Epistaksis

Hidung berdarah (Kedokteran: epistaksis atau Inggris:epistaxis) atau mimisan adalah

satu keadaan pendarahan dari hidung yang keluar melalui lubang hidung.
Ada dua tipe pendarahan pada hidung:

Tipe anterior (bagian depan). Merupakan tipe yang biasa terjadi.

Tipe posterior (bagian belakang).

Dalam kasus tertentu, darah dapat berasal dari sinus dan mata. Selain itu pendarahan
yang terjadi dapat masuk ke saluran pencernaan dan dapat mengakibatkan muntah.

Daftar isi
[sembunyikan]
1 Penyebab
2 Patofisiologi
3 Perawatan
4 Pendarahan hidung dalam cerita fiksi

5 Pranala luar

[sunting] Penyebab
Secara Umum penyebab epistaksis dibagi dua yaitu :
1. Lokal
2. Sistemik
Lokal
Penyebab lokal terutama trauma, sering karena kecelakaan lalulintas, olah raga, (seperti
karena pukulan pada hidung)yang disertai patah tulang hidung(seperti pada gambar di
halaman ini),mengorek hidung yang terlalu keras sehingga luka pada mukosa hidung,
adanya tumor di hidung, ada benda asing (sesuatu yang masuk ke hidung) biasanya pada
anak-anak, atau lintah yang masuk ke hidung, dan infeksi atau peradangan hidung dan
sinus (rinitis dan sinusitis)
Sistemik
Penyebab sistemik artinya penyakit yang tidak hanya terbatas pada hidung, yang sering
meyebabkan mimisan adalah hipertensi, infeksi sistemik seperti penyakit demam
berdarah dengue atau cikunguya, kelainan darah seperti hemofili, autoimun
trombositipenic purpura.

[sunting] Patofisiologi
Semua pendarahan hidung disebabkan lepasnya lapisan mukosa hidung yang
mengandung banyak pembuluh darah kecil. Lepasnya mukosa akan disertai luka pada
pembuluh darah yang mengakibatkan pendarahan.

[sunting] Perawatan
Aliran darah akan berhenti setelah darah berhasil dibekukan dalam proses pembekuan
darah. Sebuah opini medis mengatakan bahwa ketika pendarahan terjadi, lebih baik jika
posisi kepala dimiringkan ke depan (posisi duduk)untuk mengalirkan darah dan
mencegahnya masuk ke kerongkongan dan lambung.
Pertolongan pertama jika terjadi mimisan adalah dengan memencet hidung bagian depan
selama tiga menit. Selama pemencetan sebaiknya bernafas melalui mulut. Perdarahan
ringan biasanya akan berhenti dengan cara ini. Lakukan hal yang sama jika terjadi
perdarahan berulang, jika tidak berhenti sebaiknya kunjungi dokter untuk bantuan.
Untuk pendarahan hidung yang kronis yang disebabkan keringnya mukosa hidung,
biasanya dicegah dengan menyemprotkan salin pada hidung hingga tiga kali sehari.
Jika disebabkan tekanan, dapat digunakan kompres es untuk mengecilkan pembuluh
darah (vasokonstriksi). Jika masih tidak berhasil, dapat digunakan tampon hidung.
Tampon hidung dapat menghentikan pendarahan dan media ini dipasang 1-3 hari.
Kematian akibat pendarahan hidung adalah sesuatu yang jarang. Namun, jika disebabkan
kerusakan pada arteri maksillaris dapat mengakibatkan pendarahan hebat melalui hidung
dan sulit untuk disembuhkan. Tindakan pemberian tekanan, vasokonstriktor kurang
efektif. Dimungkinkan penyembuhan struktur arteri maksillaris (yang dapat merusak
saraf wajah) adalah solusi satu-satunya.

[sunting] Pendarahan hidung dalam cerita fiksi

Pada anime dan manga Jepang, biasanya ditemukan adegan karakter mengalami
pendarahan hidung, kadang-kadang disajikan dengan gaya ekstrim karena terangsang
secara seksual. Ini adalah hal yang jarang terjadi di dunia nyata. Adegan ini didasarkan
kisah masyarakat Jepang bahwa rangsangan seksual dapat menyebabkan hidung
berdarah.

1. EPISTAXIS

Nama lain : mimisan, pendarahan dari lubang hidung.

Penyebab penyakit :

1. Trauma ( korek-korek lubang hidung dengan jari atau benda lain ; fraktur tulang hidung
karena kecelakaan lalu lintas atau kena tinju.

2. Ada gangguan pembekuan darah ( demam berdarah, leukimia, dll )

3. Tekanan darah tinggi ( Angiofibroma, Karsinoma, dll )
4. Tumor didalam rongga hidung, apapun penyebabnya.

Gejala : pendarahan dari rongga hidung, apapun penyebabnya.

Pertolongan pertama sebelum ke dokter :

1. Penderita duduk dengan kepala menunduk

2. Cuping hidung pada lubang hidung yang keluar darah ditekan dengan jari penolong atau
jari penderita sendiri selama 5 menit
3. Bila kedua lubang hidung keluar darahnya maka kedua cuping hidung ditekan, sehingga
hidung dijepit dengan dua jari. Sementara mulut dibuka untuk bernafas.
4. Bila cara tersebut diatas tidak dapat menolong, maka penderita harus segera mendapat
pertolongan dari tenaga kesehatan terdekat.

