Epistaxis

Question 1

There are two types of epistaxis.

What are they?

Answer 1

Anterior bleed

Posterior bleed

Question 2

Which one is more common? (anterior bleed or posterior bleed)

Answer 2

Anterior bleed (80-95%)

Question 3

Which type of bleed is more severe? (anterior or posterior bleed)

Answer 3

Posterior bleed is way more severe. It tends to be more profuse and originate from deeper structures (usually caused by damage from the sphenopalatine artery in the posterior nasal cavity, which is a branch of the maxillary artery arising from the ECA)

Question 4

The majority of nosebleeds are anterior bleeds. Which part of the nasal cavity is often damaged in anterior bleeds?

Answer 4

The Kiesselbach’s plexus (also known as the Little area)!

Question 5

What vessels make up the Kiesselbach’s plexus?

Answer 5

• Sphenopalatine artery
• Posterior ethmoidal arteries
• Anterior ethmoidal arteries
• Greater palatine artery
• Superior labial artery

Question 6

How do you clinically spot a posterior bleed?

Answer 6

Suspect a posterior bleed if bleeding is profuse, from both nostrils, the bleeding site cannot be identified on speculum examination, and/or if bleeding first started down the throat (be aware that if bleeding started while the person was supine, blood is likely to have drained to the throat regardless of the bleeding site). They are more frequently seen in elderly patients and pose a higher risk of aspiration and airway compromise

Question 7

What are the causes of epistaxis?

(The causes of epistaxis can be divided into local and general causes)

Answer 7

Local causes of damage to the blood vessels:

• Trauma (most common cause) - nose-picking, nose blowing, nasal fractures, septal ulcers or perforations, FB, or blunt trauma (e.g. falls in children)
• Inflammation - Infection (e.g. chronic sinusitis), allergic rhinosinusitis, or nasal polyps
• Drug use - e.g. cocaine, intranasal decongestants, or corticosteroids
  
  • Inhaled cocaine is a powerful vasoconstrictor and repeated use may result in obliteration of the septum (septum abraded or atrophied)
• Vascular causes e.g. hereditary haemorrhagic telangiectasia (HHT) or Wegener’s granulomatosis
  
  • HHT is a rare autosomal dominant condition that leads to abnormal blood vessel formation in the skin, mucous membranes, and often in organs such as the lungs, liver, and brain
• Post-operative bleeding e.g. following ENT surgery, maxillofacial surgery, or ophthalmic surgery
• Tumours
  
  • Benign e.g. juvenile angiofibroma (a rare highly-vascularised benign nasopharyngeal tumour affecting adolescent men)
  • Malignant e.g. squamous cell carcinoma (more common in elderly people)
• Nasal oxygen therapy - causes drying of the nasal mucosa and possibly direct mucosal trauma via the nasal cannulae

General causes of damage to the blood vessels:

• Atherosclerosis
• Mitral stenosis (causes increased venous pressure)
• Blood disorders affecting clotting e.g. thrombocytopenia, platelet dysfunction, Von Willebrand disease, leukaemia, ITP, haemophilia and splenomegaly
• Systemic drugs e.g. anticoagulants and antiplatelets (aspirin, clopidogrel)
• Excessive alcohol consumption
• Environmental factors e.g. temperature, humidity, altitude, exposure to irritants e.g. dusts, certain chemicals, and cigarette smoke
• HTN

Question 8

Give 5 complications of epistaxis

Answer 8

Complications:

• Aspiration and airway compromise (esp with posterior epistaxis)
• Anaemia
• Hypovolemia
• Complications from nasal packing treatment
  
  • Sinusitis
  • Septal haematoma or abscess (due to traumatic packing)
  • Pressure necrosis (secondary to excessively tight packing)
  • Toxic shock syndrome (from prolonged packing)
  • Apnoea (associated with bilateral anterior or posterior nasal packs)
• Complication from nasal cautery treatment
  
  • Septal perforation (due to a direct effect of the silver nitrate pack)
    
    • Particularly at risk of septal perforation if cauterise both sides of the septum. Therefore, ONLY CAUTERISE ONE SIDE!
    • Patients with septoplasty is also at higher risk as they have thinner cartilage

Question 9

Epidemiology of epistaxais:

Epistaxis is most common in which age group?

Answer 9

Epistaxis is common in children >/= 2 yrs old (rare in those < 2)

Incidence peaks in children < 10 yrs old and in adults > 45 yrs old

Posterior epistaxis is more common in elderly people

Question 10

What investigations do you do in a patient with epistaxis?

Answer 10

Clinical diagnosis. Ix are not needed unless an underlying cause is suspected:

• FBC - if bleeding is heavy or recurrent, or anaemia is suspected
• Clotting screen - if a clotting disorder is suspected or an INR is required

Question 11

How do you manage acute epistaxis?

