Epistaxis: Difference between revisions
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==Background==
==Background==
[[File:Arteries of the Nose.jpg|thumb|The arteries that supply Kiesselbach's plexus (responsible for anterior nosebleeds).]]
[[File:PMC3895177 270 2013 776 Fig1 HTML.png|thumb|Schematic arterial supply of the sinonasal cavity. The majority of the posterior epistaxis episodes arise from the septum. The arterial branches involved in epistaxis include the internal maxillary artery, the facial artery, and the ophthalmic artery.]]
===Types===
===Types===
*Anterior
*Anterior
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**10% of nosebleeds
**10% of nosebleeds
**Occur from nasopalatine branch of sphenopalatine artery
**Occur from nasopalatine branch of sphenopalatine artery
**Cannot visualize
**Cannot visualize without endoscope


===Risk factors===
===Risk factors===
*Digital trauma
*Digital trauma (i.e. nose-picking)
*Rhinosinusitis
*Rhino[[sinusitis]]
*Anticoagulant/antiplatelet use
*[[Anticoagulant]]/[[antiplatelet]] use
*Trauma
*[[Facial trauma|Trauma]]
*Neoplasia
*Neoplasia, [[juvenile nasopharyngeal angiofibroma]]
*Hypertension (does not cause bleeding but prolongs existing bleeding)
*Dried mucus membranes
*[[Hypertension]] (does not cause bleeding but prolongs existing bleeding)
*Osler-Weber-Rendu ([[Hereditary hemorrhagic telangiectasia]])
 
===Essential Equipment===
*Light source
*Nasal speculum
*Suction
*Airway equipment
*Packing or constrictive devices
 
==Clinical Features==
[[File:Young child with nosebleed, smiling cropped.jpg|thumb|Anterior nosebleed after trauma in pediatric patient.]]
*Epistaxis
**Anterior: more likely from one nares
**Posterior: more likely from two nares


==Diagnosis==
==Differential Diagnosis==
*Anterior versus posterior hemorrhage
*[[Facial trauma]]
**Assume posterior if measures to control anterior bleeding fail
*[[Coagulopathy]]
**Posterior bleeding associated with:
*Nasal tumor
***Coagulopathy
*[[Juvenile Nasopharyngeal Angiofibroma (JNA)]]
***Significant hemorrhage visible in posterior nasopharynx
*[[Hemophilia]]
***Sensation of blood dripping down throat
*Arteriovenous malformation
***Hemorrhage from bilateral nares
 
***Epistaxis uncontrolled w/ either anterior rhinoscopy or anterior pack
==Evaluation==
===Anterior versus posterior hemorrhage===
*Assume posterior if measures to control anterior bleeding fail
*Posterior bleeding associated with:
**[[Coagulopathy]]
**Significant hemorrhage visible in posterior nasopharynx
**Sensation of blood dripping down throat
**Hemorrhage from bilateral nares
**Epistaxis uncontrolled with either anterior rhinoscopy or anterior pack
 
==Management==
[[File:BleedingNose.jpg|thumb|Demonstration of direct nasal pressure.]]
''Proceed down a stepwise fashion from pressure to vasoconstriction and topical devices to packing while considering risk factors that initiated the event. When initially visualizing, place the patient in the "sniffing position” with the patient slightly leaning forward. Use the speculum in the superior-inferior orientation to avoid septal trauma.  Evaluate for polyps, masses, trauma, and bleeding sources.<ref>Barnes ML, Spielmann PM, White PS. Epistaxis: a contemporary evidence based approach. Otolaryngol Clin North Am. 2012 Oct;45(5):1005-17. PMID: 22980681</ref>''


==Treatment ==
===Direct Nasal Pressure===
===Direct Nasal Pressure===
#Have pt blow nose to expel clots or suction nose
#Have patient blow nose or use suction to expel clots
#Instill topical vasoconstrictor (oxymetazoline or phenylephrine)
#Instill topical vasoconstrictor ([[oxymetazoline]] or [[phenylephrine]])
#Have pt apply direct pressure over cartilaginous area of nasal bridge (not the bony area)
#Have patient apply direct pressure over cartilaginous area of nasal bridge (not the bony area)
#Pt may lean forward to avoid aspiration of blood
#*Can use 2 tongue depressors taped together on one end to create a makeshift device to pinch the nose
#*Attempt direct pressure for at least 20 minutes before moving to additional modalities
#Patient must lean forward to avoid blood draining down nasopharynx thus preventing desired tamponade


