EPISTAXIS

PRESENTER: ELESIA POWELL-WILLIAMS

OUTLINE

• Definition
• Epidemiology
• Aetiology
• Clinical features
• Investigations
• Management
DEFINITION

Epistaxis is bleeding from the nose. This may be anteriorly or posteriorly

 ANATOMY

Figure
1
 ANATOMY
Figure 2

Last’s Anatomy, 12th Ed.

ANATOMY
• The nasal pyriform aperture is the opening of the osseous part of the nasal
cavity
ANATOMY

• Anatomically, anterior bleeds occur from vessels anterior to the nasal

aperture; posterior bleeds from behind1,2
• Woodruff’s plexus3
EPIDEMIOLOGY

• True incidence unknown as some cases treated and home and thus are un-
reported
• Small retrospective review4 at UHWI showed :
• anterior more common
• Male: Female ratio of 1.2:1
• Mean age of presentation 52.5 years
• Causes: idiopathic > nasal mass > trauma > Aspirin
AETIOLOGY

• Primary
• Idiopathic (10% in USA)5
• Secondary
• Trauma
• Coagulopathy
• Drugs
• Local infection
• Tumour
• Environmental

Note that hypertension is NOT a causative factor.

Hypertension  arteriosclerosis  fragile vessels prone to rupture
MECHANISM

• Anterior bleed
• Inciting factor  disruption of the capillaries of Little’s area  slow, low pressure ooze

• Posterior bleed
• Inciting factor  disruption of sphenopalatine artery branches high pressure arterial
bleed
CLINICAL FEATURES
History
• Chronic illness
• First episode or recurrent
• Precipitants: respiratory tract infection, seasonal, rhinitis/sinusitis
• Unilateral or bilateral
• Trauma (nose-picking and foreign body insertion in kids)
• Bleeding disorder
• Drugs: anticoagulants; aspirin, NSAIDs, cocaine
• History of migraines* (via trigeminovascular system)
CLINICAL FEATURES

• Anterior bleed: slow bleed from nostrils

• Posterior bleed: larger volume bleed from nostrils AND down nasopharynx
CLINICAL FEATURES

On examination
• General
• Anxious
• Mucosa usually pink……pale if large bleed
• Petechiae, ecchymoses
• CVS
• Normal or elevated BP; normal pulse…..hypotensive and tachycardic if large volume bleed
• ABD
• Stigmata of liver disease
CLINICAL FEATURES

Nasal examination
• May see bleeding vessel, nasal mass,
polyps

Thudichum
INVESTIGATIONS

• CBC
• PT/PTT/INR
• GXM
• Other investigations as directed by history
MANAGEMENT

Airway
Breathing
Circulation
MANAGEMENT

• Non-surgical
• Surgical
NON-SURGICAL
MANAGEMENT
 MANAGEMENT

• Equipment needed
• Don personal protective equipment
• Gown
• Gloves
• Face shield
• Additional equipment
• Head lamp
• Nasal speculum
• Chemical cautery (or electrical cautery – ENT physician)
• Suction
• Needles, syringes, gauze packs
• Local anaesthetic
• Topical vasoconstrictors: epinephrine; phenylephrine
MANAGEMENT – NON-SURGICAL

• Pinch the nostrils together, just distal to the nasal bones, for 10 minutes
(range: 5-30mins). Don’t interrupt this time frame to peek.
• Don’t tilt the head back nor lie supine. Sit quietly and lean forward slightly
• Most patients resolve with this manoeuvre
MANAGEMENT – NON-SURGICAL

