Definition and Pathophysiology:
Epistaxis, or bleeding from the nasal cavity or nasopharynx, is the most common otolaryngologic emergency. Cases of epistaxis are classified as anterior or posterior in origin, depending on whether the source of bleeding is anterior or posterior to the maxillary sinus ostium. Anterior epistaxis is by far the more common, accounting for 80-95% of cases. In most cases, anterior bleeding can be localized to the Kiesselbach plexus (also known as Little’s area), which is a vascular region of the anteroinferior nasal septum. Posterior bleeding may arise from mucosa supplied by the sphenopalatine artery and its branches or from the anterior or posterior ethmoidal arteries. It is generally more difficult to treat as it is more difficult to access. For a review of the vascular supply to the nose, please see The Nose and Paranasal Sinuses. Briefly, it should be noted that the nasal cavity contains multiple anastomoses between the internal and external carotid artery systems. The internal carotid artery supplies the nasal cavity via its ophthalmic branch, which gives off the ethmoidal arteries. The external carotid artery supplies the nasal cavity via its internal maxillary and facial branches. The sphenopalatine artery is a branch of the internal maxillary artery.
Most cases of epistaxis are idiopathic in etiology. Other causes of epistaxis include nasal neoplasms, nasal trauma, inhaled irritants, and systemic conditions. Of special note are two rare causes of epistaxis: juvenile nasal angiofibroma (JNA) and hereditary hemorrhagic telangiectasia (HHT). JNA is a highly vascular tumor originating near the sphenopalatine foramen; it is discussed in more detail in Chapter 26. HHT, also known as Osler-Weber-Rendu disease, is an autosomal dominant disorder characterized by numerous mucocutaneous telangiectasias, or vascular dilations. Several mutations involving vascular formation and repair genes have been identified and associated with different subtypes of HHT. Epistaxis is the most common feature of HHT, and is one of the criteria used to diagnose the condition. A more complete list of causes of epistaxis can be found in the section on differential diagnosis below.
Epistaxis is extremely common, accounting for almost half a million emergency room visits per year in the United States alone. Approximately 6% of these cases require inpatient hospitalization. Many more cases are self-resolving and do not require medical attention. It is estimated that 16% of Americans suffer from one or more episodes of epistaxis a year, with 60% of people having at least one episode during their lifetimes. Epistaxis may affect individuals of any age, although there is a bimodal distribution pattern, with increased incidence among those less than 10 years of age and in the elderly. There is a slightly higher incidence among males. Studies have demonstrated a higher occurrence of episodes during the winter months, likely as a result of dry air causing mucosal irritation.
The natural history of epistaxis depends on its cause and the site of hemorrhage. Most cases of epistaxis are anterior, idiopathic, and do not require medical attention. These cases typically resolve with either no intervention or with the application of pressure to the nasal septum alone. Epistaxis that is due to an underlying condition, such as a nasal tumor or systemic disease, generally recurs unless the causative pathology is treated.
The acuity of a patient presenting to the emergency room with epistaxis will depend on the severity of hemorrhage. In extreme cases of blood loss, the patient may present with symptoms of hypovolemic shock (e.g., tachycardia, pallor, altered mental status) and would require immediate resuscitation. Close attention should be given to the patient’s vital signs as is it easy to underestimate the volume of blood that the patient may have lost.
Aside from active nasal hemorrhage, other presenting symptoms of epistaxis may include hematemesis due to gastrointestinal irritation from swallowed blood, or melena, if bleeding is prolonged or chronic in nature.
Differential Diagnosis of Epistaxis:
- Self-induced (e.g., nose-picking)
- Foreign body
- Nasal injury (e.g., fracture, septal perforation)
- Iatrogenic (e.g., from nasal or sinus surgery)
- Juvenile nasal angiofibroma (JNA)
- Nasal papilloma
- Carcinoma of the nose, paranasal sinuses, and/or nasopharynx
- Pyogenic granuloma
- Rhinosinusitis (viral, allergic, or bacterial)
- Inhaled environmental irritants (e.g., cigarette smoke, chemicals)
- Nasal oxygen/nasal administration of continuous positive airway pressure (CPAP)
- Use of topical nasal steroids
- Cocaine abuse
- Wegener’s granulomatosis
- Hereditary hemorrhagic telangiectasia (HHT)
- Coagulopathies/platelet disorders (including use of medications such as warfarin or aspirin)
- Leukemia/chemotherapy/other causes of thrombocytopenia
If the patient is stable, a history should be obtained, including the estimated amount of blood loss, the duration of bleeding, measures employed to stop the bleeding, history of prior episodes, and any relevant medical or surgical history (e.g., known coagulopathy, recent nasal procedures, or use of medications that increase risk of bleeding). Laterality of the bleeding may increase suspicion for a neoplastic origin, particularly if the patient has a history of recurrent episodes of hemorrhage from a single side only. Adolescent male patients with a history of recurrent unilateral epistaxis should be evaluated for JNA. The history should also attempt to elicit any temporal or causal relationship between episodes of epistaxis and exposure to irritants. This includes bleeding due to dry skin during low humidity or cold weather seasons.
