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Epistaxis
Claire M McLarnon
Sean Carrie
Abstract
Epistaxis is extremely common and usually managed with simple first aid
measures in the community. However it can also present with life-threatening haemorrhage which requires appropriate resuscitation and arrest of
the bleeding. Of those patients presenting to local emergency services,
knowledge of the assessment and management of epistaxis are essential.
Epistaxis is classified as primary epistaxis, where no cause can be found
or secondary epistaxis where there is a defined cause. It is also described
in terms of the site of bleeding. Anterior bleeding from the nasal septum
is found in 90% of cases and can be controlled with simple first aid measures or nasal packing and/or cautery. Posterior bleeding is more dramatic
and may require a surgical procedure or radiological guided embolization.
Many patients, particularly the elderly have associated co-morbidities and
medications that need to be addressed along with the standard treatment. This article discusses the assessment and appropriate management
of patients with epistaxis and their associated morbidities.
Anatomy
Terminal branches of the external and internal carotid arteries
supply the nasal cavity with frequent anastomosis between them
on the nasal septum, lateral wall and midline. The anterior nasal
septum is a particularly well-described site of anastomosis between the external and internal carotid arterial systems where an
abundant plexus of vessels called Littles or Kiesselbachs area
are found (Figure 1). This is the site at which up to 90% of
epistaxis originates.
The branches of the external carotid artery supplying Littles
area include terminal branches of the internal maxillary artery
which are the sphenopalatine artery and the greater palatine
artery. The other external carotid branch is the facial artery,
which supplies the superior labial artery. The sphenopalatine
artery enters the nose via the sphenopalatine foramen in the
lateral nasal wall at the posterior end of the middle turbinate. It
then branches to supply most of the nasal septum and much of
the lateral nasal wall. The superior labial artery can be found
entering the nose from below just lateral to the anterior nasal
spine to supply the anterior nasal septum. This artery and the
greater palatine are often overlooked as they need to be identified
on or nearer the floor of the nose.
The internal carotid artery supplies the superior part of the
nasal cavity by way of the ophthalmic artery which gives off the
anterior and posterior ethmoidal arteries. These arteries run into
the roof of the nose from the orbit via their respective anterior
and posterior foramina. The posterior ethmoidal artery is smaller
than the anterior ethmoidal artery. It is absent in approximately
20% of individuals and can be found only a few millimetres (2e5
mm) anterior to the optic nerve as it exits the optic canal, and
about 10e12 mm posterior to the anterior ethmoidal artery.
Knowledge of the course and branching patterns of these arteries
is essential in the surgical management of epistaxis involving
these vessels.
Introduction
Epistaxis is defined as acute haemorrhage from within the nasal
cavity including the nasopharynx. It is a common condition
ranging in severity from a single short-lived episode to a less
common life-threatening haemorrhage. The majority of cases are
self-limiting and do not require medical intervention. Of those
patients who do attend Accident and Emergency with an
epistaxis, the vast majority can be managed in the A&E department. Referral to ENT is reserved for the minority of cases where
the epistaxis is severe and/or there are other associated patient
factors or co-morbidities requiring admission. Epistaxis is classified as primary epistaxis, where no cause can be found or
secondary epistaxis where there is a defined cause for example
nasal trauma.
Incidence
The reported incidence of an episode of epistaxis occurring
during a lifetime is approximately 60%, with less than 10%
requiring medical attention.1 There is a bimodal distribution of
epistaxis incidence with peaks in children and the older adult.
Epistaxis is rare in children under the age of 2 years; however it
Aetiology
Most causes of epistaxis can be identified through a directed
history and physical examination. The patient history should
include details of the initial presentation of bleeding, previous
bleeding episodes and their treatment, comorbid conditions, and
current medications. Risk factors and causes of secondary
epistaxis can be divided into local and systemic aetiologies
(Table 1). Despite no obvious cause in primary epistaxis, it is
well recognized that there is an increased frequency of epistaxis
in the autumn and winter months.4 This correlates with changes
in temperature and humidity, which may be the causative factors. It has also been found that there is a circadian rhythm, with
peaks in incidence of epistaxis in the morning and late evening.5
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Please cite this article in press as: McLarnon CM, Carrie S, Epistaxis, Surgery (2015), http://dx.doi.org/10.1016/j.mpsur.2015.09.006
Epistaxis in children
Epistaxis in children is common and often related to repeated
digital trauma (nose picking) in combination with mucosal
changes due to reduced humidification seen in the winter
months. However some children get repeated nose bleeds with
no specific cause (recurrent idiopathic epistaxis). Other common
causes include nasal injury, recurrent upper respiratory tract
infections, rhinitis and nasal foreign bodies. Epistaxis from more
serious systemic conditions such as leukaemia or tumours within
the nasal cavity is rare.
