Managing epistaxis

Author Information
Linda Diamond practices ENT head and neck surgery at Allegheny General Hospital in
Pittsburgh, Pa. The author has disclosed no potential conflicts of interest, financial or otherwise.
Earn Category I CME Credit by reading both CME articles in this issue, reviewing the post-
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Abstract
ABSTRACT: An estimated 60% of the population will have a nosebleed in their lifetime, and 6%
will require medical intervention. Uncontrolled nasal bleeding can lead to hypovolemia and
airway compromise. Understanding prevention and management of epistaxis is especially
important to clinicians who manage patients on anticoagulants, supplemental oxygen therapy, or
who have other risk factors for epistaxis. This article reviews stepwise management for epistaxis
and newer treatment options in adults.
Epistaxis is defined as acute hemorrhage from the nostril, nasal cavity, or nasopharynx.
Nosebleeds are a common condition and most are self-limiting. However, uncontrolled nasal
bleeding can lead to hypovolemia and airway compromise. This article reviews the risk factors,
prevention, and management of epistaxis, including management for patients on anticoagulants
or supplemental oxygen. Newer treatment options offer patients and clinicians a better arsenal to
treat epistaxis.

CAUSES

Epistaxis is a frequent phenomenon. An estimated 60% of the population will have a nosebleed
in their lifetime, and 6% require medical intervention. 1,2 The incidence of epistaxis is a bimodal
distribution, peaking in young children and again in adults ages 45 to 65 years. 2 Epistaxis can be
caused by a variety of factors (Table 1). Anticoagulation, underlying liver disorders, or other
blood coagulopathies can contribute to the inability to control epistaxis. Recurrent or unilateral
epistaxis along with nasal congestion or nasal obstruction, independent of the degree of bleeding,
may indicate nasal neoplasm.

ANATOMY
The nasal cavitytwo chambers divided by the nasal septumwarms and moistens the air we
breathe. The septum is lined by mucous membrane and contains a rich vascular supply
generating from branches of the internal and external carotid arteries. More than 90% of cases of
epistaxis occur on the nasal septum in the vascular area called the Kiesselbach plexus. 1 This area
is prone to digital trauma and excessive drying, and is exacerbated by the use of supplemental
oxygen via nasal cannula. The Kiesselbach plexus is supplied by both the anterior and posterior
ethmoid arteries as well as branches from the sphenopalatine and greater palatine arteries (Figure
1). Epistaxis in this area is defined as anterior and is generally self-limiting and easier to control.

The lateral wall of the nasal cavity is more complex, with three bony elevations called turbinates
or conchae. These conchae are covered with a thick mucous membrane and increase the surface
area to moisten inhaled air. Posterior nasal cavity epistaxis occurs in 5% to 10% of nasal
bleeding.1 Branches of the internal maxillary artery (sphenopalatine and descending palatine
arteries) with a small contribution from the posterior ethmoid artery make up the vascular supply
to this area. Posterior epistaxis is often more difficult to visualize and to reach anatomically,
therefore, more difficult to control.1,2

HISTORY AND ASSESSMENT

Obtaining a timeline of the patient's nosebleed is important; the duration of the bleeding may
indicate whether the patient needs more emergent treatment. Refer the patient to the nearest ED
if he or she has had recurrent hard-to-control bleeding over several days or a single significant
bleed lasting longer than 1 hour.
Review the patient's medical history, looking for chronic medical conditions that may predispose
the patient to bleeding, such as hypertension, liver disease, heart disease, or blood disorders.
Note and document if the patient is taking anticoagulants or antiplatelet drugs such as aspirin and
nonsteroidal anti-inflammatory drugs (NSAIDs).
In the initial evaluation of a patient with epistaxis, focus on airway competency and
cardiovascular stability. Patients with severe bleeding may need resuscitation and airway control.
Be sure to have adequate lighting when inspecting the nasal cavity in the office setting. A
headlight source with a nasal speculum is recommended. Inexpensive headlamps used for
camping or recreation can provide a narrow tight beam, allowing better visualization and freeing
both of the healthcare provider's hands. The patient should be sitting upright on examination
chair or table to limit head movement.
An epistaxis kit containing all the necessary instruments and packing is helpful (Table 2).
Bayonet forceps or straight sturdy blunt-ended tweezers about 8 in long are used to insert
pledgets or packing. Frasier suction #10 or small disposable suction tips are used to remove clots
and blood from the nasal cavity before treatment. Yankauer suction and an emesis basin can be
used to capture expectorated clots.