Komplikasi Epistaxis :

1. Shok karena pendarahan

2. Anemia
3. Aspirasi ( darah tersedak kedalam paru-paru )

Cara pencegahan :

1. Jangan mengorek-ngorek hidung

2. Pemeriksaan dini untuk mengetahui penyakit-penyakit sebagai penyebab Epistakxis

OTOLARYGOLOGY FOR THE INTERNIST

EPISTAXIS
Luke K. S. Tan 1 2 MD, MMedSci, FRCS
Karen H. Calhoun 1 MD, FACS
1

Department of Otolaryngology, University of Texas Medical Branch (KHC,

LKST), Galveston, Texas
2
Department of Otolaryngology, National University of Singapore, Singapore
(LKST)
Address reprint requests to
Karen H. Calhoun, MD
Department of Otolaryngology
University of Texas Medical Branch
Galveston, TX 77555-0521
Patients presenting with epistaxis are anxious and fear bleeding to death. Although
death from epistaxis is rare, it can occur, and significant morbidity is relatively
common. [5] [34] Although most pediatric epistaxis is treated on an outpatient basis,
older patients (>60 years old) more often require hospital admission. [25] [44] Initial
management of epistaxis is directed at stopping the bleeding, and long-term
treatment is directed at discovering and correcting the underlying cause. This article
updates current management options.
ANATOMIC CONSIDERATIONS IN EPISTAXIS
The blood supply to the nose arises from the internal maxillary and facial arteries via the
external carotid and the anterior and posterior ethmoid arteries via the internal carotid
artery. The anteroinferior septum (Little's area) is supplied by a confluence of both
systems (Kisselbach's plexus). Little's area is a common site of epistaxis because it is
ideally placed to receive environmental irritation (cold, dry air, cigarette smoke) and is
easily accessible to digital trauma. This area is easy to access and treat. Bleeding arising
further within the nasal cavity can be difficult to reach. Surgical ligation of the

contributing arteries can be challenging because of their deep location and complex
anatomy.
PATHOPHYSIOLOGY
Much epistaxis ceases with pressure (digital or packing) over the bleeding point. An
intact coagulation system with accumulation of platelets and clot formation is required.
Abnormal platelet numbers or function or any abnormality in the coagulation cascade
leads to failure of clot formation and persistent bleeding.
CAUSE
Epistaxis results from an interaction of factors, damaging the nasal epithelial (mucosal)
lining and vessel walls. The major causative factors include environmental factors
(humidity, temperature), local factors (trauma, anatomic abnormalities, inflammation,
allergies, iatrogenic, tumors), systemic factors (hypertension, platelet and coagulation
abnormalities, renal failure, alcohol abuse), and medications affecting clotting
(anticoagulants, nonsteroidal anti-inflammatory drugs [NSAIDs]).
Environmental Factors
Cold, dry air increases cases of epistaxis. In countries with seasonal climates, hospital
admissions for epistaxis increase during the winter months. [24] [44] [61] Patients were
admitted at a rate of 0.829 patients per day for temperatures less than 5C compared with
0.645 patients per day for temperatures between 5.1C and 10C. [61] Most had some form
of dry air heating, without humidification, in their homes.
Nasal ciliary activity decreases as temperature drops. Normal ciliary activity (at 32C to
40C) occurs at about 15 Hz frequency, dropping to less than 5 Hz below 20C. [16]
Although extremely dry air is known to promote epistaxis, the exact humidification as a
preventive measure remains undefined. Temperatures of above 52C have been
associated with cellular damage. [56]
Local Factors
Trauma
Nose picking and accidental injury are the commonest traumatic causes of epistaxis.
Except with severe facial trauma, such as motor vehicle accidents, this epistaxis is
usually from an anterior nasal source and easily treated. [18]
Nasal Septal Deviation
Nasal septal deviation is common, but its role in epistaxis is not certain. In one study,
16% of patients with severe refractory epistaxis had marked septal deviation. [23] In
another study of patients with recurrent epistaxis, 81% had septal deviation versus 31% in

the control group. [46] The epistaxis group also had a higher incidence of radiologically
demonstrated septal deviation compared with the control group (62% versus 37%
[P<.02]). The bleeding tended to occur from the side to which the septum was deviated.
Exactly how a septal deviation could cause bleeding is not clearly established. Because
septal deviations do cause nasal obstruction turbulent air flow, this may cause abnormal
mucosal drying, making the mucosa more susceptible to bleeding.
Iatrogenic
Septal, turbinate, nasal, sinus, or orbital surgery can be followed by epistaxis. Bloodstained nasal discharge is common in the initial week or two after surgery. Severe
epistaxis can occur, especially after partial turbinate resection (0.9% to 8.9%). [14]
Management of such patients is aimed at controlling the bleeding and contacting the
surgeon to provide appropriate follow-up.
Inflammation (Infection and Allergy)
Epistaxis can result from nasal lining inflammation, with acute respiratory infections,
chronic sinusitis, or allergic rhinosinusitis. In children and the mentally disabled,
intranasal foreign bodies cause unilateral foul-smelling discharge that can be
accompanied by epistaxis. Children with both nasal allergy symptoms and positive skin
tests have more frequent epistaxis (20.2%) than those with symptoms alone (9.9%),
positive skin test alone (3.4%), or neither symptoms nor positive skin test (2.1%). This
study suggests that allergic rhinitis predisposes to epistaxis, either by mucosal irritation or
possibly by the atopic state contributing to a hemostasis disorder. [43]
Tumors
Epistaxis can be the only symptom in patients with a nasal tumor. In adolescents, the
most serious cause of recurrent epistaxis is the intranasal tumor, juvenile angiofibroma.
Other neoplastic causes of pediatric epistaxis include papillomas, polyps, and
meningoceles or encephaloceles (infants). [8] In adults, almost any benign or malignant
intranasal tumor can present with epistaxis. Intranasal lesions can sometimes be seen by
looking in the nose with the otoscopic ear piece. Biopsy of intranasal lesions is
approached with caution because biopsy of highly vascular lesions, such as a juvenile
angiofibroma, can cause significant blood loss and morbidity.
Chemicals
Many airborne irritants and toxic chemicals (sulfuric acid, ammonia, gasoline, chromates,
glutaraldehyde) [65] irritate or harm the nasal mucosa, resulting in epistaxis. Cigarette
smoke, primary or secondary, is another common irritant.
Systemic Factors
Hypertension

