
After the bleeding has been controlled,
instruct the patient to use nasal saline spray
and antibiotic ointment and to avoid
strenuous activities for 7-10 days. NSAIDs
are to be avoided if at all possible. Digital
manipulation of the nose is to be avoided. A
topical vasoconstrictor may be used if minor
bleeding recurs with the dislodging of the
eschar.

Nasal Packing
Nasal packing can be used to treat epistaxis
that is not responsive to cauterization. Two
types of packing, anterior and posterior, can
be placed. In both cases, adequate
anesthesia and vasoconstriction are
necessary.
A study by Kundi and Raza suggested that
in patients with epistaxis, removal of nasal
packs after 12 hours leads to a lower
incidence of headache and excessive
lacrimation than does removal of packs after
24 hours, with no significant difference in
bleeding recurrence. The study involved 60
patients with epistaxis, evenly divided
between the 12-hour and 24-hour groups.[17]

Anterior
For anterior packing, various packing
materials are available. Petroleum jelly
gauze (0.5 in 72 in) filled with an antibiotic
ointment is traditionally used (see the image
below). Layer it tightly and far enough
posteriorly to provide adequate pressure.
Blind packing with loose gauze is to be
avoided.

Vaseline gauze packing.

Merocel sponges can be placed relatively

easily and quickly but may not provide
adequate pressure (see the image below).
They should be coated with an antibiotic
ointment and can be hydrated with a topical
vasoconstrictor.

instruct them to avoid physical strain for 1

week.
Also see Anterior Epistaxis Nasal Pack.

Posterior
Epistaxis that cannot be controlled by
anterior packing can be managed with
posterior packing. Classically, rolled gauzes
are used, but medium tonsil sponges can be
substituted.
Recently, inflatable balloon devices (eg, 12
or 14 French Foley catheters) or specially
designed catheters manufactured by
companies such as Storz and Xomed (eg,
Storz Epistaxis Catheter, Xomed Treace
Nasal Post Pac) have become popular
because they are easier to place. Avoiding
overinflation of the balloon is important
because it can cause pain and
displacement of the soft palate inferiorly,
interfering with swallowing.
A 2010 study by Garcia Callejo et al
determined that gauze packing, despite
being slower and more uncomfortable, has
a higher success rate, produces fewer local
injuries, and costs less than inflatable
balloon packing.[18]
Regardless of the type of posterior pack
used, an anterior pack should also be
placed. Admit all patients with posterior
packing to the intensive care unit (ICU) for
close monitoring of oxygenation, fluid
status, and pain control. An antibiotic should
also be given to prevent rhinosinusitis and
possible toxic shock syndrome.
Also see Posterior Epistaxis Nasal Pack.

Management of packing failure

Expandable (Merocel) packing (dry).

All packings should be removed in 3-4 days.

Absorbable materials (eg, Gelfoam,
Surgicel, Avitene) may be used in patients
with coagulopathy to prevent trauma upon
packing removal. Administer prophylactic
antibiotics to all patients with packing, and

Packing failure can be caused by

inadequate placement resulting either from
lack of patient cooperation (especially in the
pediatric age group) or from anatomic
factors (eg, deviated septum). In cases of
packing failure, a careful endoscopic
examination with the patient under general
anesthesia may be considered. Bleeding
sites can be cauterized under endoscopic

guidance, a deviated septum can be

straightened, spurs can be removed, and
meticulous packing can be placed.[19]

The posterior sinus wall is then packed with

Gelfoam, and the gingivobuccal incision is
closed.

If these steps fail to control the bleeding,

arterial ligation (see below) may be
performed at the same time.

More recently, transoral and transnasal

endoscopic approaches have been
described. The transoral approach is useful
in patients with midface trauma, hypoplastic
antra, or maxillary tumors.

Arterial Ligation
The choice of the specific vessel or vessels
to be ligated depends on the location of the
epistaxis. In general, the closer the ligation
is to the bleeding site, the more effective the
procedure tends to be.

External carotid artery

Ligation of the external carotid artery (ECA)
can be performed with the patient under
local or general anesthesia. A horizontal
skin incision is made between the hyoid
bone and the superior border of the thyroid
cartilage. Subplatysmal skin flaps are then
raised, and the sternocleidomastoid muscle
is retracted posteriorly.
Next, the carotid sheath is opened and its
contents exposed. The ECA is identified by
following the internal carotid artery (ICA) for
a few centimeters and dissecting the ECA
beyond its first few branches. After the ECA
has been positively identified, it is usually
ligated just distal to the superior thyroid
artery. Continued bleeding after ligation may
be from anastomoses with the opposite
carotid system or the ipsilateral ICA.

