I. What every physician needs to know.
Epistaxis, or nose bleed, is common but the exact prevalence is unknown as most cases are self limited and rarely come to the attention of the medical community. Epistaxis, though, can be severe and life threatening especially in patients with posterior bleeds and in patients with multiple comorbidities.
The causes of epistaxis range from local factors, such as trauma, to systemic illnesses, such as coagulation disorders. In some cases no cause can be found.
An accurate diagnosis of the cause of epistaxis is paramount to selecting the appropriate treatment. The cause of most cases of epistaxis will be apparent after a comprehensive history and physical exam. Further diagnostic testing is rarely needed.
Treatment is aimed at correcting the underlying cause and controlling bleeding usually by cautery or nasal packing. Surgery is rarely indicated.
II. Diagnostic Confirmation: Are you sure your patient has Epistaxis?
Epistaxis is a fairly easy diagnosis to make as the patient will be bleeding from the nose. The underlying cause of the bleeding though will only become apparent after a careful history and physical examination.
A. History Part I: Pattern Recognition:
Epistaxis is classified as anterior or posterior. Anterior bleeds are the most common; most occurring in the watershed area of the nasal septum known as Kiesselbach’s plexus (SeeFigure 1). Posterior bleeds most commonly arise from the branches of the sphenopalantine artery but can also arise from the carotid artery (SeeFigure 1). It can be difficult to differentiate anterior from posterior epistaxis based purely on the location of the visible blood (i.e. bleeding from the nares versus primarily expectorated blood).
Anterior epistaxis often results from mucosal trauma or irritation. Digital trauma(nose picking) is a common cause. Low moisturecontent in ambient air can dry the mucosa leading to bleeding as can allergic or viral rhinits. A foreign bodyshould be suspected as the cause of epistaxis when bleeding is accompanied by sinusitis but sinusitis can itself cause epistaxis. In the hospital the use of nasal canula oxygencan lead to epistaxis, especially if the oxygen is not humidified adequately. Nasal steroidscan also contribute to epistaxis.
Systemic conditions can also lead to both anterior and posterior epistaxis. Anticoagulatedpatients are at high risk for bleeding. Epistaxis is a common presenting symptom of hereditary hemorrhagic telangiectasiaor Osler-Weber-Rendu syndrome. Osler-Weber-Rendu syndrome should be suspected when epistaxis is accompanied by gastrointestinal bleeding, and iron deficiency anemia, along with characteristic mucocutaneous telangiectasias. Platelet disordersshould be considered in patients with mucosal bleeding, especially bleed that is spontaneous and recurrent.
In addition to the systemic diseases mentioned above, aneurysm of the carotid artery can result in posterior nosebleeds. This must be considered as a cause in a patient with massive hemorrhage wth a prior history of head and neck surgery or following trauma. Nasal endotracheal intubation can lead to anterior and posterior epistaxis. Nasal tumors can also cause posterior nosebleeds. Most posterior bleeds though arise spontaneously without obvious cause.
The contribution of hypertension to epistaxis is controversial, some studies showing an association and others failing to show the association.
The initial evaluation of a patient with epistaxis should focus on airway assessment and cardiovascular stability. Oxygenation and adequate organ perfusion should be ensured before further history is attempted.
The history should focus on:
Conditions that predispose to bleeding
Timing, frequency and severity of bleeding – is this an isolated episode or a recurrent episode
Presence of other medical conditions that might be exacerbated by blood loss (e.g., coronary artery disese)
B. History Part 2: Prevalence:
The exact prevalence of epistaxis is unknown as most cases do not come to the attention of medical personnel. Surveys have suggested that 60% of adults have experienced at least one epistaxis episode, but only 10% required medical attention. Epistaxis is common before age 10 and after age 45 and has a male predominance.
C. History Part 3: Competing diagnoses that can mimic Epistaxis.
D. Physical Examination Findings.
Proper examination of the nasal mucosa cannot be done unless that patient has stopped bleeding (See immediate management below). Once control of bleeding has occurred, it is important to get a complete view of the nasal mucosa. The patient should be pretreated with nasal anesthetic (2% lidocaine, lidocaine with epinephrine). Oxymetazoline has no anesthetic properties but can provide vasoconstriction to aid in hemostasis.