Although hypertension is often cited as a cause of epistaxis, several large studies have
shown no higher rate of underlying hypertension among epistaxis patients than in patients
without epistaxis. [41] [67] Hypertension patients taking diuretic or methyldopa medications
may have more epistaxis than those taking beta-blockers (60%). [9] Hypertension at the
time of epistaxis treatment may be anxiety related, returning to normal on control of the
epistaxis and reassurance. [23] Epistaxis patients with hypertension must be followed after
control of the bleeding, to ensure that blood pressure returns to normal on control of
epistaxis because some are found to have underlying hypertension requiring ongoing
treatment.
Renal Disease
Persistent epistaxis may be encountered in chronic renal failure patients undergoing
hemodialysis, but the true incidence remains unknown. [64] Contributing causative factors
may include elevated prostacyclin levels (platelet antiaggregatory activity) [40] and
prolonged use of low-molecular-weight heparin. [54] An 8% incidence of septal
perforations has been noted in renal failure patients. Localized irritation caused by
turbulent air flow around the perforation could also contribute to epistaxis in these
patients. [1]
Alcohol
Heavy alcohol consumption increases the risk of epistaxis. The same platelet reactivity
inhibition that provides a protective effect for the coronary arteries may also increase
bleeding time, making epistaxis more difficult to control. [37] [50] Bleeding risk, however,
was not linearly related to alcohol consumption, with those consuming 1 to 10 alcoholic
drinks per week most affected and those drinking more than 10 drinks per week less
affected. Rebound of platelet activity may explain this finding, but the mechanics have
yet to be elucidated. The use of NSAIDs did not confer an additional risk of increased
bleeding time. [50]
Coagulation and Vascular Abnormalities
Patients with hereditary conditions, such as hemophilia, von Willebrand's disease, and
thrombocytopenia, frequently experience epistaxis. Thrombocytopenia can also occur
with hematologic malignancy, chemotherapy, or viral infections, such as dengue
hemorrhagic fever [21] and human immunodeficiency virus (HIV), [15] or can be idiopathic.
Hereditary hemorrhagic telangiectasia patients are particularly prone to epistaxis
problems. [17] The abnormal vessel walls and focal endothelial degeneration contribute to
refractory epistaxis, which can be challenging to manage. Treatment is aimed at
decreasing the frequency of bleeds and need for transfusion because permanent cure is
not possible.
Medications

Numerous medications interfere with normal clotting. NSAIDs (including aspirin) are
probably the most common, with up to 75% of epistaxis patients using one of these
medications. [36] One study found that 42% of epistaxis patients were taking warfarin,
dipyridamole, or NSAIDs versus 3% of the nonepistaxis control group. [66] These
medications interfere with the cyclooxygenase pathway in arachidonic acid metabolism,
inhibiting platelet aggregation. [33] One author suggested that a history of epistaxis may be
a relative contraindication to the use of NSAIDs. [66] In addition, because 74% of aspirin
use is self-administered, the public needs to be made aware of the relationship between
aspirin and nosebleeds as potential side effects. [2]
Other medications associated with epistaxis include thioridazine, topical hyperosmolar
sodium chloride, and dipyridamole (Persantine). Epistaxis resolving when the drug is
stopped has occurred with thioridazine. The nasal mucosal drying from the
anticholinergic effects of this low-potency phenothiazine, coupled with home heating in
the dry winter season in hypertensive patients was thought to be the underlying cause of
epistaxis. [22] Dipyridamole inhibits adenosine diphosphate and collagen-induced platelet
aggregration, enhancing disaggregation and prolonging bleeding time. [42] Epistaxis has
also occurred in a patient using hyperosmolar sodium chloride (2%) eye drops. [29] The
patient developed dry nasal mucosa, presumably from osmosis, when the eye drops
arrived in the nasal cavity via the nasolacrimal duct. The problem resolved when sodium
chloride ointment was substituted for the drops. Use of steroid nasal sprays can also be
complicated by epistaxis, which is usually mild and stops after cessation of use of spray.
[24]

MANAGEMENT
There are three levels of epistaxis management: (1) first-aid measures, (2) acute
management, and (3) interventions.
First-Aid Measures
In one series of patients taking systemic anticoagulants, 25% had experienced epistaxis in
the previous year. Less than half of the patients [31] could think of a single first-aid
measure to stop nosebleeds. Clearly, additional education in this at-risk population could
reduce both morbidity and patient anxiety.
First-aid measures include the following:
1. Digital compression. Although so simple as to seem reflexic, fewer than 50% of
emergency department personnel could describe the correct site to apply digital
pressure in a nosebleed (Fig. 1) . [38] A swimmer's clip has also been used for
epistaxis. [62]
2. Cotton or tissue plug in the nose. Patients often arrive in the office with a piece of
tissue pushed into the nostril that has been bleeding.
3. Bending forward at the waist. This position allows gravity to keep blood flowing
out the nostrils, rather than posteriorly down the throat. [9]

4. Spitting out any blood that trickles down the back of the throat. The patient is
prevented from swallowing large amounts of blood.
5. Cold compress on nasal bridge. This practice has a vasoconstrictive effect. [35]
Acute Management
Hypotension associated with epistaxis can precipitate acute myocardial events or
aspiration, sometimes leading to death. The patient with an actively bleeding nose is
apprehensive and often has reactive hypertension, accentuating the bleeding. The basics
of airway, breathing, and circulation remain key principles. Securing the airway via
endotracheal intubation or trachesotomy in the severely injured unconscious patient
allows suctioning and packing of the nose and, if necessary, the oral cavity and pharynx.
Oxygen ensures good systemic oxygenation, especially important in patients with
underlying cardiopulmonary disease. Intravenous access is established in all patients
presenting with active epistaxis because significant bleeding has usually occurred before
the patient seeks medical attention. When inserting the intravenous line, it is usually
convenient to obtain blood for complete blood count and, if clinically indicated, type and
screen, coagulation profile, and electrolytes (in anticipation of surgical intervention).
An assessment of the amount of blood lost is made from the history, including the onset
of the bleeding, precipitating factors, duration and quantity (i.e., number of soaked
towels), past history of epistaxis and treatment, and history of blood dyscrasias. In adults,
a history of medication (including NSAIDs, anticoagulants), hypertension, ischemic heart
disease, diabetes mellitus, and alcohol abuse may influence management. In children, a
history of epistaxis with unilateral nasal discharge alerts the physician to the possibility of
an intranasal foreign body. Consent for blood transfusion is recommended. The vital
statistics (blood pressure and pulse) of the patient should be charted.
The patient is supplied with folded gauze 4 4 pads to soak up blood trickling from the
nose. A chart is started to keep track of the number of pads required, as further
assessment of the amount of blood lost.
Local Compression
Thumb and index finger nasal compression pressure is used as the first measure by the
physician while other treatments are being instituted. Local finger compression should be
employed for at least 5 minutes to allow formation of a hemostatic plug over the bleeding
vessel.
Cauterization
Most epistaxis originates in the anterior nasal cavity, often in Little's area. Effective local
vasoconstrictive measures include pseudoephrine (Afrin), phenylephrine (NeoSynephrine), or epinephrine (1:10,000) applied to the area on cotton pledget.

