High Yield Topics

Epistaxis

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Ovid: 5-Minute Sports Medicine Consult, The


Epistaxis
David Z. Frankel
Basics
Description
  • Bleeding from injured nasal mucosa overlying a blood vessel
  • Self-induced digital trauma (nose picking) is the most common etiology, particularly among children.
  • Affected persons usually do not seek medical attention, especially if bleeding is minor or self-limited.
  • Synonym(s): Nosebleed; Nasal bleeding
Epidemiology
  • Common problem that is estimated to occur in 60% of the general population
  • 90% of cases occur along the anterior nasal septum at Kiesselbach's plexus.
  • Bimodal age distribution with incidence peaks at ages <10 yrs and >50 yrs
Etiology
  • Local causes:
    • Local digital trauma
    • Low moisture content in ambient air
    • Nasal septal deviation
    • Intranasal neoplasm or polyps
    • Chemical irritants (eg, cigarette smoke)
    • Medications (eg, intranasal steroids)
    • Allergic or viral rhinitis
    • Chronic sinusitis
    • Facial trauma
    • Foreign body
    • Septal perforation
    • Illicit drug use (eg, cocaine)
    • Aneurysm
    • Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease)
    • Iatrogenic instrumentation
  • Systemic causes:
    • Coagulopathies (eg, Von Willebrand disease, hemophilia)
    • Renal failure
    • Platelet dysfunction
    • Thrombocytopenia
    • Hematologic malignancies (eg, leukemia)
    • Alcoholism
    • Hypertension
    • Liver disease (eg, cirrhosis)
    • Medications (eg, aspirin, NSAIDs, anticoagulants)
Diagnosis
History
  • Laterality of nosebleed
  • Amount of blood loss
  • Severity
  • Duration
  • Frequency
  • Presence of nasal obstruction: May indicate a neoplasm, especially with recurrent bleeding from the same side
  • Trauma: Consider other associated injuries.
  • Other medical conditions that predispose to bleeding:
    • Tumors and coagulation disorders
    • Cirrhosis
    • HIV infection
    • Intranasal cocaine use
  • The presence of chronic medical conditions that can be exacerbated by blood loss:
    • Coronary artery disease
    • Chronic obstructive pulmonary disease
  • Medications:
    • Aspirin
    • NSAIDs
    • Anticoagulants
    • Intranasal steroids
  • Alcohol use
  • History of severe nosebleeds or easy bruising
  • Family history of bleeding disorders
Physical Exam
  • Initial evaluation should focus on airway assessment and cardiovascular stability, looking for signs of airway compromise or hypovolemia.
  • Pretreatment/initial tamponade:
    • The patient should blow his or her nose to remove blood and clots.
    • Local anesthetic and vasoconstrictor should be applied as a topical spray or via saturated cotton pledgets.
      • Drugs commonly used for this purpose are lidocaine and oxymetazoline (Afrin).
      • One small retrospective study found that oxymetazoline spray stopped the bleeding in 65% of consecutive patients with epistaxis presenting to the ED.
    • The patient should be sitting up and leaning forward to prevent blood from tracking into the pharynx.
    • The patient should apply direct pressure over the upper lip for 5 min and by tightly pinching the nasal alae (soft cartilaginous part of the nose) against the septum continuously for 10–15 min.
    • A cold compress applied over the bridge of the nose may help with hemostasis.
  • Physical examination:
    • The examination should take place in a well-lighted room, preferably with a headlamp or mirror.
    • The patient should be seated comfortably in an upright position with head movement restricted.
    • An adequate examination for the source of bleeding requires use of a nasal speculum.
    • Clots and foreign bodies in the anterior nasal cavity can be removed with suction (Frazier suction catheter), irrigation, forceps, and cotton-tipped applicators.
    • If no anterior source is identified, a nasal endoscope can be used to visualize the remainder of the nasal cavity.
    • Posterior bleeding may be subtle, and the general location of the source of bleeding should be determined (eg, behind the middle turbinate, roof of the nasal cavity, submucosal masses).
    • This is important because different arteries supply the floor and roof of the posterior nasal cavity.
    • Epistaxis from nasal trauma warrants an evaluation for fracture.
    • Deformity of the bony structures may be notable, and palpation of the bony structures may reveal tenderness.
    • Evaluate extraocular muscle movements and stability of the teeth to rule out orbital or maxillary fracture.
    • CSF leak should be ruled out using the ring test, if indicated.
    • In patients with recurrent nosebleeds, evaluate for signs of coagulopathy (eg, ecchymoses, petechiae, telangiectatic lesions).
Diagnostic Tests & Interpretation
Lab
  • Laboratory studies should be dictated by the history, physical examination, and severity of bleeding.
  • For severe bleeding, a CBC should be performed in addition to blood type and crossmatching for possible transfusion.
  • In anticoagulated patients, coagulation studies may be required to determine if anticoagulation levels are supratherapeutic.
  • In patients with systemic conditions that could lead to coagulopathy, testing for hepatic or renal dysfunction may be required.
  • Even when testing is done selectively, the results are normal in nearly 80% of patients.
Imaging
  • Radiographic studies are usually not helpful unless nasal or facial fracture is suspected.
  • Unexplained recurrent unilateral epistaxis should raise suspicion for neoplasm and warrants consideration of CT scan or MRI and endoscopic evaluation.
Differential Diagnosis
  • Pulmonary hemoptysis
  • Upper GI bleed such as bleeding esophageal varices
  • Tumor bleeding from the pharynx, larynx, or trachea