Internal maxillary artery

In the transoral approach, the buccinator

space is first entered through a
gingivobuccal incision. The buccal fat pad is
removed, and the attachment of the
temporalis to the coronoid process is
identified. This process facilitates the
identification of the internal maxillary artery.
The vessel is then doubly clipped and
divided. This procedure has a higher failure
rate than the transantral approach because
the site of ligation is more proximal.
The transnasal endoscopic method requires
skills with endoscopic instruments. A large
middle meatal antrostomy is made to
expose the posterior sinus wall. The middle
turbinate can be partially resected to ensure
adequate exposure. The remaining steps
are similar to those of the traditional
transantral approach.
Endoscopic technique can also be used to
ligate the sphenopalatine artery at its exit
from the sphenopalatine foramen.[20, 21] An
incision is made just posterior to the
posterior attachment of the middle turbinate.
The mucosal flap is then carefully elevated
to reveal the sphenopalatine artery, which is
then clipped and ligated.

Ethmoid artery
Internal maxillary artery ligation has a higher
success rate than ECA ligation because of
the more distal site of intervention.
Traditionally, the internal maxillary artery is
accessed transantrally via a Caldwell-Luc
approach. With the help of an operating
microscope, the posterior sinus wall is
removed in a piecemeal fashion, and the
posterior periosteum is carefully opened.
The internal maxillary artery and 3 of its
terminal branches (ie, sphenopalatine,
descending palatine, pharyngeal) are
elevated with nerve hooks, then clipped.

If bleeding occurs high in the nasal vault,

consider ligation of the anterior ethmoid
artery, the posterior ethmoid artery, or both.
These arteries are approached through an
external ethmoidectomy incision.
The anterior ethmoid artery is usually found
approximately 22 mm (range, 16-29 mm)
from the anterior lacrimal crest. If clipping
the artery does not stop the bleeding, then
the posterior ethmoid artery may be ligated.
This artery is found approximately 12 mm

posterior to its anterior counterpart. It should

be clipped, not cauterized, because it is only
4-7 mm anterior to the optic nerve.

Embolization
Bleeding from the ECA system may be
controlled with embolization, either as a
primary modality in poor surgical candidates
or as a second-line treatment in those for
whom surgery has failed. Patients
considered candidates for embolization
should be transferred to hospitals with
interventional radiology capability.[19]

Preembolization angiography is performed

to check for the presence of any unsafe
communications between the ICA and ECA
systems. Selective embolization of the
internal maxillary artery[22] and sometimes
the facial artery may be performed.
Postprocedure angiography can be used to
evaluate the degree of occlusion. The most
common reason for failure is continued
bleeding from the ethmoid arteries

Palliative Therapy for

Hereditary Hemorrhagic
Telangiectasia
Management of hereditary hemorrhagic
telangiectasia (HHT) is palliative because
the underlying defect is not curable. Options
include coagulation with potassium-titanylphosphate (KTP) or neodymium:yttriumaluminum-garnet (Nd:YAG) lasers,
septodermoplasty, embolization, and
estrogen therapy.

Complications of Treatment
Potential treatment complications include
the following :

Cauterization - Synechia, septal

perforation
Anterior packing - Synechia,
rhinosinusitis, toxic shock syndrome,

eustachian tube dysfunction, scarring of

the nasal ala and columella
Posterior packing - Synechia,
rhinosinusitis, toxic shock syndrome,
eustachian tube dysfunction, dysphagia,
scarring of nasal ala and columella,
hypoventilation, sudden death
Transantral internal maxillary artery
ligation - Anesthetic risks, rhinosinusitis,
oroantral fistula, infraorbital numbness,
dental injury
Transoral internal maxillary artery
ligation - Anesthetic risks, cheek
numbness, trismus, tongue paresthesia
Anterior or posterior ethmoid artery
ligation - Anesthetic risks, rhinosinusitis,
lacrimal duct injury, telecanthus, blindness
Embolization - Facial pain, trismus,
facial paralysis, skin necrosis, blindness,
stroke, groin hematoma

Prevention of Epistaxis
To the extent possible, patients should avoid
the following:

Strenuous activities - Protection from

direct trauma from some sports activities
is afforded by the use of helmets or face
pieces.
Hot and dry environments The
effects of such environments can be
mitigated by using humidifiers, better
thermostatic control, saline spray, and
antibiotic ointment on the Kiesselbach
area.
Hot and spicy foods
Digital trauma In children, nose
picking is difficult to deter and should
probably be considered inevitable.
Keeping the childs nails well trimmed may
be helpful.
Nose blowing and excessive
sneezing - Instruct patients to sneeze
gently with the mouth open.
Inappropriate or careless use of
drugs - Consider drug education relating
to use or accidental ingestion of aspirin,
warfarin (eg, rat poison in toddlers), or
drug abuse in adolescents.