The physical examination should focus first and foremost on locating the source of bleeding. Direct visualization of the anterior nasal cavity with a nasal speculum and headlamp should be attempted first. A nasal suction may be used to remove any clots obstructing visibility. If the source of hemorrhage cannot be identified, a full nasal endoscopy can be performed. If the patient is stable, a head and neck examination should be completed, looking for signs of relevant conditions (e.g., ecchymoses or petechiae suggestive of bleeding disorders).
Radiographic studies are not generally indicated unless there is suspicion for a sinonasal neoplasm, in which case computed tomography (CT) or magnetic resonance imaging (MRI) may delineate the extent of tumor involvement and assist in operative planning.
If substantial blood loss has occurred, the patient should be resuscitated following the insertion of two large bore IV lines. The patient’s hematocrit should be checked, along with type and screen with blood cross-matched, in case a transfusion is necessary. A coagulopathy evaluation may be initiated if there is reason to suspect a bleeding disorder; this includes a complete blood count (CBC), bleeding time, prothrombin time (PT), activated partial thromboplastin time (aPTT), and international normalized ratio (INR).
The first step in management of epistaxis is the application of direct pressure. Usually, this has already been attempted by the patient without success prior to seeking medical attention, although, in many cases, improper technique is used. The correct method of manual hemostasis involves applying pressure to the anterior nasal septum. Pressure should not be applied to the bony portion of the nose. Constant pressure should be held for at least 20 minutes, with the head leaning forward to facilitate the expulsion of blood through the mouth.
If bleeding continues and an anterior source of bleeding is easily identified (such as on the nasal septum), chemical cautery can be performed using silver nitrate. Bipolar electrocautery may also be used, if available. A topical vasoconstrictor and local anesthetic (e.g., phenylephrine and lidocaine) should be applied as a preliminary measure prior to cauterizing. If bleeding is bilateral, caution must be taken not to cauterize the same area on both sides of the nasal septum, as a septal perforation could occur. If the cauterization successfully stops the hemorrhage and no underlying condition is present, the patient may be discharged with instructions to avoid strenuous activity, nose-picking, or insertion of objects in the nose. An over-the-counter nasal saline spray, an antiseptic barrier cream, and petroleum jelly may be applied. The patient is also advised to avoid dry environments or to use a humidifier.
If a bleeding vessel cannot be located for cautery, or if bleeding is too severe to allow for thorough examination, topical vasoconstrictors such as oxymetazoline or hemostatic agents such as FloSeal may be applied. These may be tried alone or used in conjunction with nasal packing. Anterior packing may be performed with a variety of materials, such as Merocel sponges (an expandable form of packing) or vaseline gauze, which can be layered in the nasal cavity in a posterior-to-anterior fashion using forceps (Figure 22.3). At this time, attention should be given to any correctable factors that may be exacerbating bleeding, such as hypertension or thrombocytopenia.
If anterior packing is insufficient to control hemorrhage, a posterior pack may be necessary. A Foley catheter may be used for this purpose. The catheter is inserted into the nasal cavity until it can be visualized in the oropharynx. The balloon is then inflated with up to 10 mL of saline, and the catheter is withdrawn until the nasopharynx is tamponaded. The catheter is then held in position anteriorly with a clip. Care must be taken to avoid pressure from the clip on the columella or nasal ala, as pressure necrosis can occur. An anterior pack should then be placed. Prophylactic antibiotic therapy with an agent active against Staphylococcus aureus is administered to prevent toxic shock syndrome. Patients requiring packing for epistaxis should be admitted for observation.