The area of bleeding can be cauterized. Silver nitrate is the most convenient cauterization
agent, available in ready-made sticks. Local anesthesia with 4% lidocaine solution
(applied by cotton pledget for 5 minutes) can reduce the stinging of cautery. Accurate
identification of the bleeding points and a good light for intranasal examination are the
keys to successful cauterization. The temptation to cauterize a large area of the septum to
cover all bleeding points should be resisted. The authors routinely use a cotton-tipped
applicator to mop up residual silver nitrate after application, to prevent local damage to
the underlying perichondrium. Postcautery, antibiotic cream or ointment is applied to the
cauterized area twice a day for 5 days to prevent crusting and infection. Both sides of the
septum should not be cauterized at the same time because of the risk of septal perforation.
Repeated cauterization in the same area can also lead to septal perforations.
Other Measures
Other local measures include
1.
2.
3.
4.
5.

Electrocautery.
Other chemical cautery (trichloroacetic acid).
Light packing with petroleum jelly (Vaseline) gauze.
Direct endoscopic electrocautery (detailed later).
Hemostatic chemical agents (thrombin-soaked absorbable gelatin powder
[Gelfoam], oxidized cellulose [Surgicel], microfibrillar collagen [Avitene],
porcine fat, oxymetazoline, or calcium alginate fiber [Kaltostat]).
6. Oxymetazoline hydrochloride (an imidazole derivative) is a topical
vasoconstrictor commonly used as a nasal decongestant. [28] Of 60 patients coming
to an emergency department with epistaxis, there was a 65% success rate with
oxymetazoline alone. A further 18% of patients required silver nitrate cautery, and
the remaining 17% required nasal packing.
7. Cryotherapy. This procedure for applying cold temperatures within the nose to
control epistaxis reportedly has less morbidity than other local methods. [20] It
requires a machine capable of delivering the necessary temperature to freeze the
target tissues.
8. Hot-water irrigation. Success in treatment of epistaxis has been reported, although
patient compliance is variable. [56]
9. Desmopressin (1-desamino-8- D-arginine vasopressin) spray. Desmopressin spray
has been effective in decreasing the duration of epistaxis [32] and Ehlers-Danlos
syndrome. [57]
10. Laser therapy, diathermy, septodermoplasty, and other surgery. Surgery has been
advocated for hereditary hemorrhagic telangiectasia with variable success. [10] [49]
[63]

Anterior Nasal Packing

Packing is needed when local measures are unsuccessful in controlling epistaxis. Nasal
packing is an uncomfortable procedure and can have life-threatening complications,
anterior packing less so than combined anterior-posterior packing. Classic anterior

packing is performed with Vaseline-impregnated narrow gauze, placed in the nose until
sufficient pressure exists to tamponade the bleeding. Although the tidy textbook diagrams
of layered packing are somewhat misleading, the general goal is to place the packing
from the back and bottom of the nose forward. A training model for nasal packing has
been reported to improve confidence and competence in the procedure. [59]
Other options for anterior nasal packing include synthetic sponge packs (tampons) such
as Merocel that expand when moistened or balloon packing. Merocel packs are easy and
quick to insert and can be used for bilateral epistaxis as well. The success rate of such
packing exceeds 90%, even when performed by inexperienced physicians. [48] Both nasal
tampons and gauze packing are efficacious and well tolerated. [7]
After anterior packing, the oropharynx is inspected. If blood is still visible trickling from
the nasopharynx, either the anterior pack is suboptimally placed, or there is a posterior
nasal bleeding source. The nasal cavity measures about 7 cm from columella to
nasopharynx, so the most common error in anterior nasal packing is failure to pack
adequately the posterior aspects of the anterior nasal cavity.
Adequate lighting and long forceps (bayonet or Tilley's nasal packing forceps) are
necessary for placement of an effective anterior gauze pack. Gauze coated with BIPP
(bismuth iodoform paraffin paste) can be left in the nasal cavity for up to a week with low
risk of infection. Vaseline gauze packing is usually removed by 72 hours. Antibiotic
prophylaxis is usually administered.
Elderly or frail patients with anterior nasal packing and most patients with posterior nasal
packing should be hospitalized for oxygen supplementation, intravenous hydration, bed
rest, and mild sedation. Because bilateral nasal packing obstructs the nose and prevents
nasal breathing, it often causes hypo-oxygenation. Anterior-posterior nasal packing with
sedation is accompanied by decreased arterial oxygen tension and altered pulmonary
mechanics. [5] Oxygen is usually administered via face mask with anterior and posterior
packing (unless the carbon dioxide is elevated). Sedation is carefully titrated, keeping in
mind the patient's cardiopulmonary status.
Other materials used for nasal packing include Kaltostat, Ativene, and porcine fat (salt
pork). A randomized trial comparing Kaltostat and bismuth tribromophenate (Xeroform)
showed similar efficacy and patient acceptance. [39] Ativene successfully controlled 77%
of idiopathic anterior epistaxis and can be useful in hereditary telangiectasia epistaxis. [60]
Salt pork has been used for nasal packing in patients with thrombocytopenia, commonly
secondary to renal failure or medications. Homogenates of salt pork contain an aqueous
factor that serves as a platelet substitute, inducing platelet aggregation and enhancing
adenosine diphosphate and collagen-induced aggregation. The pork fat is less irritating to
the mucosa on removal than gauze packs. [4] This material is not used in patients who
avoid pork for religious reasons.
Posterior Nasal Packing

