ONLINE EXCLUSIVE Amy S. Wong, BMBS, Epistaxis: A guide to Dip Surg Anat, BPhty Department of Otolaryngol- ogy Head and Neck Surgery, assessment and management Monash Cancer Centre, Monash Health, Melbourne, VIC, Australia Is your patient’s nosebleed a self-limiting occurrence, amy.wong@monashhealth. or a sign of something more worrisome? And which org.au The author reported no treatments are best in which situations? potential conflict of interest relevant to this article. pistaxis is a common presenting complaint in fam- PRACTICE ily medicine. Successful treatment requires knowledge RECOMMENDATIONS of nasal anatomy, possible causes, and a step-wise ❯ Use topical vasoconstrictor E approach. and local anesthetic agents Epistaxis predominantly affects children between the ages as a first line therapy for epistaxis. Consider the of 2 and 10 years and older adults between the ages of 45 and 1-4 additional use of topical 65. Many presentations are spontaneous and self-limiting; tranexamic acid. A often all that is required is proper first aid. It is important, how- ever, to recognize the signs and symptoms that are suggestive ❯ Perform chemical cautery with silver nitrate in cases of more worrisome conditions. of anterior epistaxis. This Management of epistaxis requires good preparation, ap- approach is cheap, easy to propriate equipment, and adequate assistance. If any of these perform, and silver nitrate are lacking, prompt nasal packing followed by referral to an is readily available. A emergency department or ear, nose, and throat (ENT) service ❯ Consider endoscopic sphe- is recommended. nopalatine artery ligation in the acute management Anatomy of the nasal cavity of posterior epistaxis. It is The nasal cavity has a rich and highly varied blood sup- superior to posterior nasal ply arising from the internal and external carotid arteries packing and embolization with multiple anastomoses and a crossover between the left when it comes to pain, cost- and right arterial systems.2,4,5 The internal maxillary artery effectiveness, risk, and overall (IMAX) supplies 80% of the nasal vault.2 The sphenopala- control of bleeding. B tine artery (SPA) supplies most of the nasal septum and the Strength of recommendation (SOR) turbinates, while the greater palatine artery (GPA) supplies 3,5 A Good-quality patient-oriented the floor of the nasal septum. The ethmoidal arteries course evidence through the cribriform plate to supply the roof of the nasal B Inconsistent or limited-quality patient-oriented evidence cavity. The ethmoidal arteries communicates with branches C Consensus, usual practice, of the SPA posteriorly and several branches anteriorly opinion, disease-oriented (FIGURE 1). evidence, case series Kiesselbach’s plexus is a highly vascularized region of cartilaginous nasal septum anteroinferiorly that is also known as Little’s area. It is supplied by the SPA, GPA, superior labial artery, and ethmoidal arteries.5 Woodruff’s plexus is the richly vascularized posterior aspect of the nasal cavity primarily sup- plied by the SPA.3,5 CONTINUED MDEDGE.COM/JFPONLINE VOL 67, NO 12 | DECEMBER 2018 | THE JOURNAL OF FAMILY PRACTICE E13 FIGURE 1 Anatomy of the nasal cavity hty , BP Anat Surg ip IMAGES COURTESY OF: AMY S. WONG, BMBS, D IMAGES COURTESY Is the bleed anterior or Numerous causes: posterior; primary or secondary? From trauma to medications Epistaxis is classified as anterior or pos- Epistaxis can be caused by local, systemic, terior based on the arterial supply and the or environmental factors; medications; or be location of the bleed in relation to the piri- idiopathic in nature (TABLE 12). It commonly form aperture.2,3 Anterior epistaxis occurs arises due to self-inflicted trauma from nose in >90% of patients and arises in Little’s picking, particularly in children; trauma to area.6 Posterior epistaxis arises from Wood- nasal bones or septum; and mucosal irrita- ruff’s plexus in the posterior nasal septum tion from topical nasal drugs, such as corti- or lateral nasal wall. It occurs in 5% to 10% costeroids and antihistamines. Other local of patients, is usually arterial in origin, and factors include septal abnormalities, such as leads to a greater risk of airway compromise, septal perforation, inflammatory diseases, aspiration, and difficulty in controlling the rhinosinusitis, illicit drug use (eg cocaine), hemorrhage.2,6 iatrogenic causes, and neoplasia. Epistaxis can be classified further as Red flags for neoplasia include unilat- primary or secondary hemorrhage. Primary eral or asymmetric symptoms, such as nasal epistaxis is idiopathic, spontaneous bleeds blockage, facial pain, rhinorrhea, headaches, without any precipitants.2 Blood vessels facial swelling or deformity, and cranial neu- within the nasal mucosa run