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Chapter 3

Epistaxis

Raymond Sacks, F.C.S., F.R.A.C.S.,1,2 Peta-Lee Sacks, MBBS,3 and Rakesh Chandra, M.D.4

ABSTRACTEpistaxis is a common problem that may range in severity from a minor nuisance to hemodynamically significant bleeding. Vascular anatomy allows for

predictable identification of suspicious bleeding sites. Historically, packing was the workhorse of management, but, currently, more directed interventions havebecome available. These modalities may result in improvements in both cost-effectiveness and patient comfort.

(Am J Rhinol Allergy 27, S9S10, 2013; doi: 10.2500/ajra.2013.27.3890)

The nasal mucosa is supplied by terminal branches of the ex-ternal and internal carotid arteries. Various anastomoses ex-ist between these two systems, the most important being Kies-selbachs plexus in the anterior nasal septum. In this location,branches of the anterior ethmoid, nasopalatine, and superior labialarteries anastomose. There is also a contribution from the terminusof the posterior septal artery. This the most common site of epi-staxis, and 90% of all epistaxis presentations occur in this area.1

These anastomoses are fundamental to an understanding of epi-staxis and its management, underlying the significance of treatingthe most distal site of bleeding.Epistaxis is often characterized as either anterior or posterior. His-

torically, these distinctions have been arbitrary, respectively, based onwhether or not the practitioner is able to identify the site of bleedingduring anterior rhinoscopy. A more useful scheme stratifies thesource according to whether it originates anterior or posterior to themaxillary sinus ostium. Anterior bleeding, which usually arises fromKisselbachs plexus, generally allows for easier visualization andaccess. In contrast, posterior epistaxis, which usually arises frombranches of the sphenopalatine artery, is more difficult to visualize. Inthis scenario, hemorrhage is often swallowed, resulting in difficultiesassessing the amount of blood lost.

ETIOLOGYEpistaxis is often idiopathic but can be occasionally caused by

underlying pathology such as sinonasal tumor. As such, the followingdifferential should be considered (Table 1).

INITIAL ASSESSMENTInitial assessment of epistaxis attempts to estimate the amount of

blood lost and the period over which the patient has been bleeding.The patients vital signs should be assessed to exclude hypovole-mic shock. It may be necessary to obtain i.v. access to check for any

clotting abnormalities and to draw blood for type and screen. Thepatient should be asked to apply constant pressure over the lowercartilaginous part of the nose for 20 minutes and to avoid swal-lowing blood in order that blood loss can be estimated.

FURTHER EVALUATIONThree steps underlie the management of epistaxis:

1. Establishing the site of bleeding2. Stopping the bleeding3. Treating the cause of bleeding2

The primary aims of the history are to assess the severity andduration of the nosebleed and the circumstances in which it occurred.The physician should also inquire about any other medical condi-tions, alcohol consumption, and any history of nosebleeds or bruising.A family history of bleeding should also be considered. Examinationbegins with anterior rhinoscopy. A significant amount of bleedingmay require suction, a headlamp, and a nasal speculum. Topicalvasoconstriction using 1% phenylephrine or 0.05% oxymetazolinecombined with a topical anesthetic may also be beneficial.3 If nosource of bleeding is revealed anteriorly, nasendoscopy should beperformed with particular attention to mucosal and submucosal le-sions or masses within the middle meatus and nasopharynx. Labora-tory investigations may be required according to the severity andfrequency of bleeding and may include a full blood count, coagula-tion studies, and hepatic and renal function tests. These tests may beparticularly relevant in patients taking warfarin and in those withdiseases that could result in coagulopathy. In the absence of a severebleed or a personal or family history suggestive of a bleeding disor-der, laboratory evaluation for coagulopathy is typically not indicated.Recurrent unilateral epistaxis that fails to respond to conservative

management should be investigated for neoplasm, particularly inthose who report symptoms of nasal obstruction, rhinorrhea, facialpain, or an abnormal cranial nerve examination.4

MANAGEMENTThe approach to managing epistaxis tends to vary according to the

severity and location of the bleed as well as a variety of other factors.As discussed previously, initial medical treatment aims to cease thebleeding and is often used to improve visualization during the clinicalexam.

ANTERIOR EPISTAXISShould topical vasoconstriction be unsuccessful and an accessible

site of bleeding can be identified, cauterization should be imple-mented.5 This should be performed with caution to avoid damage to

From the 1Australian School of Advanced Medicine at Macquarie University, 2SydneyMedical School at University of Sydney, Sydney, Australia, 3School of Medical Sci-ences, University of New South Wales, Sydney, Australia, and 4Department of Oto-laryngologyHead and Neck Surgery, Northwestern University Feinberg School ofMedicine, Chicago, IllinoisR Chandra is a consultant/advisor for Intersect ENT, Gyrus/Olympus, and Sunovionand received a research grant from Intersect ENT. P-L Sacks and R Sacks have noconflicts of interest to declare pertaining to this articleAddress correspondence and reprint request to Raymond Sacks, F.C.S., F.R.A.C.S.,Sydney Adventist Hospital, The ENT Centre, Suite 12, 2529 Hunter Street, Hornsby,NSW, Australia, 2077E-mail address: rsacks@optusnet.com.auCopyright 2013, OceanSide Publications, Inc., U.S.A.