Answer 11

If patient is haemodynamically stable:

• First aid measures to control the bleeding - ask the patient to:
  
  • Sit with their upper body tilted forward and their mouth open, and avoid lying down unless they feel faint
    
    • Leaning forward decreases blood flow to the nasopharynx and allows the patient to spit out any blood in their mouth. It also reduces the risk of aspirating blood
  • Pinch the cartilaginous (soft) part of the nose firmly and hold it for 10-15 minutes without releasing the pressure, while breathing through their mouth
• If bleeding stops with first aid measures:
  
  • Apply a topical antiseptic cream (Naseptin) to reduce crusting and vestibulitis
    
    • If allergic to neomycin, peanut, or soya, prescribe Mupirocin nasal ointment instead
• If bleeding does NOT stop after 10-15 minutes of continuous pressure on the nose, consider:
  
  • Nasal cautery - if the source of bleeding is visible and cautery is tolerated (usually adults and older children, but NOT younger children)
  • Nasal packing - if nasal cautery is ineffective or the source of bleeding cannot be seen. *Admit the patient to hospital if the nose is packed in primary care
• If first aid measures or nasal cautery in primary care is successful, give advice on self-care:
  
  • Advise the patient to avoid activities, which may increase the risk of re-bleeding, for 24 hrs. These include blowing/ picking the nose, heavy lifting, strenuous exercise, lying flat, drinking alcohol or hot drinks
  • Safety netting: advise that if bleeding restarts and does not respond to first aid mesures, seek immediate medical attention

If patient is haemodynamically unstable (e.g. feeling lightheaded, syncope, and pallor) OR a posterior bleed is suspected (i.e. bleeding is profuse, from both nostrils, and the bleeding site cannot be identified on speculum examination) –> ADMIT TO HOSPITAL + USE FIRST AID MEASURES WHLE WAITING FOR HOSPITAL TRANSFER

• Consider admission in patients with comorbidities (e.g. coronary artery disease and severe HTN), if an underlying cause is suspected, or if children are under 2 yrs old (as causes such as haemophilia or leukaemia are more likely in this age group)

(Naseptin = chlorhexidine + neomycin)

Mx of posterior bleed:

• Secure the airway as patients are at high risk of aspiration (if it’s just anterior bleed you can do the first aid measures) - note that first aid measures (pinching nose) won’t stop posterior bleed
• Monitor BP and pulse
• IV access + IV fluids
• Ix - FBC (check HCT if IV fluid is given as the fluids can give falsely low Hb level due to haemodilution), clotting screen, G&S, if bleeding heavily
• Ice pack to neck/ forehead/ nose
• Find bleeding point and stop bleeding

Question 12

Describe how to perform nasal cautery

Answer 12

Prior to cautery:

• Ask the patient to blow their nose to clear any clots and allow local anaesthetic to be applied
• Use a topical local anaesthetic spray, usually a vasoconstrictor such as lidocaine with phenylephrine. Wait 3-4 minutes to take effect

To cauterise:

• Identify the bleeding point - should look like a small red dot (< 1 mm)
• Gently apply the silver nitrate stick to the bleeding point for 3-10 seconds until a grey-white color develops
  
  • ONLY cauterise ONE SIDE of the septum to avoid nasal septal perforation

After cautery:

• Dab the cauterised area with a clean cotton bud to remove excess chemical or blood
• Apply a topical antiseptic cream (Naseptin)
  
  • If allergic, give Mupirocin nasal ointment
• Advise to avoid blowing their nose for a few hrs to prevent straining of the nostril

Question 13

Describe how a nose packing is being done

Answer 13

• Anaesthetise the nasal cavity with a topical local anaesthetic spray, usually a vasoconstrictor e.g. lidocaine with phenylephrine. Wait 3-4 minutes to take effect
• Pack the patient’s nose while they are sitting with their head tilted forward
• Secure the pack and ensure there is no pressure on the cartilage around the nostril as this can cause a cosmetic defect
• Check the oropharynx for signs of bleeding from the back of the nose. If bleeding is seen, consider packing the other nostril to increase pressure on the bleeding vessel
• Admit the patient for observation and review, and to ENT

Question 14

What are the common causes of epistaxis in children?

Answer 14

Nose picking

Allergic rhinitis

FB

URTI

Question 15

A 21-year-old woman presents to the emergency department with a 3-hour history of continued epistaxis. She was training with her university rugby team when she collided with another player.

X-ray imaging has confirmed she has not broken her nose, however, there is still profuse bleeding in spite of compression. You are unable to identify the bleeding site.

Which of the following is the most appropriate initial management option?

a) . Cryotherapy
b) . Intranasal epinephrine
c) . Cautery with silver nitrate
d) . Anterior pack insertion
e) . Ice pack

Answer 15

d). Anterior packing is the most suitable option for epistaxis where the bleeding site is difficult to localise

In a situation where there is continued heavy epistaxis and there is no visible bleeding site that may be amenable to cautery, anterior packing is the first line treatment option. Anterior packs are lengths of absorbent material that are inserted into the nose and expand to fill the nasal canal, absorbing blood and compressing the walls of the airway. Some versions contain a small balloon which can be inflated to increase the tamponade effect.

Cryotherapy or cautery with silver nitrate requires the bleeding vessel to be visible, which is not the case in this situation.

Intranasal epinephrine can be useful to prevent re-bleeding once the initial bleeding has been stopped as this will cause blood vessels in the nasal cavity to constrict. This would not be a useful option in this scenario, however, given the heavy bleeding.