Only about 5% of epistaxis originates from a posterior nasal source. [64] The posterior
nasal space is cylinder shaped, opening anteriorly into the nasal cavity and posteriorly
into the nasopharynx. Packing in this space tends to fall back and down, into the
oropharynx. To pack the posterior nasal cavity, a conforming pack is first placed in the
nasopharynx, secured anteriorly near the nostrils. Gauze or other anterior packing can
then be firmly placed against this resistance.
Classically a posterior pack is made of rolled gauze secured with umbilical tape, although
balloon packs are sometimes used (Foley catheter, Brighton Balloon, Simpson Balloon).
Posterior pack insertion begins with passing a rubber catheter through each nostril, into
the oropharynx. They are grasped here and brought out anteriorly through the mouth.
Long ties attached to each side of the gauze pack are attached to the catheters, and the
catheters are gently withdrawn through the nose, leaving a gauze pack held in the
physician's hand, with the attached long ties entering the mouth and exiting both nostrils.
With gentle traction on the nostril ends, the pack is pulled and pushed into the
oropharynx, then tucked up into the nasopharynx. The mouth ends of the ties are left
long, to be grasped later and used in pack removal. The nostril ends are secured
anteriorly, usually around the columella. Care is taken to pad and protect the columella
from excessive pressure that could cause ischemic necrosis. This unpleasant procedure
can be performed under mild sedation, but use of general anesthesia when possible is a
kindness to the patient. Posterior packs are usually left in place for 48 to 72 hours
because earlier removal is associated with an increased risk of rebleeding.
An alternative to posterior packing with gauze is balloon catheters inserted in the
nasopharynx via the nostrils and inflated with sterile water. The balloons are secured
anteriorly using a clamp (e.g., umbilical cord clamp). Either Foley catheters or balloons
designed specifically for the nasopharynx can be used. The balloons have a tendency to
deflate with time, and volume can drop by 30% or more in 72 hours. [45] The authors
usually deflate the balloons at 48 hours and remove both anterior and posterior packings
at 72 hours.
Complications of Nasal Packing
Nasal packing can be complicated by death. [5] Aspiration of blood, cardiopulmonary
failure secondary to hypoxia, and toxic shock syndrome have led to mortality in patients
with epistaxis. Complications in nasal packing include
1.
2.
3.
4.
5.
6.
7.

Nasal trauma from the packing.

Nasal-vagal response (bradycardia, hypotension, apnea).
Dislodged packing.
Aspiration.
Persistent bleeding.
Infection, toxic shock syndrome.
Hypoxia resulting from nasal obstruction--may result in myocardial infarction,
disorientation.

Most complications can be avoided if anticipated. Firm and gentle packing avoids
excessive nasal mucosal trauma. Sedation is kept to the minimum necessary to decrease
aspiration risk and respiratory suppression. Oxygen should be given when there are no
contraindications. All patients receive prophylactic antibiotics.
Toxic shock syndrome occurring with nasal packing can cause significant morbidity and
mortality. More than one third of patients undergoing nasal packing are Staphylococcus
aureus carriers. Comparison of NuGauze packs to Merocel packs removed from patients'
noses revealed NuGauze grew out substantially more S. aureus. [3] This may occur
because Merocel is a single homogeneous structure, whereas NuGauze packing has
interstices and folds of varying sizes that more readily pool secretions. Toxic shock
syndrome begins with fever, vomiting, diarrhea, hypotension, and body rash secondary to
the production of TSST-1, the primary toxin causing toxic shock syndrome. S. aureus is
often sensitive to bacitracin, so use of this intranasally can help prevent toxic shock
syndrome. Oxytetracycline and polymyxin B can also decrease the number of bacterial
strains cultured from packing used for nasal packs. [19]
Interventions

Surgery
Endoscopic Cauterization.
Endoscopes have revolutionized sinonasal surgery over the past two decades. In the
management of epistaxis, use of the endoscope can permit identification of posterior
bleeding sites, which can then be directly cauterized, avoiding packing. [12] [51] It is
especially useful in patients who continue to bleed through well-placed nasal packs.
For these patients, the packings are usually removed when the patient is under general
anesthesia. The nasal cavity is cleansed and endoscopically examined. Common bleeding
sites include the region of distribution of the sphenopalatine artery, posterior end of
inferior turbinate, posterior-inferior septum, and anterior sphenoid face. The suction
electrocautery is useful. In the rare cases in which no bleeding sites are located, Merocel
packs are placed for 48 hours.
The authors have been using endoscopic examination in the outpatient setting with
selected patients. Using good topical anesthesia and mild sedation and a
suction/electrocautery unit, some more posteriorly placed bleeding points can be
identified and cauterized with minimal patient discomfort. Many of these patients would
traditionally have required nasal packing and hospitalization, so avoidance of this is
popular with both patients and managed care companies.
Arterial Ligation.
Arterial ligation decreases arterial blood flow to the bleeding area. Commonly ligated
supplying branches include the internal maxillary artery (terminating as the

