Epistaxis

Question 1

Anterior vs posterior epistaxis

Answer 1

Anterior
- Visible source
- Due to damage of Kiesselbach’s Plexus in Little’s area (delicate capillary network on the anterior nasal septum)
- Supplied by anterior ethmoidal artery, sphenopalatine artery and facial artery (superior labial)

Posterior
- More profuse bleeding
- Older patients
- Higher risk of aspiration and airway compromise
- From the branches of the sphenopalatine artery

Question 2

Aetiology of epistaxis

Answer 2

Vascular
- Hereditary haemorrhagic telangiectasia / Osler-Weber-Rendu (elderly; prolonged nasal bleeding)
- GPA (Wegener’s)
- Coagulopathy (thrombocytopenia, splenomegaly, leukaemia, Waldenstrom’s macroglobulinaemia, ITP)
- Cocaine (powerful vasoconstrictor  repeated use obliteration of the septum)
Inflammation: chronic sinusitis from infection, allergic rhinosinusitis, nasal polyps
Trauma (most common): nose picking, nasal fractures, ulcers/perforations, foreign body, blunt trauma
Iatrogenic: nasal oxygen therapy → drying of nasal mucosa
Neoplastic : Juvenile angiofibroma (adolescent males; a benign tumour that may bleed as it is highly vascularised), squamous cell carcinoma
Pyogenic granuloma

Question 3

Signs of epistaxis on examination

Answer 3

Anterior: small red dot <1mm
Posterior: profuse bleeding, bilateral, site cannot be identified, bleeding first started down the throat

Question 4

Investigations for epistaxis

Answer 4

Clinical diagnosis
Run FBC and coagulation studies if bleeding has been heavy/recurrent or anaemia is suspected/clotting disorder suspected

Question 5

Management for epistaxis

Answer 5

1. sit up, lean forward, mouth open → compress nasal cartilage (soft area of nose) for 15 minutes
   → bleeding stops: topical antiseptic naseptin (chlorhexidine + neomycin) to prevent crusting/vestibulitis QDS up to 10 days
   (peanut/soya/neomycin All → mupirocin)
   → Still bleeding: remove clots by blowing/suction
2. Gauze (soaked in local + vasoconstrictor)
3. Rhinoscopy to identify bleeding point
   → visualised: silver nitrate cautery
   → no visualised packing
4. Admit and refer to ENT

Silver nitrate: 3-10 seconds, dab clean and add naseptin
Packing:
- Nasal tampons (merocel)
- Inflatable packs (rapid rhino)
- Ribbon gauze + vaseline/bismuth iodoform paraffin paste
- 18G foley to nasopharynx, inflate, pull back until lodging

Question 6

What advice should be given after a nose bleed

Answer 6

Don’t pick nose or blow nose
Sit upright, out of the sun
Avoid bending, lifting or straining
Sneeze through mouth
No hot food or drink
Avoid EtOH and tobacco

Question 7

What interventions can secondary care do for epistaxis

Answer 7

Resuscitation — this may include transfusion to replace blood volume and provide coagulation factors.
Formal packing (may be under general anaesthetic).
Endoscopic assessment and electrocautery.
Examination under anaesthesia, and surgical intervention (such as diathermy, septal surgery, arterial ligation, and laser treatment).
Radiological arterial embolization.
Intravenous or oral tranexamic acid.

Question 8

Complications of treatment for epistaxis

Answer 8

Nasal packing
- Sinusitis
- Septal haematoma or abscess
- Pressure necrosis
- Toxic shock syndrome
- Apnoeic episodes
Nasal cautery
- Septal perforation

Question 9

Complications of epistaxis

Answer 9

Anaemia
Hypovolaemia
Aspiration from dislodgement or mispositioning

Question 10

Prognosis for epistaxis

Answer 10

Most episodes of epistaxis are self-limiting and do not require medical treatment.
Mortality from epistaxis is rare and is usually associated with complications such as hypovolaemia (secondary to severe bleeding) or toxic shock syndrome (from prolonged nasal packing), and in people with comorbidities such as coronary artery disease, severe hypertension, a clotting disorder, or significant anaemia.