Introduction
Epistaxis refers to bleeding from the nose. In the vast majority, cases will terminate with simple manoeuvres and minimal intervention. However, in a small proportion of patients, epistaxis can lead to significant haemorrhage warranting urgent intervention.
Epistaxis can be caused from:
- Anterior bleeds – originate from ruptured blood vessels in Little’s area, a highly-vascularised region formed by the anastomosis of 5 arteries, and cause around 90% of cases
- Posterior bleeds – originate from the posterior nasal cavity, typically from branches of the sphenopalatine arteries of the nose, and cause around 10% of cases (more common in older patients)
Little’s Area
Little’s area (also known as Kiesselbach’s plexus) is found on the anterior nasal septum (Fig. 1) and is an anastomosis of 5 arteries: anterior ethmoidal artery, posterior ethmoidal artery, sphenopalatine artery, greater palatine artery, and the septal branch of the superior labial artery.
There are numerous causes for epistaxis to consider, including trauma (i.e. nose picking), hypertension, iatrogenic (e.g. anti-coagulants), or foreign bodies.
Less common causes include coagulopathies, platelet disorders, vascular malformations, vasculitis, rhinosinusitis (including allergies), malignancy, or cocaine use.
Clinical Features
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.
Every case of epistaxis should be initially approached as if severe, until deemed otherwise. Indeed, a patient having a large bleed may be bleeding posteriorly and swallowing a large volume of blood, therefore showing seemingly little external bleeding.
The below management is for non-life threatening bleeding. In cases of life-threatening epistaxis (large volume bleeds, haemodynamic compromise, failure to stop post-intervention), an A to E approach to the patient is essential; ensure appropriate airway-trained personnel are present, adequate IV access obtained, and resuscitation with blood products if required.
*Albeit rare, facial pain or otalgia may indicate a nasopharyngeal tumour (including angiofibroma)
Figure 1 – The vessels supplying Little’s area
Initial Management
The definitive management of ongoing epistaxis occurs in a stepwise manner.
All patients (even severe cases) should be kept sat up and sat forward, attempting to ensure blood passes anteriorly and out through the nares (and not posteriorly into the pharynx). Encourage the patient to spit out any blood in their mouth if present.
Compression should be applied to the anterior nose (the nares) for 20 minutes without releasing pressure (Fig 2). Ice can be applied to the bridge of the nose to stimulate further vasoconstriction.
If unsuccessful, a thudichum can be used to inspect the septum. If an anterior bleed point is identified, the vessel can be cauterised using silver nitrate (Fig. 2). The oropharynx should also be examined in all patients, to check for features of a posterior bleed.
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.
Figure 2 – (1) Application with compression on anterior nose (2) Visualisation via thudichum, with bleeding point cauterised
Further Management
If the epistaxis persists but no bleeding point is visualised, anterior packing should be trialled, whereby a nasal pack is inserted into the nasal cavity (Fig. 3) If this still fails to control the bleeding, then a contralateral nasal pack can also be inserted.
Ensure routine bloods (including FBC, clotting, and Group & Save) have been sent and any reversible underlying causes (e.g. malignant hypertension, coagulopathies) managed as require.
If the epistaxis persists and bleeding is entering the oropharynx, posterior packing with a Foley catheter (Fig. 3) is warranted*. As before, if this fails to control the bleeding, then a contralateral pack should be inserted.
*Some centres also use bismuth iodoform paraffin paste gauze (BIPP) however this is often quite traumatic for the patient
Figure 3 – Illustrations demonstrating (1) Anterior Packing (2) Posterior Packing
Surgical Intervention
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 (never embolised due to its origin from the ICA), or the external carotid artery (as a last resort).
Key Points
- There are numerous causes for epistaxis to consider, including trauma, hypertension, iatrogenic, or foreign bodies.
- Anterior bleeds form 90% of all cases of epistaxis, most arising from Little’s area
- A sequential approach is required for all cases of epistaxis management
