Epistaxis

Objectives

 

1. Be aware of the structure and function of the normal nose and sinuses with particular reference to the following:

        - External nose

        - Nasal cavity and paranasal sinuses

   

 Have an awareness of how these structures change when affected by disease and understand how this

 leads to dysfunction and patient morbidity and mortality.

2. Understand the incidence/prevalence, clinical presentation, the management and prognosis of epistaxis

Definition

 

“Medical term for a nosebleed. The commonest reason for emergency admission to the ENT ward.”

 

Prevalence

 

~ 60% of the population in a lifetime 

~ 6% require medical intervention

Mostly ages 2 -10 & 50 - 80

Potentially fatal!

 

Aetiology

 

The causes of epistaxis can be broadly split into two categories

    - Local 

    - General (systemic)

Rhinosinusitis

Commonest cause 85%

Inflammatory

Idiopathic

Blow to face

Local

Neoplastic

(rare)

Traumatic

Nose picking

Iatrogenic

Nasal sprays

Post surgery

Hereditary telangiectasia

Hereditary

Primary

Platelet disorders

General

Primary

Secondary to drugs

e.g. aspirin / clopidogrel

Bleeding diathesis

Secondary to drugs

e.g. warfarin

Clinical relevance

Hypertension does not cause epistaxis, however, it prolongs bleeding when established.

Anatomy of the nose

Here we will review the vasculature of the nasal cavity. For a more in depth of the look at the anatomy of the nose please see the nasal anatomy tutorial.

The nasal cavity has a rich and complex blood supply that makes it ideally suited for its function of warming inspired air. The crux of this adaptation is seen when disruption of this complex network of vessels causes epistaxis.

The diagram below shows clearly the nasal septum is supplied by 5 main arteries. 

The vessels anastomose to form a network of vessels on the anterior nasal septum called Little's area (Kiesselbach plexus). This is the most common bleeding site seen in 90% of anterior bleeds.

There is a second site of anastomosis seen on the posterior nasal septum called Woodruff's plexus.

Epistaxis can be broadly categorised into two main types depending on the location of the bleeding vessel.

Younger

Easier to manage

90% from Little's area

Blood from one nostril when head tilted forward

Posterior

Older

More difficult to manage

More dangerous

Woodruff's plexus

Blood passes down post nasally, oropharynx, often both nostrils anteriorly

Anterior 

Management

The management of epistaxis should be tackled with a methodical stepped approach. The algorithm below summarises this approach nicely.

Epistaxis management Algorithm

Step 1

Step 2

Assessment of the patient with ATLS principles, ABCD approach, patient resuscitation 

Simple first aid

“15 minutes of uninterrupted pressure on soft part of nose with head tilted forward”

Step 3

Examination of the nasal cavity. Identify bleeding point 

Step 4

Silver nitrate / electric cautery

Step 5

Step 6

Haemostasis achieved?

YES

NO

Patient discharged with naseptin nasal cream 2/52.

Insertion of anterior nasal

packing

Haemostasis achieved?

YES

NO

Pack removed after 24 hours

Repeat from step 2

Posterior pack insertion +/- theatre

Nasal Cautery

​Nasal cautery is the process of sealing the bleeding vessels and can be conducted in a number of ways. There are two main methods commonly used by most ENT departments

1.  Silver nitrate (cautery sticks)

             A small plastic stick with silver nitrate on the end that reacts when in contact with the moist        

             nasal mucosa. AgNO3 + H20 --> AgOH + HNO3 (Nitric acid)

2. Electrocautery (specialist ENT department)

    Usually conducted in an operating theatre. 

  • Bipolar 

  • Monopolar

Cautery should not be conducted bilaterally as this will damage the blood supply to the cartilaginous nasal septal resulting in a perforation.

The three images below illustrate cautery of an anterior epistaxis.

This is the left Little's area. A rich anastomosis is seen.

Silver nitrate cautery is applied to the periphery of the anastomosis first. It leaves a small grey chemical burn over the vessel which denatures protein and causes occlusion of the blood vessel and eventual scarring.

Cautery progresses so that all the vessels are touched. Generally one starts with the smaller ones and work towards the largest.

Anterior nasal packing

​Nasal packing is placed when simple haemostasis measures fails. Packs come in a variety of different shapes, sizes and include some that inflate with water and others that inflate with air. 

All packs work on the theory of creating a pressure tamponade on the bleeding vessels. ​

Placement method

The pack is inserted horizontally into the affected nostril.

(Parallel to the nasal floor)

Air or H20 is used to inflate the pack

The pack is left in situ for 24 hours to allow clot formation.

If haemostasis fails then a pack can be inserted into the contralateral nostril to tamponade the septum.

In persistent bleeding, a posterior pack can be inserted.

Clinical Note

If a pack is in for >24hrs then prophylactic antibiotics are given to prevent infection in the nose, sinuses or middle ear.

Posterior nasal packing

For posterior epistaxis in which an anterior nasal pack has failed to achieve haemostasis, a posterior pack can be inserted to halt the bleed.

As for anterior nasal packing if haemostasis is not achieved with a single pack, a second pack can be inserted into the collateral nostril to tamponade the septum and completely pack the nasal cavity.

Placement method

 

A Size 14fg Foley catheter is inserted into the nostril and advanced until visualised in the oropharynx.

The balloon is inflated with 10ml of sterile water to occlude the choana.

The anterior nasal cavity is packed, the pack inflated and a clamp holds the catheter in place.

The clamp is regularly rotated and gauze is used to protect from alar (pressure) necrosis.

Posterior packs are often left for 24 hours, as a temporary measure to buy time before the patient is taken to theatre. 

Clinical Note

Alar necrosis has a massive cosmetic impact, causing unsightly scarring. There are medicolegal implications!

Surgical management

 

Surgical management is a last resort for patients who have failed to achieve haemostasis with conservative management. As with all treatments a stepped approach is advised with many patients requiring simple measures in the controlled theatre environment. Other patients require higher risk procedures when all else has failed. The list below summarises this stepped approach, with a patient moving onto the next more invasive procedure if haemostasis fails with the attempted method.

  • Examination under anaesthetic

  • Electrocautery

  • Vessel ligation (e.g. SPA)

  • Embolisation

  • Ligation of external carotid

Increasingly invasive procedure