Epistaxis Flashcards
Causes of epistaxis (nose bleed)
Local (usually unilateral):
- Idiopathic causes
- Trauma to Little’s area (eg. nose picking, constant sneezing (AR))
- Trauma to base of skull
- Inflammation: Rhinosinusitis
- Tumour: JNA, NPC, SCC (rare)
- “Vascular nipple”/Mucosal arteriovenous malformations
- Carotid blowout syndrome (screen for possible NPC on RT)
Systemic (usually bilateral + other systemic bleeding):
- Hypertension, severe/uncontrolled
- Anticoagulant drugs (e.g. Aspirin, warfarin)
- Coagulopathy (e.g. thrombocytopenia, haemophilia, vWD, leukaemia, DIC)
- Hereditary hemorrhagic telangiectasia
Blood supply of the nose
A) Branches of external carotid artery and internal carotid artery
ECA:
- Sphenopalatine artery***
- Greater palatine artery
- Superior labial artery
*angioembolisation can be done
ICA:
- Ophthalmic artery -> anterior ethmoidal artery, posterior ethmoidal artery
*angioembolisation not recommended, surgical ligation
B) Kiesselbach’s plexus at Little’s area
- Anteroinferior part of nasal septum where many branches terminate and anastomose to form rich network of blood vessels
- Very close to nostrils where mucosa is prone to trauma and drying from cold air (area breaks down and underlying blood vessels bleed)
- Common place for nose bleeds
“Vascular nipple”/Muscosal arteriovenous malformation
Looks like a polyp sticking out → Poking at it will cause pulsatile bleeding
Classically spontaneous unprovoked unilateral heavy epistaxis, stops spontaneously
Common, benign, episodic, unknown cause
Trauma to base of skull
Base of skull fracture
- Results in bleeding from dural sinuses, torn ethmoidal arteries and torn nasal mucosa (vs bleeding from nasal fracture is usually self-limited)
- A/w significant head injury
Inflammation: Rhinosinusitis
Blood stained discharge rather than fresh red blood with greenish/yellowish discharge
Tumour: NPC***
Rarely presents with epistaxis unless very large
Blood stained oral secretions* &/or blood stained nasal secretions (rather than fresh blood because only surface of tumour will bleed) + clear discharge
- “I will spit out blood when I clear my throat in the morning”
Tumour: Juvenile nasopharyngeal angiofibroma (JNA)
- Adolescent male presenting with unilateral large volume epistaxis and persistent nose block
- Super vascular tumour that sits near nasopharynx: DON’T biopsy, radiological diagnosis
- Locally aggressive but not cancerous
- High risk of recurrence as many leave some tumour behind due to difficulty of resection
- A/w sinusitis, OSA
- Otological cx: OME
- Surgery with pre-op embolisation
- RF ablation
Carotid blowout syndrome
- NPC post radiotherapy
- ICA usually protected from nose environment by anterior temporal bone, bone can be eroded away by a tumour (NPC)
- Sudden massive bleed due to bone erosion and destruction by primary tumour and RT
*If untreated by RT, less likely carotid blowout as NPC protects carotid artery until RT shrinks tumour and leaves ICA exposed to environment/sinusitis - May rupture 2nd or 3rd time
- Tx: Internal carotid artery embolization (Main risks (30%): Blindness, stroke)
“Massive epistaxis and bleeding from mouth, suddenly stops, patient comes to ED with blood stained clothes”
- “Have you had NPC before and you were treated for it?”
Hereditary hemorrhagic telangiectasia
- Autosomal dominant inheritance (rare) *check FAM Hx
- Telangiectasia/spider nevi on skin and inside nose, mucosa
- Visceral arteriovenous malformations
- Iron deficiency anemia
- GI bleed
- Tends to have spider naevi from young all the way to adulthood
1st line management for epistaxis
Basic, @GP/polyclinic settings/home:
A. Epistaxis first-aid
- Sit up, lean forward
*eldery who are frail and feel more comfortable/safer lying down, then it is ok to just lie down
- Firm digital pressure on the fleshy part of the nose (not the bridge) for 10-20 min
- Avoid swallowing the blood: irritate stomach and vomit
- Apply an ice pack on the nasal bridge
- Suck on ice cubes –> Vasoconstriction of the greater palatine artery
B. Topical nasal decongestant
- Oxymetazoline: alpha adrenergic agonist
- Good for small volume bleeds
- Use PRN, do not use for more than 1 week
C. Silver nitrate (AgNO3) cautery
- must flush with NaCl saline after to stop the burning
If persistent bleed -> refer to A&E
2nd line management for epistaxis
ENT, scope
- Thorough endoscopic examination
- Hemostatic material/electrocautery** after LA given to mucosa
- Packing
a) Anterior packing
~ Start with anterior packing first whether you think it’s anterior or posterior bleed
~ Compressed sponge (Merocel*) or Bismuth Iodine Paraffin Paste (BIPP)
b) Posterior packing
~ If anterior packing fails
~ Add Foley’s balloon catheter or Gauze pack
Complications of using Foley’s balloon catheter
- Alar pressure necrosis from catheter pressuring on single point –> Applying padding to spread pressure
- Toxic shock syndrome from S. aureus from FB –> Cover with Abx (Clindamycin/ Penicillin)
- Discomfort and interferes with patient’s breathing
3rd line management of epistaxis
Invasive
- Bleeding from ICA branch: can only do examination under anaesthesia and surgically ligate ethmoidal arteries
- Bleeding from ECA branch: angioembolisation, EUA and surgical ligation of sphenopalatine artery
*30% risk of stroke in carotid artery embolisation e.g. in carotid blowout
Causes of trauma to little’s area
- Excessive nose digging
- Constant sneezing, itching -> think of possible AR symptoms triggering trauma to nose