Endoscopic sphenopalatine artery ligation (ESPAL) is preferred in many centers to prolonged posterior nasal packing due to its high (over 90%) success rate and fewer associated complications. In this procedure, the patient is placed under general anesthesia, and the sphenopalatine artery is located endoscopically near the most inferior horizontal attachment of the middle turbinate (level of the crista ethmoidalis). Care is taken to identify and clip or cauterize all of the branches of the artery within the sphenopalatine foramen. There is considerable anatomical variation in branching pattern, and failure to ligate all branches may result in continued or recurrent bleeding.
Other vascular ligation techniques include ligation of the internal maxillary artery within the pterygopalatine fossa and external carotid artery ligation. Traditionally, internal maxillary artery ligation was performed via a Caldwell-Luc approach (i.e., access to the maxillary sinus via a gingivolabial incision). While the procedure has a high reported success rate, the intraoral approach is more invasive, takes longer, and carries a higher complication rate. As a result, this has been supplanted by ESPAL. External carotid artery ligation is performed via a cervical incision, which provides easy access and does not require an endoscopic surgeon. However, due to the various anastomoses in the nose between the external and internal carotid systems, as well as with the contralateral side, this technique is not as effective as other methods.
Bleeding that is localized to the ethmoid arteries is rare; in most cases, it is a result of maxillofacial trauma or iatrogenic injury during sinus surgery. Bleeding from the ethmoid arteries can produce not only epistaxis, but also intraorbital and intracranial hemorrhage. Ethmoid hemorrhage almost always requires surgery, which can be done via external or endoscopic approaches.
An alternative to surgical arterial ligation is vascular embolization. This must be performed by an experienced interventional radiologist, as potential complications include cerebrovascular accident. Embolization is generally not considered an option for bleeding arising from the internal carotid artery system, as occlusion of the ophthalmic artery by embolic material can result in blindness.
Complications, Prognosis, and Follow-Up:
Untreated epistaxis should not be underestimated as prolonged bleeding may be fatal in the acute setting, or can produce anemia if chronic. Rare complications of nasal packing include toxic shock syndrome, hypoxemia due to the nasopulmonary reflex, pressure necrosis of nasal skin, and aspiration of packing material. ESPAL has relatively few complications, the most common being treatment failure due to unligated branches. Other potential complications are those common to transnasal endoscopic procedures, such as nasal crusting, septal perforation, palatal numbness, and lacrimal duct injury.
Embolization carries the risk of stroke, ophthalmoplegia, facial paralysis, seizures, and visual impairment. Patients may generally be discharged within 24 hours of successful arterial ligation. They should be instructed to avoid strenuous activity, low humidity environments, and nasal trauma. Nasal saline spray may be prescribed.
After acute bleeding has been controlled, any underlying conditions should be addressed. Treatment for neoplastic conditions varies depending on the type of tumor. Juvenile nasal angiofibroma is treated with surgical resection, usually with preoperative embolization. Hereditary hemorrhagic telangiectasia represents a particularly challenging disease entity for which no optimal treatment currently exists. Several methods of symptom control are available for patients with recurrent epistaxis. Laser ablation of intranasal telangiectasias with a photocoagulative laser (e.g., potassium-titanyl-phosphate) is effective in some patients, but recurrence is common and may necessitate multiple treatments. Other options are septodermoplasty, wherein affected nasal mucosa is removed and replaced with a skin graft, and nasal closure or obturation, which is thought to work by eliminating dessicating airflow over the nasal mucosa.
- Most cases of epistaxis are idiopathic in etiology and arise from the Kiesselbach plexus in the anterior nasal septum.
- Posterior bleeding may arise from the sphenopalatine artery and its branches or from the anterior or posterior ethmoidal arteries.
- The nasal cavity contains multiple anastomoses between the internal and external carotid artery systems, as well as between the two sides of the nose.
- The first step in treating a patient presenting with epistaxis is to determine the severity of hemorrhage and resuscitate the patient if necessary.
- A general treatment algorithm for epistaxis involves application of pressure to the nasal septum → chemical or electrocautery → application of hemostatic/vasoconstrictive agents → anterior nasal packing → posterior nasal packing/balloon tamponade → arterial ligation → embolization.
- Endoscopic sphenopalatine artery ligation (ESPAL) is the preferred method of treatment for persistent posterior epistaxis.