Epistaxis

Question 1

What is epistaxis?

Answer 1

Nose bleed => ENT emergency

Epistaxis can be split into anterior and posterior bleeds.

i. Anterior haemorrhage

=> visible source of bleeding

=> occurs due to insult to the network of capillaries that form Kiesselbach’s Plexus

ii. Posterior haemorrhage

=> more profuse and originate from deeper structures

=> occurs more frequently in older patients

=> higher risk of aspiration and airway compromise

Question 2

What causes epistaxis?

Answer 2

1. Trauma including:

=> insertion of foreign bodies in the nose

=> nose picking / blowing

=> nasal sprays

2. Platelet function disorders:

=> thrombocytopenia,

=> splenomegaly,

=> leukaemia,

=> idiopathic thrombocytopenia purpura

=> Waldenstrom’s macroglobulinaemia

3. Juvenile angiofibroma (benign tumour) in adolescent males may bleed profusely as highly vascularised
4. Drug use if nasal septum looks atrophied
   => cocaine is a powerful vasoconstrictor and repeated use leads to obliteration of the septum
5. Hereditary haemorrhage telangiectasia in elderly (common) - causes prolonged bleeding

Question 3

What are the risk factors for epistaxis?

Answer 3

1. Trauma / foreign body / nasal spray
2. Infection
3. Previous nasal spray
4. Drugs i.e. warfarin, aspirin, DOAC i.e. apixaban, substance abuse i.e. cocaine
5. Coagulopathies
6. Pregnancy
7. Hypertension
8. Hereditary haemorrhagic telangiectasia

Question 4

If haemodynamically stable, obtain a detailed history.

Important points to consider:

1. Unilateral predominance - which side did it start / most common side => allows to figure out likely cause
2. Anterior / posterior - does the blood run down the front first or back of the throat => patients can often tell and it helps guide management
3. Frequency

Answer 4

4. Quantity of blood loss (difficult to quantify but ask using teaspoon, cupful terms) - helpful to guide management
5. Co-morbidities i.e. hypertension, cardiac hx, anti-coagulant use and previous nasal surgical hx
6. Antecedents - traumatic bleeding has a different anatomical source to other forms of bleeding
7. Risk factors, smoker, occupation and allergy to nuts

Question 5

What is the initial management for epistaxis if patient is haemodynamically stable?

Answer 5

1. Ask patient to sit forward with their mouth open => decreases blood flow to the nasopharynx and allows patient to spit any blood out of their mouth, reducing risk of aspiration

Pinch the cartilaginous area of the nose firmly and consistently for at least 20 minutes and breathe through mouth instead

If this works, use topical antiseptic i.e. naseptin (chlorhexidine and neomycin) to reduce crusting and risk of vestibulitis

Admission & follow up considered in patients

=> with underlying comorbidity i.e. coronary artery disease or severe hypertension

=> underlying suspected cause

=> aged under 2 years (underlying haemophilia or leukaemia likely in this age group)

Question 6

How is epistaxis managed if conservative methods don’t stop the bleed?

Answer 6

If bleeding hasn’t stopped after 15-20 mins of continues pressure to the nose then consider:

1. Cautery:

=> used if source of the bleed is visible + cautery is tolerated
*not tolerated in younger children

=> Ask patient to blow nose to remove any clots (be wary as bleeding may resume)

=> topical anaesthetic spray (co-phenylcaine) and wait 3-4 minutes

=> Identify bleeding point and apply silver nitrate stick for 3-10 seconds until its grey/white.

• Avoid touching areas that don’t require treatment
• Only cauterise one side of the septum because risk of perforation

=> Dab the area clean with a cotton bud and apply naseptin and muciprocin

2. Packing:

=> used if cautery not viable or bleeding point not located

=> Topical anaesthetic spray (co-phenylcaine) and wait 3-4 minuets

=> Pack the nose whilst patient is sitting with their head forward

=> Review after inserting pack as pressure on the nostril can cause cosmetic changes

=> Examine patient’s mouth and throat for continuing bleeding
*if still bleeding, consider packing other nostril as this increases pressure on septum, occluding the vessel

=> Admit patient to hospital (ENT) for review and observations

Question 7

What is the surgical management for epistaxis?

Answer 7

If other measures fail to control bleeding or bleeding is from posteriorly in the nasal cavity

=> endoscopic sphenopalatine artery ligation under general anaesthetic

Traumatic epistaxis i.e. from sports injury is usually anterior from the anterior ethmoidal artery

=> ligation of anterior ethmoidal artery performed through external excision at the medial aspect of the orbit

*Important to rule out septal haematoma following acute traumatic injuries of the nose

=> can cause ischaemic necrosis and cartilage loss resulting in saddle nose

=> important to drain asap

Question 8

Patients who are haemodynamically unstable / bleed from unknown or posterior source following epistaxis should be admitted to A&E

Answer 8

INFO CARD

Question 9

What are the self-care advice given to patients about reducing the risk of re-bleeding?

Answer 9

Inform patients that the following should be avoided to reduce recurrence of epistaxis :

=> blowing or picking nose,

=> heavy lifting,

=> exercise,

=> laying flat,

=> drinking alcohol

=> hot drinks

*same applies after cauterisation