TREATING ANTERIOR EPISTAXIS

Epistaxis treatment is based on the site and degree of bleeding. Failure to control an anterior
bleed may indicate the presence of a posterior bleed.
Compression is recommended initially for a simple anterior septal nosebleed. Have the patient
watch a clock or set a timer while holding the fleshy part of the nose for 10 minutes without
releasing. If this method fails, the patient will require medical evaluation by a primary care
provider, ENT specialist, or in an urgent or emergency care setting.
Inspect for bleeding in the Kiesselbach plexus. A locally applied vasoconstrictor can assist
visualization and control of bleeding. Oxymetazoline, the active ingredient in several nasal
decongestant sprays, is available and easy to use. Suction or have the patient gently blow the
nose, then either spray or place a cotton pledget soaked with oxymetazoline in the nares. A
pledget can be made using a large cotton ball and unrolling it to about 4 in long. The pledget is
best placed using bayonet forceps to insure proper placement along the nasal septum. Let the
pledget remain in place with gentle compression for 5 to 10 minutes. After removing the pledget,
examine the nares with a headlight and nasal speculum.
Chemical cautery may be considered for persistent oozing of an identifiable anterior site.
Anesthetize the patient's nasal cavity with a pledget soaked with 2% lidocaine (with or without
epinephrine) for about 10 minutes. Remove the pledget and hold a silver nitrate applicator on the
site of bleeding and surrounding area for no longer than 10 seconds. The mucosa will turn
whitish gray. Holding the cautery stick on an area for more than 10 seconds poses the risk of
septal perforation. Use caution in cauterizing both sides of the septum in the same session, as this
may also cause tissue necrosis and possible septal perforation.
Nasal packing is available for anterior and posterior bleeding. For a simple anterior nasal bleed
that has failed compression and/or cautery, use a nasal tampon, balloon, or a thrombogenic agent.
Occasionally, both sides of the nares may require packing either due to bilateral bleeding or to
achieve enough compression to control the bleed. Bilateral packing is necessary for patients with
septal perforation.
Nasal tampons are made of a synthetic open-cell polymer. Although these polyvinyl alcohol
sponges are rigid, they are easy to use and effective. Anesthetize the patient's nare as described
above. Coat the nasal tampon with antibiotic ointment to act as a lubricant as well as to prevent
infection. Slide the nasal tampon directly along the floor of the nasal cavity until the entire
tampon is in the nasal cavity. Then expand the tampon by infusing about 10 mL of saline or
sterile water with an angiocatheter or needle onto the anterior nasal tampon to soak the material.
Nasal balloon catheters come in different types, including a low-pressure balloon encased in a
carboxymethylated cellulose (CMC) mesh. The mesh promotes thrombosis once it contacts
blood. These balloon catheters are considered less traumatizing to the nose than traditional nasal
tampons. They vary in length to allow compression from the anterior to more posterior bleeding
sites. CMC balloons are moistened with sterile water before insertion, and are easy to insert in
the nares in the office setting. Remove the hard outer cover, moisten the pack with sterile water,
and immediately slide the pack along the floor of the nose until it is completely inserted. (None
of the pack should be sticking out of the patient's nose.) Then inflate with air until the pilot cuff
is firm. Tape the cuff to the patient's cheek.
Gauze packing with petroleum-impregnated ribbon gauze can be used to control epistaxis. The
packing is placed with a bayonet forcep. Grasp the gauze and place it as far back in the nasal
cavity as possible, then grasp the next segment of gauze and tightly layer each segment into the
nare. This requires a greater skill in placement and may be deferred to an ENT specialist.
Thrombogenic agents are newer options to promote clot formation and stabilize epistaxis.
Forms include surgical absorbable gauze, topical thrombin gel, and fibrin glue. The medicated
gauze and topical applications conform to irregular and wet mucosal surfaces. Medicated gauze
can be placed after cautery in patients at high risk for recurrent bleeding. Studies indicate that
thrombogenic agents have a lower rebleeding rate and effectively control epistaxis. 3,4 Patients
have less nasal pressure and find these interventions more comfortable than traditional nasal
packing or balloons. Because this form of treatment is absorbable, it does not have to be
removed. This prevents clots from being dislodged or the nasal mucosa from being further
irritated, as can occur during removal of traditional packing.
Thrombogenic agents need to be applied directly to the area of bleeding and compression may
still be required initially. When evaluating bleeding, remember that these agents may take several
minutes to work.