sphenopalatine artery) and the anterior ethmoidal artery. Ligation of the external carotid
artery is also possible, although uncommonly needed.
Posterior epistaxis is usually supplied by the terminal branches of the internal maxillary
artery. The third part of the internal maxillary artery courses behind the maxillary antrum
to the sphenopalatine foramen at the superomedial sinus. As the internal maxillary artery
exits the sphenopalative foramen, it divides into medial (to the sphenoid/septum) and
lateral (lateral nasal wall) divisions. The transantral (via the maxillary antrum) approach
allows ligation just before the terminal branching. Traditionally the transantral approach
involved the removal of anterior wall of the maxillary sinus (Caldwell Luc) for surgical
access. [6] The microscope is used for dissection behind the posterior wall of the antrum.
The endoscope has provided an alternative approach with less morbidity, although it is
technically more difficult.
Ethmoidal arterial ligation is performed when bleeding arises in the superior nose (above
the middle turbinate). Ethmoidal artery ligation uses a curved incision around the medial
canthus. The globe is retracted away from the lamina papyracea, and the anterior
ethmoidal artery is encountered about 24 mm from the anterior lacrimal crest. The vessels
are clipped and ligated under direct vision. Patients with intractable epistaxis without an
identifiable bleeding point may benefit from ligation of both the anterior ethmoidal artery
and the internal maxillary artery.
Embolization.
An alternative to surgical ligation is embolization of external carotid artery branches. [11]
[26] [58]
This procedure is particularly useful in patients at high risk for a general anesthetic
or with unfavorable anatomy (small maxillary antra). [47] Embolization is successful in up
to 96% of cases, although vascular anatomic variations limit application in some cases.
One benefit of embolization over arterial ligation is that more selective blockade of
smaller branches is possible.
Complications of embolization include up to 6% of neurologic sequelae. The risk of
particulate material embolization to the internal carotid systems has been minimized by
the current use of microcoils. [13]
Blood Transfusion
With the risk of disease transmission through blood products increasing, epistaxis is
treated to minimize the need for transfusion. Nasal packing has been the first-line
treatment of patients whose bleeding cannot be managed on an outpatient basis. Packing
provides a tamponade and encourages thrombosis of vessels. There have been signs of
this shifting toward early and prophylactic intervention. [52] One study compared the cost
of hospitalization with nasal packing to hospitalization with surgical intervention and
reported a higher cost and complication rate with surgical intervention. These patients,
however, received surgical intervention only after failing nasal packing. There was a 27%
transfusion rate (3 units per patient) with nasal packing compared with 41% (5.8 units per

patient) with nasal packing failure and subsequent surgery. Another study also noted a
greater transfusion requirement with surgical intervention than without (0.91 units versus
2.93 units, P<.01). [53] These authors suggest that patients requiring more than 3 units of
blood should be considered for surgical intervention. The cost and risk of surgical
intervention must be weighed against the risks of transfusion and compromised
cardiovascular status if rebleeding occurs.
Dealing with a patient with active severe epistaxis can be bloody. The authors
recommend universal precautions for all health care personnel involved in the care of
these patients, including face mask with shields, gowns, hair coverage, and doublegloving.
SUMMARY
Epistaxis is a common clinical problem. The widespread availability of endoscopic
equipment is shifting management philosophy toward targeting the bleeding point. This
shift may have a significant impact on decreasing length of stay and blood transfusion
rates. Advances in interventional radiology have also reduced the risk of embolization.
Patient education, especially teaching first-aid measures to patients at high risk for
nosebleeds, also encourages more effective use of health care resources.
ACKNOWLEDGMENTS
The authors thank Carol Chan for her assistance with the illustration

Epistaxis
Epistaxis, or nasal bleeding, has been reported to occur in up to 60 percent of the general
population.1-3 The condition has a bimodal distribution, with incidence peaks at ages
younger than 10 years and older than 50 years. Epistaxis appears to occur more often in
males than in females.1,4
Epistaxis is common, and affected persons usually do not seek medical attention,
particularly if the bleeding is minor or self-limited. In rare cases, however, massive nasal
bleeding can lead to death.5-7
Anatomy
The rich vascular supply of the nose originates from the ethmoid branches of the internal
carotid arteries and the facial and internal maxillary divisions of the external carotid
arteries.5 Although nasal circulation is complex (Figure 1), epistaxis usually is described
as either anterior or posterior bleeding. This simple distinction provides a useful basis for
management.

Figure 1. Vascular anatomy of nasal septal blood supply.

Most cases of epistaxis occur in the anterior part of the nose, with the bleeding usually
arising from the rich arterial anastomoses of the nasal septum (Kiesselbach's plexus).

TABLE 1
Common Causes of Epistaxis

Posterior epistaxis generally arises from

the posterior nasal cavity via branches of
the sphenopalatine arteries.8 Such
bleeding usually occurs behind the
posterior portion of the middle turbinate
or at the posterior superior roof of the
nasal cavity.

Local causes

In most cases, anterior bleeding is

clinically obvious. In contrast, posterior
bleeding may be asymptomatic or may
present insidiously as nausea,
hematemesis, anemia, hemoptysis, or
melena. Infrequently, larger vessels are
involved in posterior epistaxis and can
result in sudden, massive bleeding.

Intranasal neoplasm or polyps

Etiology
Most causes of nasal bleeding can be
identified readily through a directed
history and physical examination. The
patient should be asked about the initial
presentation of the bleeding, previous
bleeding episodes and their treatment,
comorbid conditions, and current
medications, including over-the-counter
medicines and herbal and home remedies.
Although the differential diagnosis should
include both local and systemic causes
(Table 1),1,5,9 environmental factors such
as humidity and allergens also must be
considered.5,10 Often, no cause for the
bleeding is identified.

