Epistaxis: an Update on Current Management L E R Pope, C G L Hobbs
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309 REVIEW Postgrad Med J: first published as 10.1136/pgmj.2004.025007 on 5 May 2005. Downloaded from Epistaxis: an update on current management L E R Pope, C G L Hobbs ............................................................................................................................... Postgrad Med J 2005;81:309–314. doi: 10.1136/pgmj.2004.025007 Epistaxis is one of the commonest ENT emergencies. which can result in persistent nasal bleeding despite unilateral arterial ligation. Although most patients can be treated within an accident Anterior bleeds are responsible for about 80% of and emergency setting, some are complex and may epistaxis. They occur at an anastomosis called require specialist intervention. There are multiple risk Kiesselbach’s plexus on the lower part of the anterior septum known as Little’s area. Posterior factors for the development of epistaxis and it can affect bleeding derives primarily from the posterior septal any age group, but it is the elderly population with their nasal artery (a branch of the sphenopalatine associated morbidity who often require more intensive artery), which forms part of the Woodruff plexus. treatment and subsequent admission. Treatment strategies AETIOLOGY have been broadly similar for decades. However, with the The aetiology of epistaxis can be divided into local evolution of endoscopic technology, new ways of actively and general causes (box 1), however most (80%– managing epistaxis are now available. Recent evidence 90%) are actually idiopathic. An important con- tributing factor, in addition to the prominent suggests that this, combined with the use of stepwise vascularity and dual blood supply to the nose, is management plans, should limit patient complications and that blood vessels within the nasal mucosa run the need for admission. This review discusses the various superficially and are therefore comparatively unprotected. In most cases, it is damage to this treatment options and integrates the traditional methods mucosa and to vessel walls that results in bleeding. with modern techniques. Spontaneous rupture of blood vessels may occur occasionally, such as during extreme valsalva ........................................................................... when weightlifting. Although uncommon, it is important to exclude neoplasia as a cause for pistaxis, whether spontaneous or otherwise, unexplained recurrent unilateral epistaxis. is experienced by up to 60% of people in their lifetime, with 6% requiring medical E 1 MANAGEMENT attention. Although our understanding of this The traditional management of acute epistaxis condition has improved considerably, the princi- entails identification of the bleeding point by using http://pmj.bmj.com/ ple of packing the nose for a nosebleed has a head mirror or other light source. If a bleeding changed little since Hippocrates used sheep’s point is localised, then chemical or electrocautery is wool on pugilistic noses in ancient Greece. performed. If unsuccessful, further management takes a stepwise approach—initially anterior pack- EPIDEMIOLOGY ing with some form of gauze or sponge and then The incidence of epistaxis varies greatly with age. failing this, more advanced techniques such as There is a bimodal distribution with peaks in compressive balloons or posterior packing. Finally, children and young adults and the older adult arterial ligation or embolisation can be used to on September 27, 2021 by guest. Protected copyright. 2 (45–65 years). Anecdotal evidence suggests that stem intractable bleeds. Figure 1 outlines a certain stereotypical groups are more prone (for suggested management plan. example, elderly women or young boys). Resuscitation ANATOMY Epistaxis is a potential life threatening event. All One of the primary functions of the nose is to patients who are actively bleeding need full warm and humidify air. It therefore has a assessment and resuscitation if necessary. The See end of article for profuse blood supply arising from both the clinical state of an elderly patient may deteriorate authors’ affiliations internal and external carotid arteries. rapidly so aggressive resuscitation is vital. ....................... Epistaxis is normally classified into anterior or Universal precautions should be worn before Correspondence to: posterior, but it can also be classed as superior or starting any treatment including a facemask and Mr C G L Hobbs, inferior depending on the carotid supply. eye protection. Vital signs must be monitored Department of Broadly, the internal carotid (via the ethmoidal regularly. A full blood count should be taken and Otolaryngology and Head arteries) supplies the region above the middle blood group and saved. Studies