TREATING POSTERIOR EPISTAXIS

Because visualization and access to the bleeding site is difficult, posterior epistaxis is
challenging to treat. The nares can be packed with petroleum-impregnated gauze or a posterior
balloon can be placed. A dual balloon catheter is inserted along the floor of the nose until the
retention ring is at the nasal entrance. The posterior balloon is inflated with 10 mL of sterile
water and the catheter is gently pulled forward until it lodges against the nasopharynx. The
anterior balloon is then inflated with up to 30 mL of sterile water to hold the catheter in place.
Pad or protect the nasal entrance from any pressure the balloon may create in its placement.
Although not licensed for this use, an indwelling urinary catheter works well if a balloon catheter
is not available. Insert a 10-to-14 French catheter into the nasal cavity until the indwelling
urinary catheter is visible in the oropharynx. Then slowly inflate the balloon with 10 mL of
sterile water and gently withdraw the catheter until compression occurs on the posterior
nasopharynx. While maintaining pressure on the posterior nasopharynx (pulling the catheter
toward yourself), place a small C-clamp or umbilical clamp at the anterior nares to hold the
catheter. Ribbon gauze or packing may be placed around the catheter inside the nares for added
compression and control of bleeding. Apply a gauze dressing to protect the external nares from
the clamp and pressure necrosis.

AFTER PACKING TREATMENT

After the nasal cavity has been treated or packed, always use a light source and tongue blade to
evaluate the oropharynx to check for posterior bleeding. Epistaxis that persists after packing is
placed requires immediate referral to an ED. Packing that results in good control should remain
in place for 3 to 5 days. Although experts have debated whether to prescribe prophylactic oral
antibiotics to prevent toxic shock syndrome and sinusitis while the packing is in place, most ENT
surgeons prefer prophylaxis.5 Simple anterior packing on one side can be treated as an outpatient
procedure, with referral to an ENT specialist for follow-up in 3 to 5 days.
Patients who require bilateral packing or posterior packing will need hospital admission and
monitoring. The potential risk of hypotension and bradycardia caused by a nasovagal reflex is
rare. This nasopulmonary reflex was thought to occur during posterior nasal packing or
instrumentation but studies have demonstrated no change in pulmonary or cardiac function in
relation to posterior nasal packing.6Patients are at possible risk of short-term sleep apnea due to
the decreased nasal air entry from the packing. 1,4 The risk of displacement of the packing and
possible recurrent bleeding warrants ICU admission or a high level of monitoring. A hospitalized
patient will benefit from a humidified face tent to provide moisture and comfort; the nasal
packing forces patients to breathe through the mouth while sleeping.

