For greater detail see: Nose Bleed Management and Epistaxis Control

Return to: Otolaryngology Medical Student Clerkship Objectives and Exam Topics (University of Iowa)

See also: Nosebleed - Epistaxis: Anterior Ethmoid Artery Ligation (External - Open Approach)

Nosebleed - Epistaxis: Sphenopalatine Artery (SPA) Ligation - Endoscopic

Overview

• Epistaxis, or nosebleeds: common problem that most people have dealt with at some point in their life
• Though most people don't seek medical attention, severe epistaxis can have complications
• More common in winter months
• Caused by trauma or irritation
  • Children- digital trauma or other foreign object insertion 
  • Mucosal dryness
  • Chronic intranasal drug use (cocaine, steroids)
  • Neoplasm
  • Anticoagulation (warfarin therapy)
  • Nasal cannula

By TonyTheTiger (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons

Anatomy

• Anterior bleeds (90%)
  • Majority of episodes are from the anterior septum
  • Kiesselbach's plexus, anastomosis of:
    • Septal branch of anterior ethmoidal artery (ophthalmic artery)
    • Lateral nasal branch of sphenopalatine artery (maxillary artery)
    • Septal branch of superior labial artery (facial artery)
• Posterior bleeds (10%)
  • Woodruff's plexus:
    • Confluence of vessels posterior to the middle turbinate 
    • Formed from contributions of the:
      • Sphenopalatine (from maxillary artery)
      • Ascending pharyngeal (from external carotid)
      • Internal maxillary veins

Evaluation

• Severity of bleed
  • Ensure airway is secured and breathing is adequate
  • Evaluate hemodynamics if a large volume of blood loss is suspected
• Underlying causes 
  • Local
    • Trauma
    • Foreign body
    • Infection
    • Dryness
    • Benign Neoplasm
      • Severe, unilateral, recurrent bleeds in young male raises concern for Juvenile Nasopharyngeal Angiofibroma 
  • Systemic
    • Chronic disease conditions
      • Hypertension
      • Cancer
      • Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu Syndrome) 
    • Medications
    • Coagulopathy
• Anterior vs Posterior bleed
  • Important for management
  • Treatment with a vasoconstrictive and anesthetic agent can aid in visualization
  • Nasal endoscope can be helpful
• Posterior bleed in an adolescent male
  • Consider nasopharyngeal angiofibroma
  • Otolaryngology consult is required for possible surgical intervention

Management

• Anterior bleeds
  • Direct pressure for 10-15 minutes will often resolve mild cases
  • Sit patient forward so blood does not drain into nasopharynx 
    • Ingested blood can cause nausea and vomiting
    • Ingestion of blood prevents accurate estimation of blood loss as it cannot be visualized 
  • Topical vascoconstriction- pledgets soaked with oxymetazoline may be used
  • Cautery- silver nitrate sticks
  • Nasal packing
    • 3-5 days 
    • Types
      • Nasal tampons (eg. Rhino Rocket) 
      • Gauze
      • Balloon catheters
    • Some hospitalize if bilateral packing is used due to concern for airway obstruction 
    • Prophylactic antibiotics can be considered due to concern for development of toxic shock syndrome (TSS) 
• Posterior bleeds
  • More difficult to manage 
  • Hospitalization is recommended for most posterior bleeds as they are more difficult to control 
  • Nasal packing
    • Balloon catheter
    • Cotton packing
    • Consider antibiotics
• Surgical Management
  • Arterial ligation
  • Endoscopic cautery
  • Angiographic embolization by Interventional Radiology 
  • Tumor removal if present (eg. angiofibroma) 

References

American Academy of Otolaryngology–Head and Neck Surgery Foundation. (2011). Primary Care Otolaryngology, Third Edition. Retrieved from: www.entnet.org. 

Alter, H. Approach to the adult with epistaxis. In: UpToDate, Grayzel, J. (Ed), UpToDate, Waltham, MA. (Accessed on June 10, 2015.)