Chronic sinusitis
Epistaxis digitorum (nose picking)
Foreign bodies

Irritants (e.g., cigarette smoke)

Medications (e.g., topical corticosteroids)
Rhinitis
Septal deviation
Septal perforation
Trauma
Vascular malformation or telangiectasia
Systemic causes
Hemophilia
Hypertension
Leukemia
Liver disease (e.g., cirrhosis)

Management

Medications (e.g., aspirin, anticoagulants,

nonsteroidal anti-inflammatory drugs)

general approach

Platelet dysfunction

Initial management includes compression Thrombocytopenia

of the nostrils (application of direct
pressure to the septal area) and plugging
of the affected nostril with gauze or cotton Information from references 1, 5, and 9.
that has been soaked in a topical
decongestant. Direct pressure should be
applied continuously for at least five minutes, and for up to 20 minutes. Tilting the head

forward prevents blood from pooling in the posterior pharynx, thereby avoiding nausea
and airway obstruction. Hemodynamic stability and airway patency should be confirmed.
Fluid resuscitation should be initiated if volume depletion is
suspected.
Initial management of
epistaxis includes
Every attempt should be made to locate the source of
compression of the nostrils
bleeding that does not respond to simple compression and
and plugging of the
nasal plugging. The examination should be performed in a
affected nostril with gauze
well-lighted room, with the patient seated and clothing
or cotton that has been
protected by a sheet or gown. The physician should wear
soaked in a topical
gloves and other appropriate protective equipment (e.g.,
decongestant.
surgical mask, safety glasses). A headlamp or head mirror and
a nasal speculum should be used for optimal visualization.
An epistaxis tray can be created using common supplies and a few specialized
instruments (Figure 2). Clots and foreign bodies in the anterior nasal cavity can be
removed with a small (Frazier) suction tip, irrigation, forceps, and cotton-tipped
applicators.

Figure 2. Typical contents of an epistaxis tray. Top row: nasal decongestant

sprays and local anesthetic, silver nitrate cautery sticks, bayonet forceps,
nasal speculum, Frazier suction tip, posterior double balloon system and
syringe for balloon inflation. Bottom row: Packing materials, including
nonadherent gauze impregnated with petroleum jelly and 3 percent bismuth
tribromophenate (Xeroform), Merocel, Gelfoam, and suction cautery.

When posterior bleeding is suspected, the general location of the source should be
determined. This step is important because different arteries supply the floor and roof of
the posterior nasal cavity; therefore, selective ligation may be required.5,11
Diffuse oozing, multiple bleeding sites, or recurrent bleeding may indicate a systemic
process such as hypertension, anticoagulation, or coagulopathy. In such cases, a
hematologic evaluation should be performed. Appropriate tests include a complete blood
count, anticoagulant levels, a prothrombin time, a partial thromboplastin time, a platelet
count and, if indicated, blood typing and crossmatching.9,12
Although most patients with epistaxis can be treat-ed as outpatients, hospital admission
and close observation should be considered for elderly patients and patients with
posterior bleeding or coagulopathy. Admission also may be prudent for patients with
complicating comorbid conditions such as coronary artery disease, severe hypertension,
or significant anemia.
anterior epistaxis
If a single anterior bleeding site is found, vasoconstriction
should be attempted with topical application of a 4 percent
cocaine solution or an oxymetazoline or phenylephrine
solution. For bleeding that is likely to require more
aggressive treatment, a local anesthetic, such as a 4 percent
cocaine solution or tetracaine or lidocaine (Xylocaine)
solution, should be used. Adequate anesthesia should be
obtained before treatment proceeds.

Diffuse oozing, multiple

bleeding sites, or recurrent
bleeding may indicate a
systemic process such as
hypertension,
anticoagulation, or
coagulopathy.

Intravenous access should be obtained in difficult cases, especially when anxiolytic

medications are to be used.
Cotton pledgets soaked in vasoconstrictor and anesthetic should be placed in the anterior
nasal cavity, and direct pressure should be applied at both sides of the nose for at least
five minutes. Then the pledgets can be removed for reinspection of the bleeding site. If
this measure is unsuccessful, chemical cautery can be attempted using a silver nitrate
stick applied directly to the bleeding site for approximately 30 seconds.5 Other treatment
options include hemostatic packing with absorbable gelatin foam (Gelfoam) or oxidized
cellulose (Surgicel). Use of desmopressin spray (DDAVP) may be considered in a patient
with a known bleeding disorder.5,13
Larger vessels generally respond more readily to
electrocautery. However, electrocautery must be performed
cautiously to avoid excessive destruction of healthy
surrounding tissues. Note that use of electrocautery on both
sides of the septum may increase the risk of septal
perforation.9 Interestingly, at least one study14 found no

Complications of nasal
packing procedures
include septal hematomas
and abscesses, sinusitis,
neurogenic syncope, and
pressure necrosis.

difference in efficacy or complication rate between chemical cautery (silver nitrate stick)
and electrocautery.
If local treatments fail to stop anterior bleeding, the anterior nasal cavity should be
packed, from posterior to anterior, with ribbon gauze impregnated with petroleum jelly or
polymyxin B-bacitracin zinc-neomycin (Neosporin) ointment. Nonadherent gauze
impregnated with petroleum jelly and 3 percent bismuth tribromophenate (Xeroform)
also works well for this purpose.5,9 Bayonet forceps and a nasal speculum are used to
approximate the accordion-folded layers of the gauze, which should extend as far back
into the nose as possible. Each layer should be pressed down firmly before the next layer
is inserted (Figure 3). Once the cavity has been packed as completely as possible, a gauze
"drip pad may be taped over the nostrils and changed periodically.

Figure 3. Packing of the anterior nasal cavity using gauze strip impregnated with
petroleum jelly. A. Gauze is gripped with bayonet forceps and inserted into the anterior
nasal cavity. B. With a nasal speculum (not shown) used for exposure, the first packing
layer is inserted along the floor of the anterior nasal cavity. Forceps and speculum then
are withdrawn. C. Additional layers of packing are added in an accordion-fold fashion,
with the nasal speculum used to hold the positioned layers down while a new layer is
inserted. Packing is continued until the anterior nasal cavity is filled.
Alternatively, a preformed nasal tampon (Merocel or Doyle sponge) may be used.12 The
tampon is inserted carefully along the floor of the nasal cavity, where it expands on
contact with blood or other liquid. Application of lubricant jelly to the tip of the tampon
facilitates placement. After the nasal tampon has been inserted, wetting it with a small
amount of topical vasoconstrictor may hasten effectiveness. It may be necessary to drip
saline into the nostril to achieve full expansion of the tampon if the bleeding has
decreased at the time of insertion. Although one study15 found no significant difference
in patient comfort or efficacy with nasal tampons or ribbon gauze packing, simplicity of
placement makes the tampons highly useful in primary care settings. When applied in the
outpatient setting, nasal packing may be left in place for three to five days to ensure
formation of an adequate clot.12
Complications of nasal packing procedures include septal hematomas and abscesses from
traumatic packing, sinusitis, neurogenic syncope during packing, and pressure necrosis
secondary to excessively tight packing. Because of the possibility of toxic shock
syndrome with prolonged nasal packing, use of a topical antistaphylococcal antibiotic
ointment on the packing materials has been recommended.10,12