UNCONTROLLED EPISTAXIS

Angiography with embolization was first performed for epistaxis in 1972. 2 Since then, it has
become a common alternative for uncontrolled epistaxis in medical centers where it is available.
Patients usually require anesthesia and must tolerate IV contrast for this procedure.
Studying endovascular treatment for intractable epistaxis in 30 patients, Vitek found a success
rate of 87% after embolization of the internal maxillary artery and a 97% success rate after
embolization of the internal and facial arteries, with a 3% to 4% complication rate. 7Failure of
embolization treatment of epistaxis is often related to continued bleeding from the ethmoidal
branches of the ophthalmic artery. Embolization of these branches is contraindicated because
ophthalmic artery embolization carries a high risk of blindness and stroke.
Surgical treatment is reserved for ongoing hemorrhage that fails conservative interventions.
Surgery is performed in the OR under general anesthesia; rigid endoscopy is used to identify the
site of bleeding. Surgical ligation or cautery of the sphenopalatine artery is attempted initially.
Studies of posterior endoscopic cauterization report success rates of 80% to 90%.2 If the site of
bleeding is found from the ethmoidal region, a ligation of the ethmoid artery is completed. This
may require an external incision through the medial orbital wall just below the eyebrow.
Traditional or absorbable nasal packing may be placed in the nasal cavity postprocedure as a
precaution.

ANTICOAGULATION AND HYPERTENSION

Managing epistaxis in patients taking anticoagulants is challenging. Much debate and little
consensus exist as to whether anticoagulation should be continued, held, or reversed when
patients develop epistaxis.3 Medically evaluate each patient to determine the risks of stopping
anticoagulation.
The role of hypertension in the initial onset of epistaxis is controversial. 8,9 Studies have
demonstrated that patients with epistaxis presenting to the ED have higher BP on admission than
controls. These patients also have a higher incidence of previous nosebleeds. 9 Patients with
epistaxis and uncontrolled BP can have persistent bleeding that is difficult to control, so medical
management of hypertension is vital. The hypothesis that elevated BP was secondary to anxiety
during epistaxis also was studied. This prospective comparative study looked at administering
diazepam to patients with epistaxis, increased BP, and anxiety. The researchers found that
diazepam did not reduce anxiety or BP during acute epistaxis and was not
recommended.10 Therefore, evidence supports that hypertension itself must be controlled in a
patient with acute epistaxis and should be monitored closely.
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FOLLOW-UP AND PREVENTION

All patients with a history of severe or recurrent epistaxis should have an ENT evaluation.
Provide patients with written instructions for nasal care after epistaxis:
* Patients should not blow their noses for 7 to 10 days after the nosebleed. Patients should use
saline nasal spray several times a day and sniff gently instead of blowing the nose.
* Patients should apply petroleum or antibiotic ointment in the nares twice a day.
* Patients should avoid bending and lifting heavy objects.
* Advise patients to open their mouths when sneezing.
* Patients should use home humidifiers and bedside vaporizers.
* Tell patients to keep fingernails trimmed and avoid nose picking.
* For patients on supplemental oxygen, a humidified face tent or mask is recommended. Limit
the use of a nasal cannula to during meals. Patients also should trim the prongs of the tubing that
enter the nose to prevent excessive dryness on the septum.
Moisture is the key to prevention. All patients on anticoagulation or antiplatelet medications
(including NSAIDs) should use nasal care. Patients with nasal dryness or a history of nosebleeds
should add nasal care to their daily regime.
Most nosebleeds are cyclic. A patient may have an idiopathic nosebleed that stops as a clot is
formed over the bleeding site. If the patient's nose becomes dry or is blown and the clot becomes
dislodged too soon, the nose bleeds again. Until the mucosa underlying the clot is allowed to
heal, a patient may continue to have serial bleeds. Moisture and prohibiting nose-blowing stops
this cycle and lets the nasal lining heal. Teaching patients how to correctly try to control a
nosebleed and perform proper nasal care after a nosebleed may prevent an unnecessary trip to a
clinic or ED.

CONCLUSION

Epistaxis is a common medical event. Newer treatment options are available and friendlier for
healthcare providers and patients. Creating an epistaxis kit with all necessary instruments and
supplies can help clinicians treat patients in an organized, stepwise fashion with confidence.
Provide patients with written instructions about treating nosebleeds and reducing recurrences.
Encourage patients on anticoagulation or oxygen to perform nasal care on a daily basis to
prevent epistaxis.

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Keywords:
epistaxis; nosebleeds; nasal packing; thrombogenic agents; balloon catheter; anticoagulation
2014 American Academy of Physician Assistants.