Clinical history and careful examination will direct the use of
any further investigations to look for the less common and more
serious causes. Common treatments in children include silver
nitrate cautery and/or a topical antiseptic cream application. A
Cochrane review in 2012 recommended using the weaker
strength of silver nitrate (75% vs 95%) to cauterize bleeding
vessels in recurrent idiopathic epistaxis.6
Examination
Before going to examine a patient it is important to remember to
put on a disposable apron and gloves, and if available a surgical
face mask and eye protection. Patients will be extremely anxious
and it is always worth having an assistant with you to help
support the patient and help with passing and holding equipment. Good lighting is essential and ideally a head light should be
worn but if one is not available a bright torch, lamp or the
auroscope can be used. Suction is a must and you should
remember to provide a bowl and tissues for the patient who
should be sat up preferably in a proper examination chair. If the
bleeding has been controlled with first aid measures or stopped
spontaneously then routine examination of the oropharynx to
check for any on-going posterior bleeding or clots is done followed by anterior rhinoscopy. In patients that continue to bleed
the examination is often combined with the management so as to
stop or reduce bleeding to allow for a better assessment. Therefore it is important to make sure you have equipment and topical
agents to hand before starting. Equipment should include nasal
dressing forceps, nares dilators and a tongue depressor. In the
scenario of a patient continuing to bleed, getting the patient to
blow their nose and removing the clots with the sucker may
enable you to see where the bleeding is coming from. If you
Epistaxis in adults
The systemic causes of epistaxis are more relevant in adults with
particular attention to the use of anti-coagulants. Hypertension is
seen in many adults presenting with epistaxis however there is
no good evidence of a direct role, and in most patients a raised
blood pressure is due to anxiety of having a nose bleed. Trauma
to the nose usually results in an associated epistaxis which in
many cases stops spontaneously. Persistent heavy bleeding after
trauma indicates an arterial cause most often from the anterior
ethmoidal artery and sphenopalatine artery. Early reduction of a
displaced nasal fracture can help, however the patient will most
likely require a surgical intervention to stop the bleeding.
Delayed bleeding of around 7 weeks following major facial
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Please cite this article in press as: McLarnon CM, Carrie S, Epistaxis, Surgery (2015), http://dx.doi.org/10.1016/j.mpsur.2015.09.006
Causes of epistaxis
Local causes of epistaxis
Traumatic
Nasal fracture
Surgical procedures
Nasal intubation
Nose picking e digital trauma
Topical medications
(including intra-nasal steroids)
Cocaine snuffing
Nasal oxygen
Nasal foreign bodies
Structural
Nasal septum deviation
Septal perforation
Inflammatory disease
Common colds and flu
Nasal vestibulitis
Rhinosinusitis
Pyogenic granuloma
Granulomatous disease
(Wegners, TB, sarcoidosis, syphilis)
Environmental irritants
(smoking, chemicals, pollution)
Tumours and vascular malformations
Inverting papilloma, squamous cell
carcinoma, adenocarcinoma,
melanoma of nasal cavity
and paranasal sinuses
Angiofibroma
Haemangioma
Olfactory neuroblastoma
Coagulation disorders
Anticoagulant drugs
(aspirin, clopidogrel, nonsteroidal anti-inflammatory
drugs, warfarin, heparin)
Thrombocytopenia
Acquired coagulopathies
Congenital coagulopathies
Vitamin deficiencies
(A, D, C, E, K)
Liver disease including
chronic alcohol abuse
Renal failure
Malnutrition
Polycythaemia vera
Multiple myeloma
Leukaemia
Vascular disease
Atherosclerosis
Collagen abnormalities
Hereditary haemorrhagic
telangiectasia
Cardiovascular conditions
Cardiac failure, mitral valve
stenosis
Hypertension
Management
Thankfully most patients presenting to A&E will not present in
severe haemodynamic shock, although many may display varying degrees of shock in relation to their blood loss, age and underlying cardiovascular status. All patients who continue to bleed
should have intravenous access and have a blood sample
collected for full blood count and group and save. Other laboratory tests may include coagulation studies, urea and electrolytes, liver function and international normalized ratio for those
patients on warfarin. It is useful to divide epistaxis into anterior
and posterior when discussing their management.8
First aid
Position the patient sitting, with their head over a bowl. Their
nostrils should be pinched together firmly for at least 5e10 minutes, alongside cooling with an icepack on the nose or sucking
an ice lolly if available. Squeezing the top part of the nose over
the bony dorsum never works. Persistent bleeding after 20 minutes requires further intervention.
Anterior epistaxis
This is bleeding from Littles area in most cases (90%). First aid
measures to control bleeding should be attempted initially. If this
fails then the nose should be decongested and the clots cleared as
described above in examination. Any prominent vessel which
bleeds easily on touch or area with a fresh clot is the likely site of
bleeding. Nasal cautery provides an effective treatment for
bleeding here. The area should be anesthetized with a topical
local anaesthetic agent if some has not already been applied.
Silver nitrate on a special applicator is commonly used. Electrocautery is very effective however should only be used by
appropriately trained ENT medical personnel. Application of
silver nitrate is done by rolling the applicator stick between your
thumb and first finger whilst gently applying the tip to the area
you wish to cauterize for 10e20 seconds. Care should be taken to
not accidently burn the nasal skin, when you introduce the
applicator stick into the nose. It is worth starting in an area
immediately adjacent to the vessel making an orbit around the
vessel before rolling the tip in to the centre, directly on the vessel.
