Epistaxis

Background

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
• Rhinosinusitis
• Anticoagulant/antiplatelet use
• Trauma
• Neoplasia
• 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

• 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

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 to expel clots or suction nose
2. Instill topical vasoconstrictor (oxymetazoline or phenylephrine)
3. Have patient apply direct pressure over cartilaginous area of nasal bridge (not the bony area)
4. Patient must lean forward to avoid blood draining down nasopharynx thus preventing desired tamponade

Chemical Cauterization

1. Consider if two attempts at direct pressure fail
2. Only perform if the bleeding vessel is adequately visualized
3. Anesthetize with cotton pledgets soaked in 1:1 mix of 0.05% oxymetazoline:4% lidocaine
4. 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)

Thrombogenic Foams

1. Apply Gelfoam or Surgicel on visualized bleeding mucosa
2. 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

Tranexamic acid

• 500mg TXA applied to topical foam or non absorbable packing and inserted into nares.
• Can stop bleeding as fast as 10 minutes
• Higher success rate by 10 minutes compared to anterior packing in patients on Aspirin or Plavix

Posterior Nasal Packing

Only consider 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
• Inflate posterior balloon
• Foley catheter with 30-cc balloon
  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.

Disposition

Anterior Epistaxis

• consider checking Hgb to ensure no significant blood loss anemia
• Discharge after 1hr of observation
• Patients with therapeutic warfarin levels may continue medication
• Discontinue NSAIDs for 3-4d
• 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