===Chemical Cauterization===
===Chemical Cauterization===
#Consider if two attempts at direct pressure fail
''Generally only effective if acute bleeding has stopped and friable site of bleeding can be adequately visualized.  Less effective in acute hemorrhage''
#Only perform if the bleeding vessel is adequately visualized
*Usually Kesselbach's plexus for anterior bleeds
#Anesthetize w/ cotton pledgets soaked in 1:1 mix of 0.05% oxymetazoline:4% lidocaine
#Anesthetize with cotton pledgets soaked in 1:1 mix of 0.05% oxymetazoline:4% lidocaine
#Once bloodless field obtained, place silver nitrate just proximal to bleeding source
#Once bloodless field obtained, place silver nitrate just proximal to bleeding source
##Leave on for a few seconds at most
#*Leave on for a few seconds at most
##Never cauterize both sides of the septum at one go (risk of septal perforation)
#*Never cauterize both sides of the septum at one go (risk of septal perforation)
#*[https://www.nejm.org/doi/full/10.1056/NEJMvcm2020073 Video of silver nitrate cauterization].


===Thrombogenic Foams===
===Thrombogenic Foams===
#Apply Gelfoam or Surgicel on visualized bleeding mucosa
#Apply Gelfoam or Surgicel on visualized bleeding mucosa
#Bioabsorbable so removal/abx not needed
#These materials are bioabsorbable so removal/antibiotics not needed
 
===Anterior Nasal Packing===
===Anterior Nasal Packing===
*Only use if all of the above have failed
''Only use if all of the above have failed''
#Rapid Rhino
#Rapid Rhino
##Soak balloon w/ water(NOT saline) and insert along the floor of the nasal cavity
#*Soak balloon with water (NOT saline) and insert along the floor of the nasal cavity
##Inflate slowly with air(NOT saline or water) until the bleeding stops
#*Inflate slowly with air (NOT saline or water) until the bleeding stops
#Merocel
#Merocel
##Absorbent nasal tampon
#*Absorbent nasal tampon
##Coat tampon w/ water-soluble abx ointment and insert along floor of nasal cavity
#*Coat tampon with water-soluble antibiotics ointment and insert along floor of nasal cavity
##If tampon has not expanded w/in 30s of placement, irrigate it in place w/ NS
#*If tampon has not expanded within 30s of placement, irrigate it in place with NS
##Moisten three times per day with saline or water until removal
#*Moisten three times per day with saline or water until removal
#Traditional Packing
#Traditional Packing
##Apply ribbon gauze in accordion-like manner
#*Apply ribbon gauze in accordion-like manner


===Tranexamic acid===
===Posterior Nasal Packing===
#500mg TXA applied to topical foam or non absorbable packing and inserted into nares.<ref>Zahed R. et al. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial.Am J Emerg Med. 2013 Sep;31(9):1389-92</ref>
''90% of epistaxis is anterior.  Only consider posterior packing if all of the above have failed.''
#Can stop bleeding as fast as 10 minutes
*Associated with higher complication rates (pressure necrosis, infection, hypoxia)
**Temporizing measure while awaiting ENT support
*Consider nasal block as posterior packing is often very uncomfortable
*All posterior packing should be accompanied by anterior packing
*Rapid Rhino-rocket 7.5 cm +. Also a dual chamber 9 cm packing available. Inflate posterior then anterior baloons
*Foley catheter with 30-cc balloon if dedicated posterior packing not available
*#Lubricate with topical antibiotic
*#Advance transnasally until visualized in posterior oropharynx
*#Inflate balloon with 7cc of saline; retract 2-3cm until lodged in post nasopharynx
*#Inflate with additional 5-7cc of saline to complete the pack
*Keep packing for 72-96 hours, <48 hours associated with increased re-bleed.


===Posterior Nasal Packing===
===[[Tranexamic acid]]===
#Only consider if all of the above have failed
''*The NoPAC trial showed no difference in anterior packing rates with or without topical [[TXA]]. Higher quality evidence than prior studies.<ref>Reuben A, Appelboam A, Stevens KN, et al. The use of tranexamic acid to reduce the need for nasal packing in epistaxis (Nopac): randomized controlled trial. Annals of Emergency Medicine. 2021;77(6):631-640.</ref>''
#Associated w/ higher complication rates (pressure necrosis, infection, hypoxia)
*500mg [[TXA]] applied to topical foam or non-absorbable packing and inserted into nares.<ref>Zahed R. et al. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial.Am J Emerg Med. 2013 Sep;31(9):1389-92</ref>
##Temporizing measure while awaiting ENT support
**Injectable form of tranexamic acid (500mg/5mL), not the dilute form
#Consider nasal block as posterior packing is often very uncomfortable
**Can consider adding Epinephrine to non-absorbable packing to assist with vasoconstriction
#All posterior packing should be accompanied by anterior packing
 
