Epistaxis refers to bleeding from the nose. In the vast majority of cases, it is relatively insignificant. However, in a small proportion of patients, it can present with significant haemorrhage that can lead to hypovolemia and shock, and warrants urgent intervention.
There are two main types of epistaxis:
- Anterior bleeds (90%) – originate from ruptured blood vessels in Little’s area, a highly vascularised region formed by the anastomosis of 5 arteries.
- Posterior bleeds (10%) – develop from the deeper structures of the nose, occur more in older individuals, and have a greater risk of compromising the airway.
In this article, we shall look at the causes, investigations and management of epistaxis.
Little’s area (also known as Kiesselbach’s plexus) is found on the anterior nasal septum, and is an anastomosis of 5 arteries:
- Anterior ethmoidal artery – from the ophthalmic artery (derived from the ICA).
- Posterior ethmoidal artery – from the ophthalmic artery (derived from the ICA).
- Sphenopalatine artery – from the maxillary artery (derived from the ECA).
- Greater palatine artery – from the maxillary artery (derived from the ECA).
- Septal branch of the superior labial artery – from the facial artery (derived from the ECA).
Aetiology and Assessment
The large majority of epistaxis cases are due to trauma (“picking”) or a foreign body. Other significant causes to consider include:
- Iatrogenic (e.g. anti-coagulants)
- Clotting factor, platelet, or blood vessel abnormalities
- Rhinosinusitis (including allergies)
- Cocaine use
An initial history should include details of any recent trauma, co-morbidities or familial conditions (especially clotting abnormalities), relevant drug history, previous episodes, and any facial pain*, otalgia, systemic symptoms, or clinical features of clotting disorders.
*Facial pain or otalgia may indicate a nasopharyngeal tumour (including angiofibroma).
The initial management of epistaxis is dependent on the size of the bleed. All patients should be kept sat up and sat forward to protect the airway.
Large bleeds should be approached in an A to E manner. This includes adequate fluid resuscitation, with blood products given if necessary.
All patients (unless significant blood loss has occurred and urgent intervention is required), should be trialled with a nose peg applied for 20 minutes. Ice should be applied to either the back of the neck or the bridge of the nose to stimulate further vasoconstriction.
Once the patient is stable and the bleeding is controlled, a further specialised ENT assessment of the bleed can occur.
Further Investigation and Definitive Management
A thudichum can be used to inspect the septum. If there is too much blood present to visualise the septum, adrenaline-soaked gauze can be inserted into the nasal cavity to cause localised vasoconstriction and soak-up any excess blood.
If no bleeding point can be identified, it is important to examine the oropharynx (more indicative of a posterior bleed).
The definitive management of ongoing epistaxis occurs in a stepwise manner and is dependent on the degree of epistaxis. Consider obtaining routine bloods – such as full blood count, urea and electrolytes, clotting and a group and save.
If an anterior bleed point is identified, then the vessel can be cauterised using silver nitrate via anterior rhinoscopy.
Anterior packing should be trialled, whereby the nasal cavity is packed using a merocel nasal tampon. If this fails to control the bleeding, then a contralateral merocel nasal tampon can be inserted.
If the epistaxis persists and bleeding is entering the oropharynx, posterior packing with a Foley catheter and bismuth iodoform paraffin paste gauze (BIPP) is warranted. As before, if this fails to control the bleeding, then a contralateral pack should be inserted.
If nasal packing fails to stop the bleeding, then contributing blood vessels can either be ligated surgically or embolised radiologically.
The vessels that are targeted are usually the sphenopalatine artery, anterior ethmoidal artery (not for embolisation due to origin from the ICA), or the external carotid artery (as a last resort).