Pathophysiology of Epistaxis
Most nasal bleeding is anterior, originating from a plexus of vessels in the anteroinferior septum (Kiesselbach’s area).
Less common but more serious are posterior nosebleeds, which originate in the posterior septum overlying the vomer bone, or laterally on the inferior or middle turbinate. Posterior nosebleeds tend to occur in patients who have preexisting atherosclerotic vessels or bleeding disorders and have undergone nasal or sinus surgery.
Etiology of Epistaxis
The most common causes of epistaxis are
Local trauma (eg, nose blowing and picking)
Drying of the nasal mucosa
There are a number of less common causes (see table ). Hypertension Hypertension Hypertension is sustained elevation of resting systolic blood pressure (≥ 130 mm Hg), diastolic blood pressure (≥ 80 mm Hg), or both. Hypertension with no known cause (primary; formerly, essential... read more may contribute to the persistence of a nosebleed that has already begun but is unlikely to be the sole etiology.
Evaluation of Epistaxis
History of present illness should try to determine which side began bleeding first; although major epistaxis quickly involves both nares, most patients can localize the initial flow to one side, which focuses the physical examination. Also, the duration of bleeding should be established, as well as any triggers (eg, sneezing, nose blowing, picking) and attempts by the patient to stop the bleeding. Melena may occur, and swallowed blood is a gastric irritant, so patients also may describe vomiting blood. Important associated symptoms prior to onset include symptoms of an upper respiratory infection (URI), sensation of nasal obstruction, and nasal or facial pain. The time and number of previous nosebleeds and their resolution should be identified.
Review of systems should ask about symptoms of excessive bleeding, including easy bruising; bloody or tarry stools; hemoptysis; blood in urine; and excess bleeding with toothbrushing, phlebotomy, or minor trauma.
Past medical history should note presence of known bleeding disorders (including a family history) and conditions associated with defects in platelets or coagulation, particularly cancer, cirrhosis, HIV, and pregnancy. Drug history should specifically query about use of drugs that may promote bleeding, including aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), other antiplatelet drugs (eg, clopidogrel), heparin, and warfarin.
Vital signs should be reviewed for indications of intravascular volume depletion (tachycardia, hypotension) and marked hypertension. With active bleeding, treatment takes place simultaneously with evaluation.
During active bleeding, inspection is difficult, so attempts are first made to stop the bleeding as described below. The nose is then examined using a nasal speculum and a bright head lamp or head mirror, which leaves one hand free to manipulate suction or an instrument.
Anterior bleeding sites are usually apparent on direct examination. If no site is apparent and there have been only 1 or 2 minor nosebleeds, further examination is not needed. If bleeding is severe or recurrent and no site is seen, fiberoptic endoscopy may be necessary.
The general examination should look for signs of bleeding disorders, including petechiae, purpura, and perioral and oral mucosal telangiectasias as well as any intranasal masses.
The following findings are of particular concern:
Signs of hypovolemia or hemorrhagic shock
Anticoagulant drug use
Cutaneous signs of a bleeding disorder
Bleeding not stopped by direct pressure or vasoconstrictor-soaked pledgets
Multiple recurrences, particularly with no clear cause
Interpretation of findings
Many cases of epistaxis have a clear-cut trigger (particularly nose blowing or picking) as suggested by findings (see table ).
To diagnose epistaxis, routine laboratory testing is not required. Patients with symptoms or signs of a bleeding disorder and those with severe or recurrent epistaxis should have complete blood count (CBC), prothrombin time (PT), and partial thromboplastin time (PTT).
CT may be done if a foreign body, a tumor, or sinusitis is suspected.
Treatment of Epistaxis
Presumptive treatment for actively bleeding patients is that for anterior bleeding. The need for blood replacement is determined by the hemoglobin level, symptoms of anemia, and vital signs. Any identified bleeding disorders are treated.
Bleeding can usually be controlled by pinching the nasal alae together for 10 minutes while the patient sits upright (if possible). If this maneuver fails, a cotton pledget impregnated with a vasoconstrictor (eg, phenylephrine 0.25%) and a topical anesthetic (eg, lidocaine 2%) is inserted and the nose pinched for another 10 minutes. The bleeding point may then be cauterized with electrocautery or silver nitrate on an applicator stick. Cauterizing 4 quadrants immediately adjacent to the bleeding vessel is most effective. Care must be taken to avoid burning the mucous membrane too deeply; therefore, silver nitrate is the preferred method.
Alternatively, a nasal tampon of expandable foam may be inserted. Coating the tampon with a topical ointment, such as bacitracin or mupirocin, may help, both as a lubricant and as prophylaxis against infection. If these methods are ineffective, various commercial nasal balloons can be used to compress bleeding sites.
As another alternative, an anterior nasal pack consisting of 1 cm (½ in) petrolatum gauze may be inserted; up to 175 cm (72 in) of gauze may be required. This procedure is painful, and analgesics usually are needed; it should be used only when other methods fail or are not available.
Posterior bleeding may be difficult to control. Commercial nasal balloons are quick and convenient; a gauze posterior pack is effective but more difficult to position. Both are very uncomfortable; IV sedation and analgesia may be needed, and hospitalization is required.
Commercial balloons are inserted according to the instructions accompanying the product.
The posterior gauze pack consists of 10 cm gauze squares folded, rolled, tied into a tight bundle with 2 strands of heavy silk suture, and coated with antibiotic ointment. The ends of one suture are tied to a catheter that has been introduced through the nasal cavity on the side of the bleeding and brought out through the mouth. As the catheter is withdrawn from the nose, the postnasal pack is pulled into place above the soft palate in the nasopharynx. The 2nd suture, which is left long, hangs down the back of the throat and is trimmed below the level of the soft palate so that it can be used to remove the pack. The nasal cavity anterior to this pack is firmly packed with ½-in petrolatum gauze, and the 1st suture is tied over a roll of gauze at the anterior nares to secure the postnasal pack. The packing remains in place for 4 to 5 days. An antibiotic (eg, amoxicillin/clavulanate 875 mg orally 2 times a day for 7 to 10 days) is given to prevent sinusitis and otitis media. Posterior nasal packing lowers the arterial PO2, and supplementary O2 is given while the packing is in place. This procedure is uncomfortable and should be avoided if possible.
On occasion, the internal maxillary artery and its branches must be ligated to control the bleeding. The arteries may be ligated with clips using endoscopic or microscopic guidance and a surgical approach through the maxillary sinus (internal maxillary) or transnasal endoscopic approach (sphenopalatine). Alternatively, angiographic embolization may be done by a skilled radiologist. These procedures, if done in a timely manner, may shorten hospital stay.
In Rendu-Osler-Weber syndrome, a split-thickness skin graft (septal dermatoplasty) reduces the number of nosebleeds and allows the anemia to be corrected. Laser (Nd:YAG) photocoagulation can be done in the operating room. Selective embolization also is very effective, particularly in patients who cannot tolerate general anesthesia or for whom surgical intervention has not been successful. New endoscopic sinus devices have made transnasal surgery more effective.
Blood may be swallowed in large amounts and, in patients with severe liver disease, should be eliminated promptly with enemas and cathartics to prevent hepatic encephalopathy. The gastrointestinal tract should be sterilized with nonabsorbable antibiotics (eg, neomycin 1 g orally 4 times a day) to prevent the breakdown of blood and the absorption of ammonia.
Most nosebleeds are anterior and stop with direct pressure.
Screening (by history and physical examination) for bleeding disorders is important.
Patients should always be asked about aspirin, ibuprofen, or anticoagulant use.