Epistaxis

Question 1

What is epistaxis?

Answer 1

Epistaxis, or nosebleed, is bleeding from the nostril, nasal cavity, and/or nasopharynx and may be classified as anterior or posterior.  

Question 2

Describe the epidemiology of epistaxis

Answer 2

Epistaxis = Nosebleeds → most common site of bleeding is the Kiesselbach Plexus (Little’s Area - where vessels supplying nasal mucosa anastamose with each other)
- Most common in children and older people

Question 3

What are the 2 types of epistaxis a patient could have?

Answer 3

1. Anterior Epistaxis → Blood flowing out nostrils (90% of cases)
2. Posterior Epistaxis → Rarely blood can run down the throat. High risk of aspiration and airway compromise.

Question 4

What are the causes/ risk factors for epistaxis?

Answer 4

Dry weather, minor nasal trauma (nose picking or rubbing), primary coagulopathy (haemophilia), familial hereditary haemorrhagic telangiectasia (vascular malformation - autosomal dominant condition), granulomatosis with polyangiitis, thrombocytopaenias

Causes of epistaxis can be primary of secondary - majority are primary, where there is no clear and obvious cause.

Secondary occurs when there is a clearly identifiable factor including:
- Alcohol
- Antiplatelet agents (e.g. clopidogrel)
- Aspirin and NSAIDs
- Anticoagulants (e.g. warfarin)
- Coagulopathy (e.g. haemophilia, von Willebrand’s disease)
- Trauma (e.g. nasal fracture)
- Tumours
- Surgery
- Septal perforation

Question 5

What is meant by “Herediatary Haemorrhagic Telangiectasia”?

Answer 5

• Abnormal blood vessel formations (arteriovenous malformations).
• Autosomal domininant condition characterised by multiple telangiectasia over the skin and mucous membranes.
• Causes spontaneous, recurrent nosebleeds.
• First-degree relative will typically also have HHT.

Question 6

What is “Granulomatosis with Polyangiitis (Wegener’s)”?

Answer 6

epistaxis, sinusitis, dyspnoea, saddle shaped nose, rapidly progressive glomerulonephritis (’pauci-immune’).
- cANCA postive.

Question 7

What is “Idiopathic Thrombocytopaenic Purpura (ITP)”?

Answer 7

• Can cause epistaxis. Isolated thrombocytopaenia in a relatively well person.
• Also causes petichae and purpura.
• Tx with oral prednisolone.

Question 8

What is “Thrombotic Thrombocytopaenic Purpura (TTP)”?

Answer 8

Isolated thrombocytopaenia in a very unwell person. HUS (haemolytic anaemia, thrombocytopenia, AKI) + fever + neurological signs.

Question 9

What are the presenting symptoms/ signs of epistaxis?

Answer 9

1. Blood in one nostril or on both sides of nose
2. Recurrent Epistaxis → suggests anterior vessel on affected side. Common in children
3. Septal Deviation → increases likelihood for epistaxis

Question 10

How is epistaxis managed?

Answer 10

1. Begin fluid resuscitation if patient is haemodynamically unstable
   - Pinch the cartilaginous (soft) area of the nose firmly and bend their head forward (NOT BACK as blood may go into pharynx and cause haematemesis)
   - If does not stop after 10-15 mins → Nasal Cautery (1st line if source of bleed is visible), Nasal Packing (2nd line or If bleeding point difficult to localize)
   - Recurrent Epistaxis ⇒ Naseptin (antiseptic cream)
   - Posterior Epistaxis → should be dealt with by ENT specialist

a. Direct Compression: This involves compression of the nasal alae and is the first-line management for epistaxis. Most anterior bleeds resolve after 10-15 minutes of compression without interruption.
b. Cautery: If direct compression does not resolve the epistaxis, cautery can be performed. This can either be chemical or electrical.
c. Nasal Packing: If nasal cautery fails or if there is severe bleeding, nasal packing can be performed to tamponade the local bleeding.
d. Aggressive Therapies: These are reserved for patients with posterior bleeds and uncontrollable severe bleeding unamenable to nasal packing. They may include nasal balloon catheter and transnasal endoscopy with direct cautery/arterial ligation.

Question 11

Which arteries do you perform surgical ligation on as part of the management of epistaxis?

Answer 11

1. The most likely vessel to bleed is the sphenopalatine artery
2. The anterior ethmoidal artery
3. The external carotid artery may also be targeted in theatre, however, it should be the last resort if intervention in other arteries has failed to stop the bleeding.