Epistaxis

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

• Digital trauma (i.e. nose-picking)
• Rhinosinusitis
• Anticoagulant/antiplatelet use
• Trauma
• Neoplasia, juvenile nasopharyngeal angiofibroma
• 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

Anterior nosebleed after trauma in pediatric patient.

• Epistaxis
  • Anterior: more likely from one nares
  • Posterior: more likely from two nares

Differential Diagnosis

• Facial trauma
• Coagulopathy
• Nasal tumor
• Juvenile Nasopharyngeal Angiofibroma (JNA)
• Hemophilia
• Arteriovenous malformation

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.

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
   • Leave on for a few seconds at most
   • Never cauterize both sides of the septum at one go (risk of septal perforation)
   • Video of silver nitrate cauterization.

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.

• 500mg TXA applied to topical foam or non-absorbable packing and inserted into nares.
  • 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
• 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

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

See Also

• In-Training Exam Review