Going straight for the vessel usually culminates in making it
bleed again. The danger here is continuing and ending up with a
large area of septal mucosa cauterized and the patient still
bleeding. Occasionally anterior bleeding occurs from the margins
of a septal perforation where cautery can similarly be effective. If
cautery cannot control the bleeding then a nasal pack will be
required. There are numerous types ranging from impregnated
ribbon with Vaseline or bismuth iodoform paraffin paste (BIPP),
nasal tampons and anterior nasal balloons (Figure 2). Availability and familiarity tend to dictate choice as all are similarly
effective.9 Nasal packs should be introduced into the nose
directly front to back following the floor of the nose which is the
same as the roof of the mouth (Figure 3). Never try to place a
pack in an upwards direction as this will not work and will be
Table 1
cannot, then the nose will need to be gently packed with plain
gauze ribbon soaked in a topical decongestant and local anaesthetic agent. Examples of agents used include 2% lidocaine with
1 in 80,000 adrenaline or 1 in 100,000 plain adrenaline with 1%
lidocaine. These should be left in the nasal cavity for 5e10 minutes. During this time you can continue your head and neck
examination including examination of the external nose and face,
ears, neck, oral cavity and oropharynx. It is important to do this
as you may find other physical signs such as telangiectasia seen
in hereditary haemorrhagic telangiectasia (HHT), or petechiae as
a result of thrombocytopenia, or a neck mass secondary to a
sinonasal malignancy. The application of topical vasoconstrictors
in many cases temporarily stops the bleeding. So once you have
removed the impregnated gauze dressing this is the best opportunity to inspect the nasal cavity. Anterior rhinoscopy is ideally
performed with a nares dilator (e.g. a Thudicum nasal speculum), looking for any obvious vessel especially in Littles area.
Again the auroscope can also be used to look at the anterior nasal
septum. Any obvious bleeding source can be cauterized at this
point. If no obvious cause is seen anteriorly then a look posteriorly is required especially looking at the lateral wall in the area
of the sphenopalatine artery. It is difficult to do this with a
headlight and a rigid nasal endoscope is recommended. While
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Posterior epistaxis
This tends to present with much heavier bleeding and many
patients will have signs of haemodynamic shock. Bleeding is
from larger arterial vessels, namely the sphenopalatine artery at
the back of the nasal cavity. There is usually a pattern of rapid
profuse bleeding over 10e20 minutes. It can be difficult to assess
which side the bleeding is from as blood tends to pour down into
the throat and out of both sides of the nose. As the vessel goes
into a reactionary vasospasm the bleeding subsides, however it
will most certainly start again as the vessel relaxes and opens up.
Therefore if you suspect this type of bleeding, even if it has
stopped it is unwise to send the patient home. Because much of
the bleeding goes down the back of the throat, it is then swallowed and some patients present with a clinical picture more like
an upper gastrointestinal bleed with haematemesis. This can be
an even more confusing picture in a patient with a background of
alcoholic liver disease, and a multidisciplinary approach with
Figure 2 From left to right: a) Rapid Rhino nasal pack b) Netcell tampon c)
Co-phenylcaine nasal spray d) Nasal dressing forceps e) Ribbon gauze f )
Silver nitrate cautery stick.
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Please cite this article in press as: McLarnon CM, Carrie S, Epistaxis, Surgery (2015), http://dx.doi.org/10.1016/j.mpsur.2015.09.006
Surgical intervention
Septal surgery
Septoplasty and submucous resection (SMR) have a role in epistaxis
management. Elevating the mucoperiosteum from the septum interrupts the blood supply here and provides effective bleeding
control.11 Straightening of the nasal septum is a useful adjunct for
other procedures where a deviated septum makes access difficult to
assess where the bleeding is coming from and to manage it.
Arterial embolization
Selective angiography and embolization of external carotid arterial
branches is an effective and comparatively successful (80e90%)
alternative to surgical arterial ligation. It is performed by an experienced interventional radiologist under local anaesthetic. Contraindications include severe atherosclerotic disease, untreated coagulopathies and allergy to contrast material. The risk of serious
cerebrovascular injury is around 4%.12 The choice of surgical
ligation or embolization depends on numerous factors including
patient status, availability of personnel and local resources.
Medical therapies
There are numerous individual studies published looking at
various haemostatic products available and their efficacy in
epistaxis but as yet no overall consensus on their use. A review
of locally applied haemostatic agents in epistaxis had been proposed by a Cochrane collaborative group in 2011, however a final
report was never issued recommending any particular agents.13
Products include fibrin-based agents which are typically
SURGERY --:-
Please cite this article in press as: McLarnon CM, Carrie S, Epistaxis, Surgery (2015), http://dx.doi.org/10.1016/j.mpsur.2015.09.006
SURGERY --:-
Please cite this article in press as: McLarnon CM, Carrie S, Epistaxis, Surgery (2015), http://dx.doi.org/10.1016/j.mpsur.2015.09.006