#Rapid Rhino
==Disposition==
##Inflate posterior balloon
===Anterior Epistaxis===
#Foley catheter w/ 30-cc balloon
*Consider checking hemoglobin to ensure no significant blood loss anemia
##Lubricate w/ topical antibiotic
*Discharge after 1 hour of observation
##Advance transnasally until visualized in posterior oropharynx
*Patients on Warfarin with therapeutic INR may continue medication
##Inflate balloon w/ 7cc of saline; retract 2-3cm until lodged in post nasopharynx
*Discontinue [[NSAIDs]] for 3-4 days
##Inflate w/ additional 5-7cc of saline to complete the pack
*Possible [[amoxicillin-clavulanate]] if anterior packing was placed as prophylaxis for bacterial sinus infection or [[Toxic shock syndrome]] although no robust evidence base<ref>Cohn B. Are prophylactic antibiotics necessary for anterior nasal packing in epistaxis? Ann Emerg Med. 2015 Jan;65(1):109-11</ref>
#Keep packing for 72-96 hours, <48 hours associated with increased re-bleed.
*ENT or ED follow-up in 2-3d for removal of nonbiodegradable packing
*Admit if bilateral packing, symptomatic [[anemia]], or anemia requiring [[transfusion]]
 
===Posterior Epistaxis===
*Admission to telemetry is strongly advised
*Posterior packing causes vagal stimulation, increasing risk of [[dysrhythmia]] and bronchoconstriction


==Complications==
==Complications==
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*[[Toxic Shock Syndrome]]
*[[Toxic Shock Syndrome]]


==Disposition==
==See Also==
#Anterior Epistaxis
*[[In-Training Exam Review]]
##Discharge after 1hr of observation
##Pts w/ therapeutic warfarin levels may continue medication
##Discontinue NSAIDs for 3-4d
##Possible amoxicillin-clavulanate if anterior packing was placed as prophylaxis for bacterial sinus infection or TSS, though not standard of care.
##ENT or ED follow-up in 2-3d for removal of nonbiodegradable packing
#Posterior Epistaxis
##Admission is strongly advised


==References==
==References==
<references/>
<references/>
[[Category:ENT]]
[[Category:ENT]]
[[Category:Symptoms]]

Latest revision as of 19:49, 26 April 2023

Background

The arteries that supply Kiesselbach's plexus (responsible for anterior nosebleeds).
Schematic arterial supply of the sinonasal cavity. The majority of the posterior epistaxis episodes arise from the septum. The arterial branches involved in epistaxis include the internal maxillary artery, the facial artery, and the ophthalmic artery.

Types

  • Anterior
    • 90% of nosebleeds
    • Occur in anterior septum (Kiesselbach plexus)
    • Can visualize with anterior rhinoscopy
  • Posterior
    • 10% of nosebleeds
    • Occur from nasopalatine branch of sphenopalatine artery
    • Cannot visualize without endoscope

Risk factors

Essential Equipment

  • Light source
  • Nasal speculum
  • Suction
  • Airway equipment
  • Packing or constrictive devices

Clinical Features

Anterior nosebleed after trauma in pediatric patient.
  • Epistaxis
    • Anterior: more likely from one nares
    • Posterior: more likely from two nares

Differential Diagnosis

Evaluation

Anterior versus posterior hemorrhage

  • Assume posterior if measures to control anterior bleeding fail
  • Posterior bleeding associated with:
    • Coagulopathy
    • Significant hemorrhage visible in posterior nasopharynx
    • Sensation of blood dripping down throat
    • Hemorrhage from bilateral nares
    • Epistaxis uncontrolled with either anterior rhinoscopy or anterior pack

Management

Demonstration of direct nasal pressure.

