Epistaxis

Background
The arteries that supply Kiesselbach's plexus (responsible for anterior nosebleeds).
Schematic arterial supply of the sinonasal cavity. The majority of the posterior epistaxis episodes arise from the septum. The arterial branches involved in epistaxis include the internal maxillary artery, the facial artery, and the ophthalmic artery.

Types
  • Anterior
    • 90% of nosebleeds
    • Occur in anterior septum (Kiesselbach plexus)
    • Can visualize with anterior rhinoscopy
  • Posterior
    • 10% of nosebleeds
    • Occur from nasopalatine branch of sphenopalatine artery
    • Cannot visualize without endoscope

Risk factors

Essential Equipment
  • Light source
  • Nasal speculum
  • Suction
  • Airway equipment
  • Packing or constrictive devices

Clinical Features
Anterior nosebleed after trauma in pediatric patient.
  • Epistaxis
    • Anterior: more likely from one nares
    • Posterior: more likely from two nares

Differential Diagnosis
  • Facial trauma
  • Coagulopathy
  • Nasal tumor
  • Juvenile Nasopharyngeal Angiofibroma (JNA)
  • Hemophilia
  • Arteriovenous malformation

Evaluation

Anterior versus posterior hemorrhage
  • Assume posterior if measures to control anterior bleeding fail
  • Posterior bleeding associated with:
    • Coagulopathy
    • Significant hemorrhage visible in posterior nasopharynx
    • Sensation of blood dripping down throat
    • Hemorrhage from bilateral nares
    • Epistaxis uncontrolled with either anterior rhinoscopy or anterior pack

Management
Demonstration of direct nasal pressure.

Proceed down a stepwise fashion from pressure to vasoconstriction and topical devices to packing while considering risk factors that initiated the event. When initially visualizing, place the patient in the "sniffing position” with the patient slightly leaning forward. Use the speculum in the superior-inferior orientation to avoid septal trauma. Evaluate for polyps, masses, trauma, and bleeding sources.[1]

Direct Nasal Pressure
  1. Have patient blow nose to expel clots or suction nose
  2. Instill topical vasoconstrictor (oxymetazoline or phenylephrine)
  3. Have patient apply direct pressure over cartilaginous area of nasal bridge (not the bony area)
  4. Patient must lean forward to avoid blood draining down nasopharynx thus preventing desired tamponade

Chemical Cauterization

Generally only effective if acute bleeding has stopped and friable site of bleeding can be adequately visualized. Less effective in acute hemorrhage

  • Usually Kesselbach's plexus for anterior bleeds
  1. Anesthetize with cotton pledgets soaked in 1:1 mix of 0.05% oxymetazoline:4% lidocaine
  2. Once bloodless field obtained, place silver nitrate just proximal to bleeding source
    • Leave on for a few seconds at most
    • Never cauterize both sides of the septum at one go (risk of septal perforation)

Thrombogenic Foams
  1. Apply Gelfoam or Surgicel on visualized bleeding mucosa
  2. Bioabsorbable so removal/antibiotics not needed

Anterior Nasal Packing

Only use if all of the above have failed

  1. Rapid Rhino
    • Soak balloon with water (NOT saline) and insert along the floor of the nasal cavity
    • Inflate slowly with air (NOT saline or water) until the bleeding stops
  2. Merocel
    • Absorbent nasal tampon
    • Coat tampon with water-soluble antibiotics ointment and insert along floor of nasal cavity
    • If tampon has not expanded within 30s of placement, irrigate it in place with NS
    • Moisten three times per day with saline or water until removal
  3. Traditional Packing
    • Apply ribbon gauze in accordion-like manner

Tranexamic acid
  • 500mg TXA applied to topical foam or non absorbable packing and inserted into nares.[2]
  • injectable form of tranexamic acid (500mg/5mL)not the dilute form
  • Can stop bleeding as fast as 10 minutes
  • Higher success rate by 10 minutes compared to anterior packing in patients on Aspirin or Plavix[3]
  • NNT of 5 for preventing one episode of rebleeding without adverse events. [4][5]

Posterior Nasal Packing

90% of epistaxis is anterior. Only consider posterior packing if all of the above have failed.

  • Associated with higher complication rates (pressure necrosis, infection, hypoxia)
    • Temporizing measure while awaiting ENT support
  • Consider nasal block as posterior packing is often very uncomfortable
  • All posterior packing should be accompanied by anterior packing
  • Rapid Rhino-rocket 7.5 cm +. Also a dual chamber 9 cm packing available. Inflate posterior then anterior baloons
  • Foley catheter with 30-cc balloon if dedicated posterior packing not available
    1. Lubricate with topical antibiotic
    2. Advance transnasally until visualized in posterior oropharynx
    3. Inflate balloon with 7cc of saline; retract 2-3cm until lodged in post nasopharynx
    4. Inflate with additional 5-7cc of saline to complete the pack
  • Keep packing for 72-96 hours, <48 hours associated with increased re-bleed.

Disposition

Anterior Epistaxis
  • consider checking Hgb to ensure no significant blood loss anemia
  • Discharge after 1hr of observation
  • Patients with therapeutic warfarin levels may continue medication
  • Discontinue NSAIDs for 3-4d
  • Possible amoxicillin-clavulanate if anterior packing was placed as prophylaxis for bacterial sinus infection or Toxic shock syndrome although no robust evidence base[6]
  • ENT or ED follow-up in 2-3d for removal of nonbiodegradable packing
  • Admit if bilateral packing, symptomatic anemia, or anemia requiring transfusion

Posterior Epistaxis
  • Admission to telemetry is strongly advised
  • Posterior packing causes vagal stimulation, increasing risk of dysrhythmia and bronchoconstriction

Complications

See Also

References
  1. Barnes ML, Spielmann PM, White PS. Epistaxis: a contemporary evidence based approach. Otolaryngol Clin North Am. 2012 Oct;45(5):1005-17. PMID: 22980681
  2. Zahed R. et al. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial.Am J Emerg Med. 2013 Sep;31(9):1389-92
  3. Zahed R et al. Topical Tranexamic Acid Compared With Anterior Nasal Packing for Treatment of Epistaxis in Patients Taking Antiplatelet Drugs: Randomized Controlled Trial. Acad Emerg Med 2017.
  4. Tranexamic Acid for the Treatment of Epistaxis theNNT.com
  5. Gottlieb et al Tranexamic Acid for the Treatment of Epistaxis Acad Emerg Med. 2019 Nov;26(11):1292-1293
  6. Cohn B. Are prophylactic antibiotics necessary for anterior nasal packing in epistaxis? Ann Emerg Med. 2015 Jan;65(1):109-11
  7. Primary malignant melanoma of the nose: a rare cause of epistaxis in the elderly. PDF
  8. Kaposiform hemangioendothelioma arising in the ethmoid sinus of an 8‐year‐old girl with severe epistaxis PDF
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