posterior epistaxis
Posterior bleeding is much less common than anterior bleeding16 and usually is treated
by an otolaryngologist. Posterior packing may be accomplished by passing a catheter
through one nostril (or both nostrils), through the nasopharynx, and out the mouth
(Figure 4). A gauze pack then is secured to the end of the catheter and positioned in the
posterior nasopharynx by pulling back on the catheter until the pack is seated in the
posterior choana, sealing the posterior nasal passage and applying pressure to the site of
the posterior bleeding.5 Although this procedure is not outside the scope of family
practice, it requires special training and usually is performed by an otolaryngologist.

Figure 4. Posterior nasal packing. A. After adequate anesthesia has been

obtained, a catheter is passed through the affected nostril and through the
nasopharynx, and drawn out the mouth with the aid of ring forceps. B. A
gauze pack is secured to the end of the catheter using umbilical tape or suture
material, with long tails left to protrude from the mouth. C. The gauze pack is
guided through the mouth and around the soft palate using a combination of
careful traction on the catheter and pushing with a gloved finger. This is the
most uncomfortable (and most dangerous) part of the procedure; it should be
completed smoothly and with the aid of a bite block (not shown) to protect
the physician's finger. D. The gauze pack should come to rest in the posterior
nasal cavity. It is secured in position by maintaining tension on the catheter
with a padded clamp or firm gauze roll placed anterior to the nostril. The ties
protruding from the mouth, which will be used to remove the pack, are taped

to the patient's cheek.

Various balloon systems are effective for managing posterior bleeding and are less
complicated than the packing procedure. The double-balloon device (Figure 2) is passed
into the affected nostril under topical anesthesia until it reaches the nasopharynx. The
posterior balloon then is inflated with 7 to 10 mL of saline, and the catheter extending out
of the nostril is withdrawn carefully so that the balloon seats in the posterior nasal cavity
to tamponade the bleeding source. Next, the anterior balloon is inflated with roughly 15
to 30 mL of saline in the anterior nasal cavity to prevent retrograde travel of the posterior
balloon and subsequent airway obstruction. An umbilical clamp or other device can be
placed across the stalk of the balloon adjacent to the nostril to further prevent
dislodgement; the clamp should be padded to prevent pressure necrosis of the nasal skin.
Balloon packs generally are left in place for two to five days. As with anterior packing,
tissue necrosis can occur if a posterior pack is inserted improperly or balloons are
overinflated.
If a specialized balloon device is not available, a Foley catheter (10 to 14 French) with a
30-mL balloon may be used. The catheter is inserted through the bleeding nostril and
visualized in the oropharynx before inflation of the balloon.18 The balloon then is
inflated with approximately 10 mL of saline, and the catheter is withdrawn gently
through the nostril, pulling the balloon up and forward. The balloon should seat in the
posterior nasal cavity and tamponade a posterior bleed. With traction maintained on the
catheter, the anterior nasal cavity then is packed as previously described. Traction is
maintained by placing an umbilical clamp on the catheter beyond the nostrils, which
should be padded to prevent soft tissue damage. As with anterior epistaxis, topical
antistaphylococcal antibiotic ointment may be used to prevent toxic shock syndrome.
However, use of oral or intravenous antibiotics for posterior nasal packing most likely is
unnecessary.19
persistent bleeding
Patients with anterior or posterior bleeding that continues despite packing or balloon
procedures may require treatment by an otolaryngologist. Endoscopy may be used to
locate the exact site of bleeding for direct cauterization.
Hot water irrigation, a technique described more than 100 years ago, has been
reexamined recently. This technique has shown promise in reducing discomfort and
length of hospitalization in patients with posterior epistaxis.20,21 More invasive
alternatives include arterial ligation and angiographic arterial embolization.
Strength of Recommendations
Key clinical recommendation

LabelReferences

If local treatments fail to stop anterior bleeding, the anterior nasal cavity

5, 9

should be packed from posterior to anterior with ribbon gauze

impregnated with petroleum jelly or antibiotic ointment.
Based on one study, chemical cautery (silver nitrate sticks) can be used for C
simple anterior epistaxis because it has efficacy and complication rates
similar to electrocautery.

14

Because of the possibility of toxic shock syndrome with prolonged nasal C

packing, use of a topical antistaphylococcal antibiotic ointment on the
packing materials has been recommended.

10, 12

Either ribbon gauze packing or nasal tampons can be used for packing;
one study found no significant difference in patient comfort or efficacy.

15

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality

patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, opinion,
or case series. See page 225 for more information.
The authors indicate they do not have any conflicts of interest. Sources of funding: none
reported.
The opinions and assertions contained herein are the private views of the authors and are
not to be construed as official or as reflecting the views of the U.S. Navy Medical
Department or the U.S. Naval Service at large.
The authors thank James R. Phelan, CDR, MC, USN, head of otorhinolaryngology at the
Naval Aerospace Medical Institute, Pensacola, Fla., for guidance and review of the
manuscript.
Members of various family practice departments develop articles for "Practical
Therapeutics. This article is one in a series coordinated by the Department of Family
Medicine at Naval Hospital, Jacksonville, Fla. Guest editor of the series is Anthony J.
Viera, LCDR, MC, USNR.