have shown that and Neck Surgery, St Michael’s Hospital, turbinate while the remaining areas are supplied routine clotting studies need to be performed Southwell Street, Bristol by branches of the external carotid artery. This only if there is a suspected clotting diathesis or BS2 8EG, UK; chris. includes the sphenopalatine artery, which sup- the patient is anticoagulated.3 Fluid management [email protected] plies most of the septum and turbinates on the should be instigated if signs of hypovolaemia are lateral wall. The interface between the two present or admission is required. During resusci- Submitted 4 June 2004 Accepted carotid systems varies in position according to tation, bleeding can commonly be controlled by 14 September 2004 the pressure in each one. There is also crossover digital pressure over the lower soft cartilaginous ....................... between the right and left arterial systems, part of the nose. This is often best performed by www.postgradmedj.com 310 Pope, Hobbs the nasopharynx, which is less uncomfortable for the patient Postgrad Med J: first published as 10.1136/pgmj.2004.025007 on 5 May 2005. Downloaded from Box 1 Causes of epistaxis and will help to reduce swallowing of blood and its subsequent nausea. Local N Idiopathic Nasal preparation Good nasal preparation is critical to elucidate and treat the N Trauma cause of epistaxis. The nasal cavity is often obscured by clots. – Nose picking Thus immediately before examination a forceful blow by the – Facial injury patient through the nose can clear these clots. Although this – Foreign body action may restart bleeding it will enable improved access for anaesthetic. A precautionary view of the cavity should be N Inflammation undertaken by anterior rhinoscopy using a Thudicum’s spec- – Infection ulum; this will enable stubborn clots to be evacuated by suction – Allergic rhinosinusitis and permit initial assessment of the bleeding point. – Nasal polyps Local anaesthetic, ideally including a vasoconstrictor, should be applied to the nasal mucosa over Little’s area (box 2). The N Neoplasia application method varies on the preparation, but most entail – Benign (for example, juvenile angiofibroma) either a solution applied on cotton wool or as a nasal spray. Time should be allowed for the anaesthetic to work. – Malignant (for example, squamous cell carcinoma) Generally, systemic analgesia is not necessary when inspect- N Vascular ing or packing the nose, although mild sedation (with a small dose of diazepam) is often used in hypertensive or anxious – Congenital (for example, hereditary haemorrhagic patients. Once adequate local anaesthesia is achieved, the nasal telangiectasia) cavity can be examined and treatment instigated to stem the – Acquired (for example, Wegener’s granulomatosis) haemorrhage. Little’s area is viewed first. N Iatrogenic Cautery – Surgery (for example, ENT/maxillofacial/ophthal- Chemical cautery is achieved by a using silver nitrate stick mic) (75% silver nitrate, 25% potassium nitrate BP w/w) that – Nasal apparatus (for example, nasogastric tube) reacts to the mucosal lining to produce local chemical damage. The technique entails applying the stick to the N Structural bleeding point with firm pressure for 5–10 seconds. The – Septal spurs or deviation effect varies with concentration and exposure. Feeding – Septal perforations vessels can also be cauterised to limit recurrence. Careful removal of excess silver nitrate helps prevent staining of the N Drugs vestibule or upper lip. If staining does occur, it should be – Nasal sprays (for example, topical decongestants) neutralised immediately by applying normal saline. Only one side of the septum should be cauterised, as there is a small – Abuse (for example, cocaine) risk of septal perforation resulting from decreased vascular- General isation to the septal cartilage. For this reason, we suggest a http://pmj.bmj.com/ four to six week interval between cautery treatments. N Haematological Electrocautery is usually performed in clinic by otolaryngol- – Coagulopathies (for example, haemophilia) ogists under local anaesthetic; it consists of an electrical circuit – Thrombocytopenia (for example, leukaemia) that heats up a metal loop. With this technique thermal energy – Platelet dysfunction (for example, Von Willebrand’s seals the bleeding vessel by radiation, not by direct contact. A disease) potential complication is heat damage to the anterior nares and inferior turbinate. This risk can be reduced by using a large aural N Environmental speculum under microscopic examination. on September 27, 2021 by guest. Protected copyright. – Temperature Anterior packing – Humidity The nose should be packed if bleeding continues despite – Altitude cautery or if no obvious bleeding is seen. There are many forms of anterior nasal packing although