A nasal speculum should be used in preference over an otoscope speculum. The nasal speculum should be inserted such that the blades are oriented superiorly and inferiorly. Patients should be encouraged to look directly ahead in the sniffing position and not tilt the head back as this will obscure much of the nasal cavity from view (SeeFigure 2). Inspect the area of Kiesselbach’s plexus first as most nosebleeds arise here. Examine the mucose for bleeding, ulceration, telangiectasias, or erosion. During the exam you might have to displace blood clots to look for the source of bleeding.
Distinguishing anterior from posterior bleeds:This can be difficult. Often the only way to distinguish the two is after anterior nasal packing. Brisk bleeding that continues after adequate anterior nasal packing suggests a posterior source. Consultation with an Otolaryngologist for nasal endoscopy is likely needed to define the source of a posterior bleed.
E. What diagnostic tests should be performed?
Careful nasal inspection for the source of bleeding is the most important diagnostic test. Further testing is indicated when systemic disorders are suspected. See the chapter Bleeding disorders for more information.
1. What laboratory studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?
A hemoglobin and type and crossmatch should be ordered in patients with massive hemorrhage or prolonged hemorrhage.
2. What imaging studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?
Imaging studies are rarely needed in the diagnosis or management of epistaxis. Imaging is indicated where neoplasm is the suspected cause of nosebleeding. Nearly all patients with benign or malignant sinonasal neoplasms present with unilateral (or at least asymmetric) symptoms, which may include nasal obstruction, rhinorrhea, facial pain, or evidence of cranial neuropathies. Any recurrent unilateral epistaxis warrants consideration of radiographic studies, such as computed tomography (CT) or magnetic resonance imaging (MRI), and endoscopic evaluation to rule out a neoplasm.
F. Over-utilized or “wasted” diagnostic tests associated with this diagnosis.
Coagulation studies are not indicatedas a routine test. An INR should only be ordered on an anticoagulated patient.
III. Default Management.
Goals of management of epistaxis are to:
Ensure adequate airway protection and organ perfusion
Stop the bleeding
Perform appropriate history and physical examination
Perform further diagnostic tests as needed
A. Immediate management.
Patients should be instructed to help achieve hemostasis. Patients should blow their nose to remove blood and clots. The clinician should then spray the nares with oxymetazoline. The patient should then pinch the alae distally and tightly against the nasal septum for 10 to 15 minutes (SeeFigure 3).
Treatment of Anterior Bleeding
Many minor anterior nosebleeds will resolve spontaneously requiring no further intervention. If bleeding recurs rapidlythe nose should be packed. Otherwise, no further intervention is needed.
Cautery- if an anterior bleeding source is identified it should be cauterized either chemically or electrically after proper nasal anesthesia is achieved. Chemical cautery is achieved with silver nitrate sicks. Start at the periphery of the area of bleeding and cauterize toward the center. Cautery is applied for 10 seconds or less until a white precipitate forms. Both sides of the septum should not be cauterized as this can lead to tissue necrosis. Both electrical and chemical cautery require moisture to act but will only act on a bloodless surface.
Nasal Packing – if cautery is unsuccessful, the next step is to pack the anterior nares to tamponade local bleeding. Several options for packing are available including nasal tampons, guaze packing and balloon catheters (SeeFigure 4).
Nasal tampons- pretreat with a topical anesthetic and topical vasoconstrictor. Coat the tampon with bacitracin ointment to facilitate placement and to reduce the risk of toxic-shock syndrome. Insert the tampon along the floor of the nasal cavity until nearly the entire tampon is in the nasal cavity. Finally, expand the tampon by infusing approximately 10 cc of saline.
Gauze packing- layers of gauze are inserted using forcepts in an accordion fashion starting on the floor of the nasal cavity.
Balloon catheters- balloon catheters are easier to use than gauze packing. Different catheters are available to tamponade anterior and posterior nosebleeds. The Rapid Rhino is an air balloon encased in carboxycellulose mesh that acts to promote thrombosis when it contacts blood. Pretreat with a topical anesthetic and soak the Rapid Rhino in water for 30 seconds. Slide the catheter along the floor of the nasal cavity until the plastic proximal fabric ring lies within the nares. Inflate the balloon using a 20ml syringe until the cuff is round and firm. Tape the cuff to the patient’s cheek. The cuff will need to be reassessed periodically to make sure it is adequately inflated.(http://www.salusa.se/Filer/Produktinfo/Rapid%20Rhino/rr117.gb_rev_a_techguide_epistaxis.pdf) Accessed April 26, 2011)
If bleeding persists after initial packing, the contralateral nare may be packed. At this point otolaryngologic consultation should be obtained.
