Module 8.10 - Epistaxis

Question 1

What is epistaxis?

Answer 1

Bleeding from the nostril, nasal cavity, or nasopharynx caused by bursting of a blood vessel within the nose; may be spontaneous or caused by trauma.

Question 2

What causes epistaxis?

Answer 2

A. The vast majority (90%) of cases occur in the anteroinferior (front bottom) nasal septum in an area known as Kiesselbach’s plexus- where 5 arteries join together.

B. The lesser cases (5-10%) arise from the posterior nasal cavity in an area known as Woodruff’s plexus. Posterior bleeds usually originate from the lateral wall and more rarely from the nasal septum.

C. More common in winter months

D. Forceful expiration- such as sneezing or coughing

E. Trauma – blow to the nose, fracture, picking the nose, foreign bodies

F. Drying or thinning as the result of oxygen use and nasal sprays

G. Infectious/allergic sinusitis, rhinitis, and systemic infection

H. Hypertension

I. Nasopharyngeal fibroma, angioma and malignant tumors

J. Coagulopathies

K. Change in atmospheric pressure.

Question 3

What are the subjective/physical exam findings associated with epistaxis?

Answer 3

A. History of bleeding from the nose

B. Acute bleeding from nasal fossa or posterior nasopharynx

C. Site of bleeding - anterior or posterior

D. Ulcerations or erosions of tissue/septal wall

E. Blood pressure may be normal or elevated

Question 4

What lab/diagnostic tests are done to diagnose epistaxis?

Answer 4

A. Sinus series to rule out sinusitis, tumor and angiofibroma

B. May consider CBC, PT, PTT to rule out coagulopathy

Question 5

How do you manage a patient with epistaxis?

Answer 5

A. Position the patient with head erect and elevated

B. Provide reassurance.

C. Clear blood from nostrils- remove clots with gentle suctioning and visualize point of bleed

D. Saturate a cotton ball with oxymetazoline (Afrin) and gently insert it into the site of bleeding

E. Apply gentle pressure by compressing the nose together just below the bridge for 10-15 minutes.

F. Examine nostril for bleeding site

G. Apply topical lidocaine anesthetic, then touch the site with a silver nitrate stick until the vessel ends are completely cauterized (very painful)

H. If unable to cauterize, then insert nasal packing

I. If the bleeding is uncontrollable or occurs from a posterior site, immediate referral to an ENT specialist is indicated. Posterior bleeding can be difficult to control and may require cauterization with silver nitrate stick, electrocautery or balloon inflation compression.

Question 6

What is Rendu-Osler-Weber disease?

Answer 6

• The most serious vascular etiology of epistaxis is Rendu-Osler-Weber disease – also known as hereditary hemorrhagic telangiectasia.
• It is an autosomal dominant disease caused by vascular malformations. It can cause severe, recurrent epistaxis resulting from arteriovenous aneurysms in the mucous membranes.
• A thorough family history is essential to uncover Rendu-Osler-Weber disease. If there is a history of recurrent profuse nosebleeds, refer to ENT specialist.