Proceed down a stepwise fashion from pressure to vasoconstriction and topical devices to packing while considering risk factors that initiated the event. When initially visualizing, place the patient in the "sniffing position” with the patient slightly leaning forward. Use the speculum in the superior-inferior orientation to avoid septal trauma. Evaluate for polyps, masses, trauma, and bleeding sources.[1]

Direct Nasal Pressure

  1. Have patient blow nose or use suction to expel clots
  2. Instill topical vasoconstrictor (oxymetazoline or phenylephrine)
  3. Have patient apply direct pressure over cartilaginous area of nasal bridge (not the bony area)
    • Can use 2 tongue depressors taped together on one end to create a makeshift device to pinch the nose
    • Attempt direct pressure for at least 20 minutes before moving to additional modalities
  4. Patient must lean forward to avoid blood draining down nasopharynx thus preventing desired tamponade

Chemical Cauterization

Generally only effective if acute bleeding has stopped and friable site of bleeding can be adequately visualized. Less effective in acute hemorrhage

  • Usually Kesselbach's plexus for anterior bleeds
  1. Anesthetize with cotton pledgets soaked in 1:1 mix of 0.05% oxymetazoline:4% lidocaine
  2. Once bloodless field obtained, place silver nitrate just proximal to bleeding source

Thrombogenic Foams

  1. Apply Gelfoam or Surgicel on visualized bleeding mucosa
  2. These materials are bioabsorbable so removal/antibiotics not needed

Anterior Nasal Packing

Only use if all of the above have failed

  1. Rapid Rhino
    • Soak balloon with water (NOT saline) and insert along the floor of the nasal cavity
    • Inflate slowly with air (NOT saline or water) until the bleeding stops
  2. Merocel
    • Absorbent nasal tampon
    • Coat tampon with water-soluble antibiotics ointment and insert along floor of nasal cavity
    • If tampon has not expanded within 30s of placement, irrigate it in place with NS
    • Moisten three times per day with saline or water until removal
  3. Traditional Packing
    • Apply ribbon gauze in accordion-like manner

Posterior Nasal Packing

90% of epistaxis is anterior. Only consider posterior packing if all of the above have failed.

  • Associated with higher complication rates (pressure necrosis, infection, hypoxia)
    • Temporizing measure while awaiting ENT support
  • Consider nasal block as posterior packing is often very uncomfortable
  • All posterior packing should be accompanied by anterior packing
  • Rapid Rhino-rocket 7.5 cm +. Also a dual chamber 9 cm packing available. Inflate posterior then anterior baloons
  • Foley catheter with 30-cc balloon if dedicated posterior packing not available
    1. Lubricate with topical antibiotic
    2. Advance transnasally until visualized in posterior oropharynx
    3. Inflate balloon with 7cc of saline; retract 2-3cm until lodged in post nasopharynx
    4. Inflate with additional 5-7cc of saline to complete the pack
  • Keep packing for 72-96 hours, <48 hours associated with increased re-bleed.

Tranexamic acid

*The NoPAC trial showed no difference in anterior packing rates with or without topical TXA. Higher quality evidence than prior studies.[2]

  • 500mg TXA applied to topical foam or non-absorbable packing and inserted into nares.[3]
    • Injectable form of tranexamic acid (500mg/5mL), not the dilute form
    • Can consider adding Epinephrine to non-absorbable packing to assist with vasoconstriction

Disposition

Anterior Epistaxis

  • Consider checking hemoglobin to ensure no significant blood loss anemia
  • Discharge after 1 hour of observation
  • Patients on Warfarin with therapeutic INR may continue medication
  • Discontinue NSAIDs for 3-4 days
  • Possible amoxicillin-clavulanate if anterior packing was placed as prophylaxis for bacterial sinus infection or Toxic shock syndrome although no robust evidence base[4]
  • ENT or ED follow-up in 2-3d for removal of nonbiodegradable packing
  • Admit if bilateral packing, symptomatic anemia, or anemia requiring transfusion

Posterior Epistaxis

  • Admission to telemetry is strongly advised
  • Posterior packing causes vagal stimulation, increasing risk of dysrhythmia and bronchoconstriction

Complications

See Also

References

  1. ↑ Barnes ML, Spielmann PM, White PS. Epistaxis: a contemporary evidence based approach. Otolaryngol Clin North Am. 2012 Oct;45(5):1005-17. PMID: 22980681
  2. ↑ Reuben A, Appelboam A, Stevens KN, et al. The use of tranexamic acid to reduce the need for nasal packing in epistaxis (Nopac): randomized controlled trial. Annals of Emergency Medicine. 2021;77(6):631-640.
  3. ↑ Zahed R. et al. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial.Am J Emerg Med. 2013 Sep;31(9):1389-92
  4. ↑ Cohn B. Are prophylactic antibiotics necessary for anterior nasal packing in epistaxis? Ann Emerg Med. 2015 Jan;65(1):109-11
  5. ↑ Primary malignant melanoma of the nose: a rare cause of epistaxis in the elderly. PDF
  6. ↑ Kaposiform hemangioendothelioma arising in the ethmoid sinus of an 8‐year‐old girl with severe epistaxis PDF
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