Nasal packing should remain in place for 24 to 48 hours and be removed after rehydration with saline.
Treatment of Posterior Bleeding
Posterior packing is accomplished by nasal balloon catheters or a 10-14 French Foley catheter. Patients will require hospitalization and monitoring when posterior packs are in place.
Foley catheter- Before insertion, coat the catheter with a petroleum-free lubricant and trim the tip of the catheter to minimize irritation of the posterior structures. Advance the catheter along the floor of the nose until it is visible in the posterior oropharynx. Partially fill the balloon with 5 to 7 mL of sterile saline. Retract the catheter gently until it lodges against the posterior choana in the nasopharynx. Complete the filling of the balloon by adding another 5 mL of sterile saline. Clamp the catheter in place with an umbilical clamp or small c-clamp, as from a nasogastric tube. Place padding between the clamp and the alae to prevent excessive pressure.
Balloon catheter- the technique for insertion is similar to that described above.
Many clinicians would obtain otolaryngologic consultation for placement and management of posterior nasal bleeds.
If the above measures fail to control bleeding otolaryngologic consultation should be obtained for surgical treatment. Angiographic embolization could also be undertaken in this setting.
B. Physical Examination Tips to Guide Management.
Control of bleeding guides further management. If bleeding persists otolaryngologic consultation should be obtained.
C. Laboratory Tests to Monitor Response To, and Adjustments in, Management.
D. Long-term management.
E. Common Pitfalls and Side-Effects of Management.
Proper placement of tamponading materials is key to controlling bleeding. Not adequately prepping the patient with nasal anesthetic will make placement of tamponade materials painful and worsen patient anxiety. Inadequate hydration of nasal tampons and inadequate inflation of balloons will fail to control bleeding adequately.
IV. Management with Co-Morbidities.
Whenever possible correction of underlying systemic disorders should be undertaken. If patients are thrombocytopenic, platelet transfusions will be necessary. Excessively anticoagulated patients will need consideration of anticoagulation reversal.
Patients with evidence of hemodyanamic instability should be resucitated with fluids and, if needed, blood transfusions.
A. Renal Insufficiency.
B. Liver Insufficiency.
Liver insufficiency can lead to coagulation disorders and epistaxis. These patients can be particularly challenging and will likely require infusion of fresh frozen plasma or cryoprecipitate.
C. Systolic and Diastolic Heart Failure.
Systolic heart failure can be worsened by massive blood loss. In this setting patients should be transfused to lessen symptoms.
D. Coronary Artery Disease or Peripheral Vascular Disease.
Patients with coronary artery disease are at risk for developing cardiac ischemia during episodes of massive hemorrhage. These patients should have their hemoglobin monitored closely and should be transfused as needed.
E. Diabetes or other Endocrine issues.
G. Immunosuppression (HIV, chronic steroids, etc).
H. Primary Lung Disease (COPD, Asthma, ILD).
I. Gastrointestinal or Nutrition Issues.
J. Hematologic or Coagulation Issues.
Specific identified coagulation disorders should be treated. Details on treatment are beyond the scope of this chapter. Readers are referred to Bleeding Disorders.
K. Dementia or Psychiatric Illness/Treatment.
V. Transitions of Care.
A. Sign-out considerations While Hospitalized.
Hospitalized patients with epistaxis will likely be comanaged by otolaryngologists. Depending on the circumstances hemoglobin should be regularly monitored and adequate placement of packing and securing of balloons should be ensured regularly.
B. Anticipated Length of Stay.
Patients with posterior packing will remain in the hospital for at least 48 hours while packing is in place. Those with anterior packing can be discharged with packing in place once they are hemodynamically stable.
C. When is the Patient Ready for Discharge.
D. Arranging for Clinic Follow-up.
If vital signs and respiratory function remain normal after packing, the patient may be safely referred for specialist follow up in 24 to 48 hours, with advice to present to an emergency department sooner if bleeding recurs.
