Epistaxis

Background•What is epistaxis?

•Anterior bleeds and posterior bleeds

•Most nosebleeds are benign, self-limiting, and spontaneous, but some can be recurrent

•True prevalence of epistaxis is not known

Anatomy• ICA:

▫ Ophthalmic → Posterior ethmoid → Anterior ethmoid

• ECA:▫ Facial

→ Superior labial▫ Internal maxillary

→ Descending palatine → Sphenopalatine

• Little’s area (Kiesselbach plexus)

Pathophysiology• Mucosa is eroded and vessels become exposed and

subsequently break

• >90% bleeds from Little’s area (constant ooze, not profuse bleeding)

• Posterior bleeds▫More profuse▫Often of arterial origin▫Greater risk of airway compromise and aspiration of

blood▫Greater difficulty controlling bleeding

Etiology• Local causes:

▫ Trauma▫ Mucosal Irritation (e.g. topical drugs, NSAIDs)▫ Septal abnormality▫ Inflammatory diseases▫ Tumors

• Systemic causes:▫ Blood dyscrasias▫ Arteriosclerosis▫ Hereditary hemorrhagic telangiectasia (HHT)▫ Hypertension

• Idiopathic (10%)

Etiology (Most Common Causes)•Local trauma•Facial trauma•Foreign bodies•Nasal/Sinus infection•Prolonged inhalation of dry air

Epidemiology•Lifelong incidence in general population

~ 60%

•<10% seek medical attention

•Age distribution is bimodal (2-10y, 50-80y)

•M>F (58/42)

History - 1• Control the bleeding or hemodynamic instability first• Severity, frequency, duration, and laterality of the nosebleed• Does bleed occurs after exercise or during sleep or is

associated with a migraine• Hematemesis or melena• Precipitating and aggravating factors• Methods used to stop the bleeding• Foreign body: less bleeding, ± foul or purulent unilateral

discharge▫ Small battery: chemical alkali burn → local tissue necrosis

• Traumatic aneurysm: delayed epistaxis in trauma patient• General head & neck history, with emphasis on nasal

symptoms

History - 2• General medical history, current medications, and smoking

and drinking habits• Previous epistaxis• Hypertension• Hepatic or other systemic disease• Easy bruising or prolonged bleeding after minor surgical

procedures• Family history of bleeding disorders or leukemia

▫ Although unusual, children with bleeding disorders (e.g., von Willebrand disease) can occasionally have normal coagulation profiles. More than 1 sample may be required to notice the abnormality due to biologic variability throughout the day.

• Medications: esp. aspirin, NSAIDs, warfarin, heparin, ticlopidine, dipyridamole

Physical examination - 1• Required materials:

▫Sufficient illumination▫Adequate suction▫Topical medications▫Cauterization materials▫Packing materials▫Adequate anesthesia▫Adequate vasoconstriction

• Thorough and methodical examination of the nasal cavity

Physical examination - 2• Blowing the nose• Topical vasoconstrictor• Topical anesthetic• Suctioning of clots• Nasal speculum• Site of bleed: Anterior? Posterior?• Fiberoptic endoscopy: flexible vs. rigid• Skin: bruises / petechiae• Vital signs:

▫↑BP → complete workup▫↑pulse → IV fluid replacement ± transfusion

Complications•Sinusitis•Septal hematoma/perforation•External nasal deformity•Mucosal pressure necrosis•Vasovagal episode•Balloon migration•Aspiration

Workup• Laboratory tests not needed when:

▫ First-time nosebleed▫ Minor bleed▫ Infrequent recurrences▫ Good history of nose picking or trauma to nose

• Laboratory tests needed when:▫ Major bleeding → Hematocrit count, blood type, and cross-match▫ Suspicion of coagulopathy (e.g. recurrent epistaxis, platelet

disorder, or neoplasia) → CBC with differential, BT, also PT, APTT, INR

• Other tests: mostly not needed; CT / MRI to evaluate surgical anatomy / rhinosinusitis / foreign body / neoplasm

Treatment - 1•Manual hemostasis:

▫Initial treatment▫Squeeze nostrils together for 5-10 mins

straight (without frequent peeking to see if bleeding is controlled); max. 30 mins

▫Keep head elevated, but not hyperextended▫Hyperextension → bleeding into pharynx →

possible aspiration▫Consider vasoconstrictor if squeezing does

not work

Treatment - 2•Humidification & Moisturization:

▫Humidify the air if cause is excessive dryness in home (e.g. radiator heating)

▫Nasal saline spray▫Oxymetazoline▫Local application of bacitracin or

petroleum ointment directly to the Kiesselbach area

Treatment - 3•Cauterization:

▫Silver nitrate cautery: Often done for bleeding from Little’s area Manage the vessels leading to the site before

managing the actual bleeding site. Avoid random and aggressive cauterization and cautery on opposing surfaces of the septum.

▫Electrocauterization with insulated suction cautery unit Done for more severe bleed or posterior bleed

▫Rigid endoscopy

Treatment - 4•Nasal packing:

▫Done if cautery fails▫Anterior packing▫Posterior packing

Also place anterior pack Admit patient in ICU (for close monitoring of

oxygenation, fluid status, and pain control)▫Remove packing in 3-4 days▫Give prophylactic antibiotics▫Avoid physical strain for 1 week

Treatment - 5•Management of packing failure:

▫Packing failure is due to inadequate placement (e.g. uncooperative child, DNS)

▫Endoscopic examination under G/A cautery of bleeding site straightening of DNS removal of spur meticulous packing

Treatment - 6•Arterial ligation:

▫Done if all else fails▫Vessel ligated depends on bleeding site▫External carotid artery▫Internal maxillary artery▫Sphenopalatine artery▫Anterior and/or Posterior ethmoid arteries

Treatment - 7•Embolization:

▫Done if arterial ligation fails▫Selective embolization of internal maxillary

artery (or facial artery)

•Palliative therapy for HHT:▫Coagulation with laser, Septodermoplasty,

Embolization, Estrogen therapy

Treatment - 8• Instructions to patient after bleeding is controlled:

▫Use nasal saline spray▫Use antibiotic ointment▫Use digital pressure, topical vasoconstrictor, and ice

packs if nasal bleed recurs▫Avoid strenuous activities▫Avoid nose blowing and excessive sneezing▫Avoid digital manipulation of nose▫Avoid NSAIDs▫Avoid hot and dry environments▫Avoid hot showers▫Avoid hot & spicy foods and drink plenty of fluids

Treatment - 9•Complications of treatment:

▫Cauterization: synechia, septal perforation

▫Anterior packing: synechia, rhinosinusitis, toxic shock syndrome, eustachian tube dysfunction, scarring of the nasal ala and columella

▫Posterior packing: As above, plus dysphagia, hypoventilation, and sudden death