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Epistaxis
Brian E. Neubauer, MD
image BASICS
DESCRIPTION
  • Hemorrhage from the nose involving either the anterior or posterior mucosal surfaces
  • Synonym(s): nosebleed
  • Intractable or refractory epistaxis: recurrent or persistent despite appropriate packing or multiple episodes during a short period, each requiring medical attention
EPIDEMIOLOGY
Incidence
  • In the United States: common
  • Estimated lifetime prevalence: ˜60%
  • Bimodal, with peaks in children up to 15 years and in adults >50 years, particularly ages 70 to 79 years
  • Most common in males <49 years.
  • Rare in children <2 years.
  • ˜6% of patients require medical or surgical intervention; accounts for ˜1 in 200 ER visits
ETIOLOGY AND PATHOPHYSIOLOGY
  • Local versus systemic disease. Most are due to local causes.
  • Anterior: 90-95% of all cases (Kiesselbach plexus)
  • Posterior: 5-10% of cases. Usually branches of sphenopalatine arteries: may be asymptomatic or may present with other symptoms (hematemesis, hemoptysis)
  • Idiopathic
  • Local inflammation/irritation
    • Infection (viral URI, sinusitis, TB, syphilis)
    • Irritant inhalation (smoking, rhinitis)
    • Topical steroid or antihistamine use
    • Septal deviation (more air movement on one side)
    • Low humidity, nasal oxygen use, CPAP
    • Tumors: benign, malignant
    • Vascular malformations
  • Trauma
    • Epistaxis digitorum (nose picking)
    • Foreign bodies
    • Septal perforation
    • Nasal fracture
    • Nasal surgery
  • Systemic
    • Thrombocytopenia
    • Congenital or acquired coagulopathies
    • Liver or renal disease
    • Chronic alcohol abuse
    • Leukemia
    • Anticoagulant drug use
    • CHF
    • Hereditary hemorrhagic telangiectasia (HHT)
    • Collagen abnormalities
    • Mitral valve stenosis
    • Multiple myeloma
    • Polycythemia vera
RISK FACTORS
  • Local irritation from multiple causes (see “Etiology and Pathophysiology”)
  • Medications/supplements including aspirin, clopidogrel, ginseng, garlic, ginkgo biloba, warfarin, and other anticoagulants
GENERAL PREVENTION
  • Humidification at night
  • Cut fingernails to minimize picking.
  • For topical-nasal medication users, direct spray laterally away from septum. Use opposite hand to spray (i.e., right hand to spray in left nostril).
  • Petroleum jelly to prevent anterior mucosal drying
COMMONLY ASSOCIATED CONDITIONS
  • Vascular malformation/telangiectasia (HHT)
  • Neoplasm (rare, but consider in persistent unilateral cases)
  • Systemic
    • Coagulopathy: primary or iatrogenic
    • Thrombocytopenia
    • Cirrhosis
    • Renal failure
    • Alcoholism
  • No proven association with hypertension (HTN) but may make control of bleeding more difficult.
image DIAGNOSIS
PHYSICAL EXAM
  • Blood loss through one or both nostrils in most cases is due to anterior nasal septal bleeding and can often be directly visualized.
  • Focus on localizing site of bleeding to anterior versus posterior nasal cavity.
  • Patient is seated, head forward, to avoid blood going down the posterior pharynx.
  • Use of nasal speculum improves visualization.
DIFFERENTIAL DIAGNOSIS
  • Diagnosis usually apparent; the differential for the etiology is key.
  • Posterior bleeding must be included in the differential for any chronic blood loss.
DIAGNOSTIC TESTS & INTERPRETATION
  • Indicated only in complicated cases and/or profuse blood loss
  • Lab testing is not indicated in most uncomplicated cases in which bleeding is reasonably easily controlled and is not truly hemorrhagic.
Initial Tests (lab, imaging)
  • Mild cases, responsive to pressure: no labs
  • For recurrent or intractable cases
  • CBC, PT/PTT, BMP
  • PT/PTT if on warfarin or other medications affecting coagulation.
  • Cross-match when appropriate.
  • Toxicology screen when nasal use of illicit drugs is suspected
  • For most cases, imaging is not indicated.
Follow-Up Tests & Special Considerations
If recurrent unilateral epistaxis, especially if not responding to treatment measures, consider evaluation for neoplasm.
Diagnostic Procedures/Other
Nasal endoscopy
Pediatric Considerations
More likely anterior, idiopathic, and recurrent
Geriatric Considerations
More likely to be posterior bleed
image TREATMENT
  • Most cases are managed as outpatient (1)[B].
  • Home use—Nosebleed QR: a nonprescription powder of hydrophilic polymer with potassium salt; induces scab formation
  • Patient applies direct pressure by pinching the lower part of the nose (nasal ala) for 5 to 20 minutes without a break. This will stop active bleeding in most patients.
  • An ice pack placed over the dorsum of the nose may help with hemostasis.
  • Inspect the nasal septum for the bleeding site.
GENERAL MEASURES
Resuscitation, as indicated. Use universal “ABC” approach.
P.355

MEDICATION
First Line
  • If general measures fail, affected naris may be sprayed with topical vasoconstrictor, such as:
    • Phenylephrine: 0.5-1%
    • Oxymetazoline: 0.05%
    • Epinephrine: 1:1,000
    • Cocaine: 4%
Second Line
  • Chemical (silver nitrate) or electrical cautery
  • Nasal packing: ribbon gauze, nasal tampons, nasal balloon catheter
  • For intractable/refractory: Consider surgical ligation, endoscopic ligation/cautery, endovascular embolization.