Specialty referral may not be necessary for healthy patients with stable vital signs and uncomplicated bleeding from a clearly identified source that resolves with simple cautery or one-time packing. Such patients should be reassessed when the packing is removed at 48 hours.
1. When should clinic follow up be arranged and with whom.
2. What tests should be conducted prior to discharge to enable best clinic first visit.
3. What tests should be ordered as an outpatient prior to, or on the day of, the clinic visit.
E. Placement Considerations.
F. Prognosis and Patient Counseling.
Patients should be counseled to leave packing in place until seen 24-48 hours later. If bleeding recurs they should present to an emergency department.
VI. Patient Safety and Quality Measures.
A. Core Indicator Standards and Documentation.
B. Appropriate Prophylaxis and Other Measures to Prevent Readmission.
VII. What's the evidence?
Schlosser, RJ. “Clinical practice. Epistaxis.”. N Engl J Med. vol. 360. 2009. pp. 78
Shah, RK, Dhingra, JK, Shapshay, SM. “Hereditary hemorrhagic telangiectasia: a review of 76 cases.”. Laryngoscope. vol. 112. 2002. pp. 767
Liu, JK, Gottfried, ON, Amini, A, Couldwell, WT. “Aneurysms of the petrous internal carotid artery: anatomy, origins, and treatment.”. Neurosurg Focus. vol. 17. 2004. pp. E13
Petruson, B, Rudin, R. “The frequency of epistaxis in a male population sample.”. Rhinology. vol. 13. 1975. pp. 129
Kucik, CJ, Clenney, T. ” Management of epistaxis.”. Am Fam Physician. vol. 71. 2005. pp. 305
Thaha, MA, Nilssen, EL, Holland, S. “Routine coagulation screening in the management of emergency admission for epistaxis–is it necessary?”. J Laryngol Otol. vol. 114. 2000. pp. 38
Riviello, RJ, Roberts, JR, Hedges, JR. “Otolaryngologic procedures.”. Clinical Procedures in Emergency Medicine,. 2004. pp. 1300
Tseng, EY, Narducci, CA, Willing, SJ, Sillers, MJ. “Angiographic embolization for epistaxis: a review of 114 cases.”. Laryngoscope. vol. 108. 1998. pp. 615
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- I. What every physician needs to know.
- II. Diagnostic Confirmation: Are you sure your patient has Epistaxis?
- A. History Part I: Pattern Recognition:
- B. History Part 2: Prevalence:
- C. History Part 3: Competing diagnoses that can mimic Epistaxis.
- D. Physical Examination Findings.
- E. What diagnostic tests should be performed?
- F. Over-utilized or “wasted” diagnostic tests associated with this diagnosis.
- III. Default Management.
- A. Immediate management.
- B. Physical Examination Tips to Guide Management.
- C. Laboratory Tests to Monitor Response To, and Adjustments in, Management.
- D. Long-term management.
- E. Common Pitfalls and Side-Effects of Management.
- IV. Management with Co-Morbidities.
- A. Renal Insufficiency.
- B. Liver Insufficiency.
- C. Systolic and Diastolic Heart Failure.
- D. Coronary Artery Disease or Peripheral Vascular Disease.
- E. Diabetes or other Endocrine issues.
- F. Malignancy.
- G. Immunosuppression (HIV, chronic steroids, etc).
- H. Primary Lung Disease (COPD, Asthma, ILD).
- I. Gastrointestinal or Nutrition Issues.
- J. Hematologic or Coagulation Issues.
- K. Dementia or Psychiatric Illness/Treatment.
- V. Transitions of Care.
- A. Sign-out considerations While Hospitalized.
- B. Anticipated Length of Stay.
- C. When is the Patient Ready for Discharge.
- D. Arranging for Clinic Follow-up.
- 1. When should clinic follow up be arranged and with whom.
- 2. What tests should be conducted prior to discharge to enable best clinic first visit.
- 3. What tests should be ordered as an outpatient prior to, or on the day of, the clinic visit.
- E. Placement Considerations.
- F. Prognosis and Patient Counseling.
- VI. Patient Safety and Quality Measures.
- A. Core Indicator Standards and Documentation.
- B. Appropriate Prophylaxis and Other Measures to Prevent Readmission.
- VII. What's the evidence?