Epistaxis

• Overview:

  • Bleeding from the nose
  • 80-95% of cases bleeding originates from little's area on the anterior nasal septum - contains the Kiesselbach plexus of vessels - anastomosis of multiple arteries
  • Less commonly bleeding originates from branches of the sphenopalatine artery in the posterior nasal cavity
• Demographics:

  • Very common
  • Common in children >2 years and becomes less likely after a child is >10 years
  • Posterior epistaxis is more common in adults, and tends to be seen in over 45s
• Local causes of damage to blood vessels:

  • Trauma e.g. picking nose, fracture, FB, fall
  • Inflammation/infection e.g. rhinosinusitis, nasal polyps
  • Topical drugs e.g. cocaine, decongestants, steroids
  • Vascular e.g. hereditary haemorrhagic telangiectasia, granulomatosis with polyangiitis
  • Tumours
  • Nasal oxygen therapy - drying of nasal mucosa
• More general causes of damage:

  • Clotting disorders - thrombocytopenia, haemophilia, Von Willebrand, leukaemia
  • Environmental - temperature, dust, chemicals
  • Systemic drugs - anticoagulants and antiplatelets
  • Atherosclerosis
• Hypertension is common in people who present with epistaxis
• Symptoms:

  • Bleeding usually unilateral
  • Suspect posterior bleed if - bleeding profuse, from both nostrils, bleeding site cannot be identified on speculum exam
  • Rarely bleeding loss is enough to cause anaemia and haemodynamic compromise - most likely if patient is older and frail
  • Can present with vomiting blood - swallowed blood rather than GI bleed
  • May be symptoms of underlying cause
• Examination:

  • If able get patient to gently blow nose to clear old blood
  • Look for for bleeding point - looks like a small red dot (<1mm)
  • If history of trauma check for septal haematoma - collects between septal cartilage and perichondrium - needs urgent drainage as can lead to septal necrosis (perichondrium supplied blood to septal cartilage)
• Investigations:

  • Only need bloods if suspect underling cause e.g. coagulation problem
  • Or if concerned about significant bleeding and want to check for anaemia
• Acute epistaxis management:

  • Sit up, tilt head forward, mouth open
  • Pinch soft part of nose firmly and hold for 10-15 mins without releasing pressure (wont compress posterior bleed)
  • Once bleeding stopped consider topical antiseptic (naseptin) cream 4 times daily for 10 days to reduce crusting and vestibulitis
  • If can't use naseptin an alternative is mupirocin nasal ointment 2-3 times a day for 5-7 days
• Admit to hospital if:

  • Haemodynamically compromised
  • Bleeding from posterior area of nose
  • If bleeding doesn't stop after 10-15 mins of nasal pressure may need:
  • Nasal cautery: topical anaesthetic spray, cauterize by lightly applying silver nitrate stick to bleeding point for 3-10 seconds
  • Nasal packing if cautery ineffective or bleeding point not seen - topical anaesthetic then pack (tampon, inflatable pack, ribbon gauze)
• After bleeding stops:

  • Avoid activities that increase risk of re-bleeding for 24 hours:
  • Blowing/picking nose
  • Heavy lifting
  • Strenuous exercise
  • Lying flat
  • Drinking alcohol or hot drinks
• If applying pressure, cautery and packing don't work:

  • Further specialist measures may be required
  • Formal packing under GA
  • Endoscopic assessment and electrocautery
  • Arterial ligation
  • Radiological arterial embolization
  • Tranexamic acid
• Recurrent episodes:

  • Consider investigating for underlying cause e.g. FBC and clotting
  • Refer to ENT if concerned about serious underlying cause e.g. tumours or telangiectasia
  • If patient not at risk of serious underlying cause then consider - topical treatments with naseptin or mupirocin, nasal cautery
  • If despite treatment remains recurrent then refer to ENT
• main anatomy principles:

  • There is dual arterial supply from both the internal and external carotid arteries
  • Most bleeds originate anteriorly in the nasal cavity in Little's area within the Kiesselbach's plexus - area particularly vulnerable to dryness and trauma
• The following clinical features may suggest a more serious underlying diagnosis.

  • Nasopharyngeal carcinoma: unilateral bleeding, progressive hoarseness, dysphagia, hearing loss, significant smoking history, Southeast Asian descent.
  • Juvenile nasal angiofibroma: younger patients with unilateral epistaxis.
  • Hereditary haemorrhagic telangiectasia (HHT): young age, family history of HHT, partially blanching cutaneous lesions.
• Posterior bleeds management:

  • First line = packing