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healthy surrounding mucosa. Cautery can be performed chemicallyor electrically depending on the severity of the bleed. Silver nitratesticks, which release oxygen free radicals to coagulate tissue, areuseful in minor bleeding; however, it will likely be washed away bysevere bleeding before becoming effective. Electric cauterization canbe applied to anesthetized mucosa and is more useful in severebleeding. Laser cauterization has a limited role in acute epistaxis butmay be used in patients with hereditary hemorrhagic telangiectasia.3,6

It is important to note that cauterization by any means should beapplied only to one side of the septum to avoid perforation over aperiod of 46 weeks.4

Failure of cauterization may indicate the need for nasal packing.5

There are various types of absorbable and nonabsorbable options.Patients with nasal packing should commence topical antibiotics toavoid toxic shock syndrome.3 Other complications of nasal packinginclude septal hematomas, abscesses, and sinusitis. In the rare casethat anterior packing should fail, ethmoidal vessels may be ligatedthrough a Lynch incision. This approach reduces the risk of strokeand blindness associated with embolization of anterior and posteriorethmoid arteries.7

POSTERIOR EPISTAXISPosterior bleeding most commonly arises from branches of the

sphenopalatine artery,8 which is the medial (distal) termination of theinternal maxillary. The main modes of treatment in these patientsinclude endoscopic electric cauterization, posterior packing, emboli-

zation,9 and surgical arterial ligation.3 Severe cases typically requireone of the two latter methods.1011 Embolization is performed by aneurointerventional radiologist. This method is 85% effective butcarries risks of cerebrovascular accident if particles are released intothe internal carotid system iatrogenically or via collateral circulation.Patients may also have postprocedural jaw discomfort and claudica-tion. Presently, transnasal endoscopic sphenopalatine artery ligationor cautery is the primary surgical alternative in these intractablecases. The artery is controlled where it enters into the posterior nasalcavity via the sphenopalatine foramen. This region is situated behindthe crista ethmoidalis, a landmark formed by the orbital process of thepalatine bone. Overall success is also in the range of 85%, and majorcomplications are rare. Minor complications include nasal crustingand nasal/palatal paresthesias. There is significant debate as to whichof these methods, angiography with embolization or endoscopicsphenopalatine artery ligation, is preferred. However, current per-spectives indicate that early treatment with either of these modalitiesis more successful and cost-effective than prolonged inpatient poste-rior packing, which is markedly uncomfortable and also carries risksincluding staphylococcal infection, toxic shock syndrome, and brady-dysrhythmia. Often, the algorithm for management of severe intrac-table posterior epistaxis will depend on the resources available at aparticular institution.

CLINICAL PEARLS

The vast majority of epistaxis arises anteriorly, from Kiesselbachsplexus in the anterior nasal septum.

Posterior epistaxis can be difficult to visualize but most often arisesfrom branches of the sphenopalatine artery.

Although it may seem trivial to state, it is important to highlightthat finding the exact site of the bleeding is critical for safe andefficient management.

Maintain suspicion for underlying neoplastic conditions. Current trends favor early intervention for posterior epistaxis, witheither embolization or sphenopalatine artery ligation, rather thanprolonged packing.

REFERENCES1. Douglas R, and Wormald PJ. Update on epistaxis. Curr Opin Otolar-

yngol Head Neck Surg 15:180183, 2007.2. Simmen D, and Jones N. Epistaxis. In Cummings Otolaryngology:

Head and Neck Surgery, 5th ed. Flint P, Haughey B, Lund V, et al.(Ed). Philadelphia, PA: Mosby, Elsevier, 682693, 2010.

3. Gifford TO, and Orlandi RR. Epistaxis. Otolaryngol Clin North Am41:525536, viii, 2008.

4. Schlosser RJ. Clinical practice. Epistaxis. N Engl J Med 360:784789,2009.

5. Kucik CJ, and Clenney T. Management of epistaxis. Am Fam Physi-cian 71:305311, 2005.

6. Harvey RJ, Kanagalingam J, and Lund VJ. The impact of septoder-moplasty and potassium-titanyl-phosphate (KTP) laser therapy in thetreatment of hereditary hemorrhagic telangiectasia-related epistaxis.Am J Rhinol 22:182187, 2008.

7. Srinivasan V, Sherman IW, and OSullivan G. Surgical managementof intractable epistaxis: Audit of results. J Laryngol Otol 114:697700,2000.

8. Schwartzbauer HR, Shete M, and Tami TA. Endoscopic anatomy ofthe sphenopalatine and posterior nasal arteries: Implications for theendoscopic management of epistaxis. Am J Rhinol 17:6366, 2003.

9. Gurney TA, Dowd CF, and Murr AH. Embolization for the treatmentof idiopathic posterior epistaxis. Am J Rhinol 18:335339, 2004.

10. Christensen NP, Smith DS, Barnwell SL, and Wax MK. Arterialembolization in the management of posterior epistaxis. OtolaryngolHead Neck Surg 133:748753, 2005.

11. Snyderman CH, Goldman SA, Carrau RL, et al. Endoscopic spheno-palatine artery ligation is an effective method of treatment for pos-terior epistaxis. Am J Rhinol 13:137140, 1999. e

Table 1 Etiology of epistaxis

Local causesIdiopathicTrauma Digit trauma

Foreign bodyNasal oxygen and CPAPNasal fracturePostoperative

Anatomical Septal deviationSpurs

Inflammatory/infectious Viral/bacterial rhinosinusitisAllergic rhinosinusitisGranulomatous diseaseEnvironmental irritants

Neoplastic Hemangioma of septum or turbinatesHemangiopericytomaNasal papillomaPyogenic granulomaAngiofibromaCarcinoma

Drugs Topical intranasal corticosteroidsCocaine abuse

Systemic causesInherited Hemophilia

Von Willebrands diseaseHereditary hemorrhagictelangiectasia

Platelet abnormalities ThrombocytopeniaPlatelet dysfunction

Malignancy LeukemiasDrugs Chemotherapy

Chronic alcoholismAnticoagulants, e.g. WarfarinAnti-platelet, e.g. aspirin

CPAP continuous positive airway pressure.

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