Epistaxis 

Classification

• 90% of epistaxis are anterior: they arise from the anterior nasal septum at Little’s area. This area contains the Kesselbach’s plexus (anastomotic network of vessels).
• 10% of epistaxis are posterior: generally more difficult to control, and prone to get airway compromise.

Causes

1. Idiopathic (large majority)
2. Local:
   • nose picking
   • nasal or sinus infections
   • septal abnormality
   • tumours (benign and malignant)
   • FB (esp children)
3. Environmental:
   • usually worse in winter due to the dryness, Prolonged inhalation of dry air (Oxygen)
4. Drugs:
   • Anticoagulants
   • Antiplatelets
   • Solvent inhalation (huffing)
   • cocaine
5. Iatrogenic:
   • Nasogastric tube insertion, Nasotracheal intubation
6. Coagulopathies:
   • Inherited coagulopathies: von Willebrand disease, haemophilia A & B
   • Splenomegaly
   • Thrombocytopenia
   • Platelet disorders
   • Liver disease
   • Renal failure
   • Chronic alcohol abuse
   • AIDS
7. Vascular Abnormalities:
   • Sclerotic vessels
   • Hereditary haemorrhagic telangiectasia
   • Arteriovenous malformation
   • Neoplasm
   • Aneurysms
   • Septal perforation/deviation
   • Endometriosis

Hypertension:

• Controversial topic and is often misunderstood in epistaxis.
• Hypertension is rarely a direct cause of epistaxis
• Epistaxis is however more common in hypertensive patients this is postulated to be caused from long standing hypertension causing vascular fragility of the blood vessels.
• Epistaxis in patients presenting to ED, will generally have an associated anxiety that will increase blood pressure.
• Despite multiple causes for epistaxis, literature shows that in 85% of cases no causes in found.

Red Flags

• Unilateral nasal blockage
• Facial pain / swelling / deformities
• Headaches
• Loose teeth
• Deep otalgia
• South-East Asian: high incidence of nasopharyngeal carcinoma (according to my Chinese GP supervisor; in China nasoendoscopy is routinely performed for epistaxis to exclude cancer)

History

• Duration; frequency; trauma; FB
• Previous episodes
• Drugs and medications
• Bleeding from elsewhere

Management

Acute bleed

• Resuscitation: ABC if haemodynamically unstable. Lean patient forward, pinch the cartilaginous part of the nose for at least 10 minutes. May need transfer to hospital with ENT service.
•  Patients can and have died from epistaxis be prepared to resuscitate!!!

• Vasoconstriction:
  • soaked cotton pledgets inserted into the nasal cavity. Local anaesthesia (Lignocaine) should be used were possible to provide analgesia.
  • Agents
    •  1:1000 Adrenaline
    • Co-Phenylcaine
  • extremely effective in anterior epistaxis, aid in the visualisation of the bleeding site, and assist if packing is required.
  • Following successful application of topical vasoconstriction, patients should be encouraged to apply  topical steroid creams, and petroleum jelly to the nasal cavity weekly for six weeks, this has been shown to have a 94% success rate of resolution of symptoms.

• Cautery:
  • Chemical:
    • application of silver nitrate sticks, by wiping the tip of the silver nitrate stick over Little’s area until it becomes discoloured and grey.
    • The area should be suctions and as dry as possible to maximise the effectiveness of silver nitrate sticks, localised pain can occur on application.
    • The sticks should be applied for 4-5secs until a grey residue or eschar develops.
    • Only one septum should be cauterised using silver nitrate, as bilateral can cause sepal perforation
    • Generally effective in anterior bleeds, however there is a risk of rebleeding.

• Electrocautery:
  • Generally performed by ENT specialist after effective topical anaesthetic needs to be provide first.
  • The red-hot electrocautery loop is passed over the mucosal blood vessels effecting cautery.
  • Topical antibiotics and/or petroleum jelly can be used post-operatively.

• Packing:
  • Anterior packing is required when the bleeding fails to stop with vasoconstrictors and cautery.
  • Options include traditional nasal packing, a prefabricated nasal sponge, an epistaxis ballon, or absorbable materials.
  • Nasal tampons that are moistened, gel-coated, with an inflatable balloon are less painful and show equal effectiveness when compared to dry hydrophilic nasal tampon

• Posterior Packing/ Balloon Catheters:
  • Posterior nasal bleeds can be difficult to manage related to the relatively inaccessible site of bleeding and generally don’t respond the above standard medical treatment and packing.
  • Analgesia will be required for patients with posterior packing and balloon catheters
  • Double balloon catheters consist off of a posterior and anterior balloon, are relatively easy to insert, although cost may limit their use. Generally used in difficult posterior epistaxis.
  • The catheter is inserted to the back of the nasopharyngeal space, and then inflate the posterior balloon first and bring forward sealing off the post nasopharyngeal space. Then inflate the  anterior balloon to apply pressure to the internal cavity of the nose.
  • Saline is preferred over air to inflate balloon as air can leak out causing deflation and further rebleeding.
  • Avoid over-inflating balloon catheters as will cause increased discomfort, rupture of the balloon, or pressure necrosis of the nasal mucosa.

Followup

• Refer for ENT assessment if there are red flags or if the source of bleeding is unknown.
• Also consider systemic causes (eg bleeding disorders).