EPISTAXIS

Quick facts
 Most common otolaryngologic emergency
 60% lifetime prevalence; only 6% of cases require medical attention

Vascular supply to septum and nose:

 ECA IMA SPA  nasopalatine artery + posterior superior br. + inferior

nasopalatine br. (posterior septum)
 ICA  ophthalmic artery  Anterior ethmoid + posterior ethmoid arteries 
Kiesselbach’s plexus (anterior septum)

Causes
 Local factors
o Digital trauma, septal deviation, neoplasm, chemical irritants, fractures
o Tumours: juvenile nasal angiofibroma, papillomas,
esthesioneuroblastomas, melanomas, adenocarcinomas
 Systemic factors
o Coagulopathies, thrombocytopenia, renal failure, chronic alcoholism,
ASA/NSAID use, anticoagulation (coumadin, enoxaprin, heparin)
o HTN can make control of bleeding more difficult
o Osler-Weber-Rendu or HHT (hereditary hemorrhagic telangiectasia)
 By incidence:
o Idiopathic, primary neoplasms, trauma/iatrogenic

Local Causes
   Idiopathic—spontaneous
Trauma:
   Nose picking
      Foreign body
   Nasal oxygen and continuous positive airway pressure
   Nasal fracture
Inflammatory/infectious:
   Common cold, viral rhinosinusitis
   Allergic rhinosinusitis
  
   Bacterial rhinosinusitis
   Granulomatous diseases (Wegener's granulomatosis, sarcoid, tuberculosis)
   Environmental irritants (cigarette smoking, chemicals, pollution, altitude)

  
Postoperative—iatrogenic:
   Nasal surgery
   Primary neoplasm:
   Hemangioma of the septum, turbinates
   Hemangiopericytoma
   Nasal papilloma
   Pyogenic granuloma
    Angiofibroma
   Carcinoma and other nasal malignancies
Structural:
      Septal deformity, spurs
   Septal perforation
Drugs:
   Topical nasal steroids
  
   Cocaine abuse
   Occupational substances
General Disorders, Systemic Causes
   Hypertension (not more common, but more troublesome)
   Arteriosclerosis
   Platelet deficiencies, dysfunction; coagulopathies (e.g., warfarin, liver disease)
   Leukemia, von Willebrand's disease
   Hereditary hemorrhagic telangiectasia
   Organ failure (liver, kidney)

Types and Classification

 Anterior bleeding
o Arising from anterior ethmoid artery, superior labial artery branches
 Posterior bleeding
o Arising from sphenopalatine and posterior ethmoidal arteries
 Maxillary sinus ostium also serves as dividing line

Management
o ABCs
 Ensure airway patency
 Maintain/establish hemodynamic stability
o History
 Onset, quantity, laterality, symptoms of nasal obstruction, possible
precipitating factors
 R/O medication induced bleeding, bleeding diasthesis, alcohol use,
renal and hepatic dysfunction
o Examination
 Identify source of bleeding
 Identify possible causes (e.g. neoplasms, polyps)
 Equipment needed: headlight, suction, oxymetazoline or
phenylephrine + topical anaesthetic (e.g. 2% lidocaine)

Management (cont’d)
 Cautery
o Identify source of bleeding on anterior rhinoscopy or endoscopy
 Chemical cauterization (silver nitrate – reacts with water to release
neutral silver metal and nitric acid)
  Only cauterize one side of the septum to avoid septal
perforation
 Limited role in posterior bleeds
 Electrical cauterization
 For more aggressive bleeding
 Anesthetize bilaterally using local anesthesia
 May require endoscopic visualization for posterior bleeds
 Laser cautery
 Generally reserved for outpatient, elective cauterization of
visible telangiectasias
 Nasal packing
o Absorbable
 Surgicel – oxidized cellulose
 Gelfoam
 Floseal – thrombin + gelatin
o Non-absorbable
 Inflatable balloons (e.g. rhino rockets, foley catheters)
 Carboxymethylcellulose sponges (Merocel)
 Calcium alginate
 Petroleum jelly-impregnated gauze
o Anterior packing is uncomfortable and requires removal; antibiotic
prophylaxis for toxic shock syndrome
 Can be left for 1 to 5 days
o Posterior packing
 Foley cather (12 or 14F, inflated with 5 – 10 cc saline)
o Complications: ulcerations, septal perforaiton, sinusitis, synechiae,
hypoxemia, arrhytmias
 Specific for posterior packing: alar, colunellar, palatal necrosis,
simulation fo the nasopulmonary (diving) reflex
 Embolization
o CANNOT embolize anterior ethmoid artery (branch of ophthalmic artery,
risk of blindness and stroke)
o IMA and Facial artery are common sites
o Emoblization materials: cyanoacrylate glue, polyvinyl alcohol sponges,
metal coilds, gelatin foam
o Complications: rebleeding, stroke, blindness, facial numbness, skin
sloughing, carotid artery dissection, groin hematoma
 Endoscopic surgery/ligation
o Anterior bleeding (anterior ethmoid artery)
 Lynch incision
 Raise periosteium off lacrimal crest and posteriorly into the
orbit
 Clip artery located 24mm posterior to the lacrimal crest
 Endoscopic ligation through the lamina papyracea
o Posterior bleeding
  Ligation of SPA (Transnasal endoscopic sphenopalatine artery
ligation)
 Enters nose posterior to the crista ethmoidalis through the
sphenopalatine foramen
 Vidian artery anastomosses with the SPA and

Post-control management

 Nasal saline washes and water-soluble ointments to humidify the nasal mucosa
and promate healing
 Humidified air (esp. for patients using nasal cannula oxygen)
 Control of inflammation (e.g. nasal corticosteroids)
 Consider work-up for coagulopathy (e.g. vWD)

On-Call Cheat Sheet

Answering ER/consult:

1. Ensure patient is hemodynamically stable

2. Ensure patient doesn’t have severe medical comorbidities
3. Ensure preliminary bloodwork has been sent (CBCD, PTT, INR, etc.)
4. Attempt at digital pressure overall alar cartilages and septum for at least 20
minutes

Equipment
 Suction with Fraser tip and tonsillar suckers
 Kidney basin/bowl
 Head-Light (these are in the ENT ER rooms)
 Epistaxis tray (in rooms and 3D4)
 Garbage bin
 4% Xylo with Otrivin (50/50) mix you make yourself
 Several 4 by 4s, polysporin and tape
 2 large Merocel sponges and/or 2 Vaseline gauze packs unraveled
 Silver nitrate sticks

TSS prophylaxis:

Keflex 500 mg PO QID

Clindamycin 300 mg PO QID