EPISTAXIS

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Patients presenting with epistaxis are anxious and fear bleeding to death. Although death from epistaxis is rare, it can occur, and significant morbidity is relatively common.5, 34 Although most pediatric epistaxis is treated on an outpatient basis, older patients (>60 years old) more often require hospital admission.25, 44 Initial management of epistaxis is directed at stopping the bleeding, and long-term treatment is directed at discovering and correcting the underlying cause. This article updates current management options.

Section snippets

ANATOMIC CONSIDERATIONS IN EPISTAXIS

The blood supply to the nose arises from the internal maxillary and facial arteries via the external carotid and the anterior and posterior ethmoid arteries via the internal carotid artery. The anteroinferior septum (Little's area) is supplied by a confluence of both systems (Kisselbach's plexus). Little's area is a common site of epistaxis because it is ideally placed to receive environmental irritation (cold, dry air, cigarette smoke) and is easily accessible to digital trauma. This area is

PATHOPHYSIOLOGY

Much epistaxis ceases with pressure (digital or packing) over the bleeding point. An intact coagulation system with accumulation of platelets and clot formation is required. Abnormal platelet numbers or function or any abnormality in the coagulation cascade leads to failure of clot formation and persistent bleeding.

CAUSE

Epistaxis results from an interaction of factors, damaging the nasal epithelial (mucosal) lining and vessel walls. The major causative factors include environmental factors (humidity, temperature), local factors (trauma, anatomic abnormalities, inflammation, allergies, iatrogenic, tumors), systemic factors (hypertension, platelet and coagulation abnormalities, renal failure, alcohol abuse), and medications affecting clotting (anticoagulants, nonsteroidal anti-inflammatory drugs [NSAIDs]).

MANAGEMENT

There are three levels of epistaxis management: (1) first-aid measures, (2) acute management, and (3) interventions.

SUMMARY

Epistaxis is a common clinical problem. The widespread availability of endoscopic equipment is shifting management philosophy toward targeting the bleeding point. This shift may have a significant impact on decreasing length of stay and blood transfusion rates. Advances in interventional radiology have also reduced the risk of embolization. Patient education, especially teaching first-aid measures to patients at high risk for nosebleeds, also encourages more effective use of health care

ACKNOWLEDGMENTS

The authors thank Carol Chan for her assistance with the illustrations.

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    Address reprint requests to Karen H. Calhoun, MD, Department of Otolaryngology, University of Texas Medical Branch, Galveston, TX 77555-0521

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