If nose-pinch fails, local vasoconstriction may be induced inserting cotton

soaked in a 1:10,000 epinephrine solution (this is NOT the same as anterior
packing)
 MANAGEMENT – NON-SURGICAL
• Electrocautery:
• Likely used by ENT, not A&E
• Chemical cauterization
• Silver nitrate sticks used (anterior bleeds)
• Clear the work field with suction and have clear visualization of bleeding site
• DO NOT blindly sweep stick in nostril, as it burns; and if excess silver nitrate mixes with blood and
mucous, and gets into nasopharynx, it can cause a chemical burn
• DO NOT cauterize both sides of the septum at the same time, as there is risk of septal perforation
• After bleed controlled:
• No strenuous activity for 7-10 days
• Don’t pick nose
• Avoid NSAIDs
• Prescribe antibiotic ointment and normal saline nasal spray
MANAGEMENT – NON-SURGICAL

Silver
nitrate
stick

Septum
MANAGEMENT – NON-SURGICAL

Anterior nasal packing

• Used when first two methods fail
• Commercial nasal packs exist, or ribbon gauze infused with petrolatum jelly
may be used
MANAGEMENT – NON-SURGICAL
Nasal
tampon – Nasal tampons –
air-inflated uninflated &
liquid-inflated.

Epistaxis tray with:

Ribbon
Frazier suction tip, gauze, cotton,
gauze
speculum
MANAGEMENT – NON-SURGICAL

Anterior nasal packing steps

• Don PPE and head lamp
• Have the patient seated upright unless resuscitation requires otherwise
• Place lidocaine [2%]-and-epinephrine [1:1000] soaked cotton balls x 2 in nostril
for 10mins, with a dry cotton ball at the entrance of the naris. (other
vasoconstrictors: phenylephrine; epinephrine 1:10,000; oxymetazoline)
• Gently suction collected blood for better visualization
MANAGEMENT – NON-SURGICAL

Anterior nasal packing

Gauze strips
• Infuse with petrolatum jelly
• Use bayonet forceps to layer, from anterior to posterior
as far back as possible, starting along the nasal floor
• Leave one end at the naris for easy removal
 MANAGEMENT – NON-SURGICAL

Anterior nasal packing

Fluid-inflatable nasal tampon
• Apply anaesthetic and topical vasoconstrictor to nasal cavity first
• Apply surgical lubricant to tampon then insert in a direction parallel to hard
palate (not aimed superiorly)
• Apply water to inserted tampon, which then expands to fit nasal cavity
MANAGEMENT – NON-SURGICAL

Anterior nasal packing

Air-inflatable nasal tampon
• Apply local anaesthetic and vasoconstrictor
• Apply water to tampon before insertion as a lubricant will form from the coating
material when it contacts water. Tampon is high volume-low pressure
• Insert tampon then inflate cuff with air. Assess pressure by feeling pilot balloon
which should be taut, but not hard
MANAGEMENT – NON-SURGICAL

Anterior nasal packing

• After procedure
• Advise no strenuous activity
• No NSAIDs
• Prescribe oral antibiotics with Staphylococcus coverage
• Remove packs after 3-4 days
MANAGEMENT – NON-SURGICAL

Posterior nasal packing

• Indications
• Failed anterior nasal packing
• High likelihood/suspicion of posterior bleed
• Contraindications
• Cribriform plate fracture
 MANAGEMENT – NON-SURGICAL
Posterior nasal packing
1. Procedural sedation may be required because of discomfort
2. Local anaesthetic-vasoconstrictor applied by patient inhalation
3. Apply double balloon
1. Coat with Mupirocin
2. Insert. Inflate distal balloon with 7-10ml sterile water. Pull catheter until balloon seated in posterior nasal cavity
3. Inflate anterior balloon with 15-30ml
4. Alternatively:
• Foley catheter can be used. Repeat above steps. Then, additionally, pack the anterior nasal
cavity, to control any anterior bleed.
• Nasopharyngeal packs may be used: rolled gauze sutured to deflated catheter, packed at
posterior nasal cavity
MANAGEMENT – NON-SURGICAL

Posterior nasal packing

5. Admit all patients

Complications of posterior nasal packing:

• Bradydysrhythmias (via trigemino-
Cardiac reflex)
• Aspiration if dislodged
 SURGICAL
MANAGEMENT
MANAGEMENT - SURGICAL