superficially ropathies (ie, facial numbness or double vi- and are relatively unprotected. Damage to sion). Other red flags include Southeast Asian this mucosa and to vessel walls can result origin (nasopharyngeal carcinoma), loose in bleeding.4 Spontaneous rupture of ves- maxillary teeth, and deep otalgia (TABLE 22). sels may occur occasionally, during, say In adolescent males, it is important to con- the Valsalva maneuver or when straining sider juvenile nasopharyngeal angiofibroma, to lift heavy objects.4 Secondary epistaxis a benign tumor that can bleed extensively. occurs when there is a clear and definite Systemic factors include age, hyperten- cause (eg trauma, anticoagulant use, or sion, alcohol use, acquired coagulopathies surgery). due to liver or renal disease, hematologic ab- E14 THE JOURNAL OF FAMILY PRACTICE | DECEMBER 2018 | VOL 67, NO 12 EPISTAXIS normalities, circadian rhythms, and genetic TABLE 1 disorders such as hereditary hemorrhagic Etiology of epistaxis2 telangiectasia (HHT), hemophilia, and von Willebrand’s disease.2 Local factors Medications that contribute to epi- Trauma staxis include antiplatelet agents, such as Mucosal irritation aspirin and clopidogrel; nonsteroidal anti- Septal abnormalities (eg septal perforation) inflammatory drugs (NSAIDs); warfarin and novel oral anticoagulants (NOACs); and com- Inflammatory diseases plementary and alternative medicines, such Rhinosinusitis garlic, gingko, and ginseng. Environmental Illicit drug use factors include temperature and humidity.2 Iatrogenic causes Ask about trauma, but also Neoplasia about upper GI hemorrhage Systemic factors Resuscitation and control of bleeding (which Age (2-10 years and 45-65 years) we’ll discuss in a moment) should always Hypertension take priority. A thorough history and exami- nation are also essential. It’s important to Alcohol use elicit details of the acute episode and any Circadian rhythms (morning and late afternoon) previous episodes, including the duration, Genetic disorders (eg HHT, hemophilia, and von Willebrand’s disease) severity, frequency, laterality of bleed, and Juvenile nasopharyngeal angiofibroma (males) contributing or inciting factors.1,2 Posterior epistaxis often occurs from both nostrils and Medications feels as though blood is dripping down the Antiplatelet agents (eg aspirin and clopidogrel) throat rather than the nose. NSAIDs Hematemesis and melena from upper Anticoagulant therapy (eg warfarin and NOACs) gastrointestinal hemorrhage can often be overlooked. Elicit history of local trauma, in- Complementary and alternative medicines (eg garlic, gingko, and ginseng) cluding nose picking, possible foreign body (particularly batteries in children), and re- Environmental factors current upper respiratory tract infections. Temperature (cooler months) Treatments, including methods pre- Low humidity viously used to control episodes, can be Idiopathic causes instructive. Pinching over the nasal bones— HHT, hereditary hemorrhagic telangiectasia; NSAIDs, nonsteroidal anti-inflammatory drugs; rather than the soft cartilaginous part of the NOACs, novel oral anticoagulants. nose—unfortunately remains relatively com- mon. Ask about any past medical history that TABLE 2 can give clues to the cause of bleeding, such Red flags for neoplasia2 as hypertension, hepatic impairment, easy Unilateral or asymmetric symptoms bruising, family history of coagulation dis- orders, and social history including alcohol Nasal blockage intake, smoking, and recreational drug use— Facial pain particularly cocaine use. A detailed medica- Rhinorrhea tion history, as discussed earlier, is vital. Headaches Facial swelling or deformity Initial management: Cranial neuropathies such as facial numbness or double vision Digital pressure Southeast Asian origin (nasopharyngeal carcinoma) Epistaxis is potentially a life-threatening Loose teeth event. All patients who are actively bleed- ing require full assessment, resuscitation, Deep otalgia MDEDGE.COM/JFPONLINE VOL 67, NO 12 | DECEMBER 2018 | THE JOURNAL OF FAMILY PRACTICE E15 FIGURE 2 conditions that could lead to coagulopathy. Thudicum’s speculum The clinical state of an elderly patient may deteriorate rapidly, so aggressive resuscita- tion is vital.4 Getting a better look requires the proper equipment Universal precautions including facemask, eye protection, and gloves should be worn. Have equipment easily accessible, including sufficient lighting and suction. A headlight enables the use of both hands to assess and treat the patient. The nasal cavity often is ob- scured by clots, so ask the patient to blow and clear their nose. Although this may lead to a recurrence of bleeding, it could assist in iden- tifying the bleeding point.2 Local anesthetic with a vasoconstrictor should be