P.139


Treatment
  • Anterior bleed:
    • Minor anterior nosebleeds may resolve without intervention prior to clinical evaluation or with initial tamponade.
    • Epistaxis that is refractory to pressure and topical vasoconstrictors may require cautery.
    • If an anterior bleeding source is visualized, 1st-line treatment consists of chemical or electrical cautery.
      • Chemical cautery is usually performed with silver nitrate.
        • Most useful for minor active bleeds or after active bleeding has stopped and prominent vessels have been identified.
        • Apply the cautery for ∼10 sec.
        • Begin at the periphery of a small area surrounding the bleeding site and move centrally.
        • Exercise caution with silver nitrate because it cauterizes everything that it touches.
        • Never cauterize both sides of the nasal septum in the same session to reduce the risk of iatrogenic septal perforation.
      • Electrical cautery is useful for more aggressive bleeding or larger vessels of the anterior nasal septum.
        • The nose must first be anesthetized using injected local anesthetic because electrical cautery can be extremely painful.
        • Anesthetize bilaterally because the electrical current is transmitted through the septum.
        • Electrocautery must be performed cautiously to avoid excessive destruction of healthy tissue.
        • The use of electrocautery on both sides of the septum may increase the risk of septal perforation.
      • Laser cautery has little role in the treatment of acute epistaxis, although it is used commonly for patients who have chronic epistaxis secondary to hereditary hemorrhagic telangiectasias.
    • If cautery is unsuccessful, or if no obvious site of bleeding is seen, nasal packing should be considered to tamponade the epistaxis.
    • A number of absorbable and nonabsorbable packing materials are available for anterior nasal packing.
    • Traditional packing products consist of nondegradable materials.
      • Gauze impregnated with petroleum jelly (eg, Xeroform) may be inserted in layers from the floor of the nasal cavity to tamponade the epistaxis.
      • A preformed nasal tampon made of polyvinyl alcohol that expands when wet (eg, Merocel) will swell and fill the nasal cavity, applying pressure over the bleeding area.
      • An inflatable carboxymethylcellulose pack consisting of a balloon catheter and hydrocolloid coating (eg, Rapid Rhino) that forms a lubricant on contact with water and remains in contact with mucosa on balloon deflation may cause less discomfort and be easier to insert and remove.
    • Absorbable or degradable materials that do not require formal removal are useful.
      • Oxidized cellulose (eg, Surgicel) and gelatin foams (eg, Gelfoam) increase clot formation and provide a degree of tamponade.
      • Bovine-derived thrombin gel (eg, FloSeal) is conformable to the contours of the nasal cavity, easy to apply, and less painful. Higher costs of its use may be offset by the lack of need for packing removal.
    • Packing generally is left in place for 1–5 days to ensure adequate clot formation.
    • Topical or oral antibiotics typically are used with prolonged nasal packing because of the possibility of toxic shock syndrome.
    • Other complications of nasal packing include septal hematomas, abscesses, or pressure necrosis from traumatic packing; sinusitis from blockage of sinus drainage; hypoxia from nasal airway blockage or apneic spells; stimulation of the nasovagal reflex causing syncope during packing; and acute airway obstruction from pack displacement into the oropharynx.
    • Failure to control anterior bleeding with cautery or packing may necessitate embolization or surgical ligation of the offending vessels.
    • Referral to an otolaryngologist is appropriate when bleeding is refractory, complications are present, or specialized treatment is required.
    • Continued bleeding despite an anterior pack may be due to a posterior bleed.
  • Posterior bleed:
    • These bleeds can be difficult to treat and may require either balloon insertion or a formal posterior pack.
    • If a specialized balloon device (eg, Brighton balloon, Simpson plug, Epistat nasal catheter) is not available, posterior tamponade can be achieved using a Foley catheter.
    • Posterior packing usually necessitates hospitalization out of concern for hypoxic complications, cardiopulmonary events, and the risk of asphyxiation should the packing become dislodged.
    • Posterior packing can be quite uncomfortable and may require significant anesthesia.
    • A posterior pack may be an emergent temporizing measure before surgery or angiographic embolization.
Ongoing Care
  • Once epistaxis is controlled, conservative measures may prevent recurrent bleeding owing to local factors.
  • Refrain from activities that may stimulate bleeding:
    • Blowing or picking nose
    • Heavy lifting
    • Strenuous activity
  • Patient should abstain from alcohol or hot drinks that may cause vasodilatation of the nasal vessels.
  • Nasal saline washes and water-soluble ointments assist in humidification of the nasal mucosa and promote healing.
  • Humidified air, especially for patients using oxygen via nasal canula, may improve local conditions within the nose.
Follow-Up Recommendations
  • Patients should meet with their primary care physician to search for and address underlying causes and risk factors for epistaxis.
  • All patients with recurrent epistaxis, particularly if unilateral, require formal evaluation with radiographic studies and nasal endoscopy to rule out a neoplastic lesion.
Additional Reading
Alter H. Approach to the adult with epistaxis. In: UpToDate, Basow DS (Ed), UpToDate, Waltham, MA, 2009.
Gifford TO, Orlandi RR. Epistaxis. Otolaryngol Clin North Am. 2008;41:525–536, viii.
Kucik CJ, Clenney T. Management of epistaxis. Am Fam Physician. 2005;71:305–311.
Leong SC, Roe RJ, Karkanevatos A. No frills management of epistaxis. Emerg Med J. 2005;22:470–472.
Pope LE, Hobbs CG. Epistaxis: an update on current management. Postgrad Med J. 2005;81:309–314.
Schlosser RJ. Clinical practice. Epistaxis. N Engl J Med. 2009;360:784–789.
Codes
ICD9
784.7 Epistaxis
Clinical Pearls
Athletes with an anterior bleed that is easily controlled and without significant facial trauma or underlying condition may return to play during the same event after cessation of bleeding and appropriate counseling.


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