ISSUES FOR REFERRAL
  • Posterior bleeding frequently requires an otolaryngology consultation.
  • Anterior bleeding that fails conservative measures, packing, and cauterization
  • Recurrent episodes
  • Patients with HHT should establish care with ENT early.
ADDITIONAL THERAPIES
  • Nasal packing: either with ribbon gauze or preformed nasal tampons. Systemic prophylactic antibiotics are unnecessary in the majority of patients with nasal packs; topical antibiotics may be as effective and cheaper (2)[B].
  • FloSeal: A biodegradable hemostatic sealant (a thrombin-type gel) in one study is more effective and better tolerated than packing (3)[B].
  • If an actively bleeding anterior septal site is visualized, this may be treated with gentle and specific silver nitrate cautery for ˜10 seconds for definitive treatment. 75% silver nitrate is preferred. Apply in a spiral fashion, starting around the bleeding vessel, moving inward.
  • Limit cautery (silver nitrate) to one side of septum, or wait 4 to 6 weeks in between treatments to reduce risk of perforation.
  • Posterior: posterior packing or tamponade with balloon devices (Foley catheter has been used). Inpatient monitoring is generally required.
  • Recurrent epistaxis: Cochrane review in children shows no difference in effectiveness between antiseptic nasal cream, petroleum jelly, silver nitrate cautery, or no treatment (4)[A].
    • Silver nitrate cautery followed by 4 weeks of antiseptic cream may be better than antiseptic cream alone (5)[B].
SURGERY/OTHER PROCEDURES
  • Packing
    • Layering of Vaseline ribbon gauze (1/2 inch)
      • For gauze packing, be certain that both ends of the ribbon gauze protrude from the nostril.
      • Packing is layered from the floor upward.
      • Secure packing with gauze across the outside of the nostril.
    • Nasal tampon may be used after lubricating the tip with KY Jelly or antibiotic cream or ointment.
    • Additional saline may be needed to expand the tampon if the bleeding has slowed.
    • Merocel and Rapid Rhino packs are easier to use than gauze packing and are usually well tolerated.
  • Posterior bleed
    • In the emergent setting, this may be attempted utilizing a Foley catheter or a specific posterior packing balloon.
    • With both methods, the tubing is introduced through the nose similar to the passage of a nasogastric tube. Once it reaches the posterior oral pharynx, the balloon is inflated and the tubing is pulled back outward to tamponade the posterior bleeding source.
      • If using a Foley catheter (10 to 14F catheter), the balloon can be inflated with 10 mL of saline.
      • Traction is maintained with an umbilical cord clamp with adequate padding between the clip and the nose to avoid injury.
INPATIENT CONSIDERATIONS
Consider hospitalization for elderly or for patients with posterior bleeding or coagulopathy. May also consider if significant comorbidities
Admission Criteria/Initial Stabilization
  • Posterior bleed
  • Hemodynamic changes
  • Clotting dysfunction
  • Universal “airway/breathing/circulation” (ABC) approach. Stop blood loss.
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
  • When significant blood loss, hemodynamic monitoring
  • 24-Hour minimum of packing in place; some authors recommend 3 to 5 days. The latter recommendation carries the risk of mucosal injury and toxic shock syndrome. The former has the risk of rebleed, which usually occurs between 24 and 48 hours.
PATIENT EDUCATION
  • Demonstrate proper pinching pressure techniques.
  • Avoidance of trauma or irritants is key.
  • Management of systemic illness and proper use of medication
PROGNOSIS
  • Most are self-limited.
  • Good results with proper treatment
REFERENCES
1. Melia L, McGarry GW. Epistaxis: update on management. Curr Opin Otolaryngol Head Neck Surg. 2011;19(1):30-35.
2. Biggs TC, Nightingale K, Patel NN, et al. Should prophylactic antibiotics be used routinely in epistaxis patients with nasal packs? Ann R Coll Surg Engl. 2013;95(1):40-42.
3. Mathiasen RA, Cruz RM. Prospective, randomized, controlled clinical trial of a novel matrix hemostatic sealant in patients with acute anterior epistaxis. Laryngoscope. 2005;115(2):899-902.
4. Qureishi A, Burton MJ. Interventions for recurrent idiopathic epistaxis (nosebleeds) in children. Cochrane Database Syst Rev. 2012;(9):CD004461.
5. Calder N, Kang S, Fraser L, et al. A double-blind randomized controlled trial of management of recurrent nosebleeds in children. Otolaryngol Head Neck Surg. 2009;140(5):670-674.
Additional Reading
&NA;
  • Manes RP. Evaluating and managing the patient with nosebleeds. Med Clin North Am. 2010;94(5): 903-912.
  • Schlosser RJ. Clinical practice. Epistaxis. N Engl J Med. 2009;360(8):784-789.
Codes
&NA;
ICD10
R04.0 Epistaxis
Clinical Pearls
&NA;
  • Most episodes are anterior in etiology and respond to timed pressure over the anterior nares for 5 to 20 minutes.
  • Most are idiopathic or as a result of nose picking.
  • Posterior nosebleeds can be asymptomatic or present with nausea, hematemesis, or heme-positive stool.
  • Consider evaluation for neoplasm if recurrent unilateral episodes.