Epistaxis

Background

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

Risk factors

• Digital trauma
• Rhinosinusitis
• Anticoagulant/antiplatelet use
• Trauma
• Neoplasia
• Hypertension (does not cause bleeding but prolongs existing bleeding)
• Osler-Weber-Rendu aka hereditary hemorrhagic telangiectasia (HHT)

Diagnosis

• 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 w/ either anterior rhinoscopy or anterior pack

Treatment

Direct Nasal Pressure

• Have pt blow nose to expel clots or suction nose
• Instill topical vasoconstrictor (oxymetazoline or phenylephrine)
• Have pt apply direct pressure over cartilaginous area of nasal bridge (not the bony area)
• Pt may lean forward to avoid aspiration of blood

Chemical Cauterization

• Consider if two attempts at direct pressure fail
• Only perform if the bleeding vessel is adequately visualized
• Anesthetize w/ 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
  • Leave on for a few seconds at most
  • Never cauterize both sides of the septum at one go (risk of septal perforation)

Thrombogenic Foams

• Apply Gelfoam or Surgicel on visualized bleeding mucosa
• Bioabsorbable so removal/abx not needed

Anterior Nasal Packing

• Only use if all of the above have failed
• Rapid Rhino
  • Soak balloon w/ water(NOT saline) and insert along the floor of the nasal cavity
  • Inflate slowly with air(NOT saline or water) until the bleeding stops
• Merocel
  • Absorbent nasal tampon
  • Coat tampon w/ water-soluble abx ointment and insert along floor of nasal cavity
  • If tampon has not expanded w/in 30s of placement, irrigate it in place w/ NS
  • Moisten three times per day with saline or water until removal
• Traditional Packing
  • Apply ribbon gauze in accordion-like manner

Tranexamic acid

• 500mg TXA applied to topical foam or non absorbable packing and inserted into nares.
• Can stop bleeding as fast as 10 minutes

Posterior Nasal Packing

• Only consider if all of the above have failed
• Associated w/ 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
  • Inflate posterior balloon
• Foley catheter w/ 30-cc balloon
  • Lubricate w/ topical antibiotic
  • Advance transnasally until visualized in posterior oropharynx
  • Inflate balloon w/ 7cc of saline; retract 2-3cm until lodged in post nasopharynx
  • Inflate w/ additional 5-7cc of saline to complete the pack
• Keep packing for 72-96 hours, <48 hours associated with increased re-bleed.

Disposition

Anterior Epistaxis

• 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 Toxic shock syndrome although no robust evidence base
• ENT or ED follow-up in 2-3d for removal of nonbiodegradable packing

Posterior Epistaxis

• Admission is strongly advised

Complications

• Recurrent unilateral epistaxis has been described in association with malignancy
• Toxic Shock Syndrome