Arterial ligation options

• External carotid artery
• Maxillary artery
• Ethmoidal artery(ies)

Arterial embolization via interventional radiology

• Maxillary artery
• Ethmoidal artery(ies)
PREVENTION

• Use humidifiers at home

• Avoid nose-picking
• Sneeze with an open mouth
• Gentle nose-blowing if necessary
SUMMARY

Epistaxis is a common presentation. Most cases are anterior, and most cases
can be resolved with non-surgical intervention.
CASE

“A 52-year-old bicyclist was hit by an car at high speed. He sustained extensive

maxillofacial fractures, including frontal and sphenoid sinus fractures. He presented
to the emergency room with brisk nasopharyngeal hemorrhage”.
Prior to intubation he was awake, alert and cooperative.
His primary source of blood loss is determined to be posterior-nasal.
Vitals: BP 100/58 P: 110 SpO2: 99% on RA
He has no comorbidities, nor history of anticoagulant, aspirin or NSAID use.
CASE

Is it appropriate to use a Foley catheter to achieve hemostasis?

CASE
 CASE
“Foley catheter placed in left nare and inflated for tamponade. CT later revealed
insertion of the Foley catheter and deployment of the balloon in the frontal lobe.
Same was deflated and catheter removed. Patient underwent bifrontal craniotomy
for dural repair of CSF leak.
Made good neurologic recovery”
 CASE

“If a Foley catheter is the only available treatment for posterior epistaxis, use a large
catheter and insert in parallel to the floor of the nasal cavity with direct visualization
along the inferior meatus. Confirm appropriate position of the balloon tip using a Foley
tube filled with contrast medium before nasal packing. After inserting first 10cm of
catheter, identification of its trajectory and position using C-arm or portable X-ray to
prevent upward migration.”

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3710897/
 REFERENCES
1. Wong AS, Anat DS. Epistaxis: A guide to assessment and management. J Fam Pract.
2018;67(12):E13-E20.
https://www.mdedge.com/familymedicine/article/190507/pain/epistaxis-guide-
assessment-and-management Accessed August 2, 2019.
2. Moran N, Das D. Epistaxis—Incidence, Etiology, and Management: A Hospital-
based Study. AIJCR. January-April 2016;9(1):18-20
https://pdfs.semanticscholar.org/72fc/61b0a9d8380c734c298b5490c45aace6304a.pd
f Accessed August 2, 2019.
3. Chiu, Shaw-Dunn, Mcgarry. Woodruff’s naso-nasopharyngeal plexus: how
important is it in posterior epistaxis? Clin Otolaryngol Allied Sci. 1998;23(3):279-
279. doi:10.1046/j.1365-2273.1998.0137r.x
REFERENCES

4. Forde R, Cargill R, Batchelor A, Williams E. Adult Epistaxis, Epidemiology and

Management at the University Hospital of The West Indies. West Indian Med J.
November 2015. doi:10.7727/wimj.2015.007 Accessed August 1, 2019.
5. Nguyen Q. Epistaxis: Practice Essentials, Anatomy, Pathophysiology.
https://emedicine.medscape.com/article/863220-overview#a5. Published 2018.
Accessed August 2, 2019.
6. Sinnatamby C. Last’s Anatomy Regional and Applied. Page 556. 12th ed. (Horne T,
Bowes J, Davies S, eds.). Elsevier; 2011.
REFERENCES

7. Posterior Epistaxis Nasal Pack: Overview, Technique, Preparation [Internet]. [cited

2019 Aug 18]. Available from: https://emedicine.medscape.com/article/80545-
overview
Accessed August 18, 2019
8. Anterior Nasal Packing for Epistaxis: Overview, Technique, Preparation [Internet].
[cited 2019 Aug 18]. Available from: https://emedicine.medscape.com/article/80526-
overview
Accessed August 18, 2019
END