EPISTAXIS
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.
References (68)
- et al.
Nasal packing with porcine fatty tissue for epistaxis complicated by qualitative platelet disorders
J Emerg Med
(1985) - et al.
Extensive bleeding following extractions in a patient undergoing chronic hemodialysis
Oral Surg Oral Med Oral Pathol
(1983) - et al.
Intractable epistaxis: Transantral ligation vs embolization: Efficacy review and cost analysis
Otolaryngol Head Neck Surg
(1995) - et al.
Perforation of the nasal septum in patients with renal failure
Laryngoscope
(1980) - et al.
Epistaxis induced by a non-steriodal anti-inflammatory drug?
J R Soc Med
(1990) - et al.
Toxic shock syndrome in nasal surgery: A physiochemical and microbiologic evaluation of Merocel and NuGauze nasal packing
Laryngoscope
(1987) - et al.
Changes in arterial oxygen tension and pulmonary mechanics with the use of posterior packing in epistaxis: A preliminary report
Laryngoscope
(1971) - et al.
Transantral ligation of the internal maxillary artery for epistaxis
Laryngoscope
(1965) - et al.
A prospective randomised controlled trial comparing the use of Merocel nasal tampons and BIPP in the control of acute epistaxis
Clin Otolaryngol
(1995) - et al.
Epistaxis
Ear, Nose and Throat and Head and Neck Surgery
Treatment of haemorrhagic telangiectasia with flashlamp-pulsed dye laser
J Otolaryngol
Therapeutic embolisation in the treatment of intractable epistaxis
Arch Otolaryngol Head Neck Surg
Endoscopic control of posterior epistaxis
J Laryngol Otol
Endovascular therapy of intractable epistaxis complicated by carotid artery occlusive disease
AJNR Am J Neuroradiol
Haemorrhage as a complication of inferior turbinectomy: A comparison of anterior and radical trimming
Clin Otolaryngol
Thrombocytopenia in patients infected with human immunodeficiency virus: Treatment update
Clin Infect Dis
The effect of temperature on nasal ciliary beat frequency
Clin Otolaryngol
Epistaxis in hereditary haemorrhagic telangiectasia
Rhinology
Severe epistaxis
Arch Otolaryngol
Bacteremia and local infections with nasal packing
Arch Otolaryngol
Office treatment by cryotherapy for severe posterior nasal epistaxis—update
Laryngoscope
Adult dengue haemorrhagic fever at Kuala Lumpur Hospital: A retrospective study of 102 cases
Br J Clin Pract
Epistaxis in hypertensive patient taking thioridazine
Am J Pyschiatry
Factors associated with active, refractory epistaxis
Arch Otolaryngol Head Neck Surg
Triamcinolone acetonide: A review of its pharmacololgical properties and therapeutic efficacy in the management of allergic rhinitis
Drugs
Epistaxis: A clinical study of 1724 patients
J Laryngol Otol
Endovascular embolization treatment for intractable epistaxis
Laryngorhinootologie
Management of epistaxis: A national survey
Ann R Coll Surg Engl
Use of oxymetazoline in the management of epistaxis
Ann Otol Rhinol Laryngol
Sodium chloride eye drops as a cause of epistaxis
Arch Ophthalmol
Epistaxis in anticoagulated patients: Educating an at risk population
Br J Haematol
First aid treatment of epistaxis—are patients well informed?
J Accid Emerg Med
Self-treatment with desmopressin intranasal spray in patients with bleeding disorders: Effect on bleeding symptoms and socioeconomic factors
Ann Hematol
Cited by (63)
Management of Post-Traumatic Maxillofacial Pseudoaneurysms: Review of the Literature and Suggested Algorithm
2020, Journal of Oral and Maxillofacial SurgeryCitation Excerpt :For example, if the artery of origin is believed to be the internal maxillary or descending palatine artery, a ruptured APA presents as pulsatile bright red blood from nose. Bleeding control can be achieved with local digital pressure, anterior and posterior nasal packing,22 or an inflatable nasal balloon.4,23 CTA determines surgical accessibility.
Epistaxis
2018, Evidence-Based Clinical Practice in OtolaryngologyDelayed Presentation of an Extracranial Internal Carotid Artery Pseudoaneurysm and Massive Epistaxis Secondary to a Nasal Foreign Body: Case Report and Review of the Literature
2016, World NeurosurgeryCitation Excerpt :Most often, nasal bleeding originates from small arterial vessels in the anterior nasal septum. Common bleeding sites are remedied with basic care that includes manual pressure, nasal packing, electrocautery, chemical/topical hemostatic agents, and endonasal vessel control.5 In approximately 5% of cases of epistaxis, a more posterior origin of the hemorrhage is discovered.
Interventional Neuroradiology Applications in Otolaryngology, Head and Neck Surgery
2012, Otolaryngologic Clinics of North AmericaCitation Excerpt :In most cases, an attempt will be made to control such posterior bleeding with the application of anterior and posterior packs. These packs should be applied with care because they can lead to nasal trauma, cartilage necrosis, vagal response, aspiration, infection, sepsis, and airway obstruction, which can lead to hypoxia, cardiac arrhythmia, myocardial infarction, and, rarely, even death.21,23 The success rate of nasal packs in this setting has been reported to lie between 48% and 83%.24–26
Epistaxis: A Contemporary Evidence Based Approach
2012, Otolaryngologic Clinics of North AmericaCitation Excerpt :Other complications of nasal packs (especially nasopharyngeal) include displacement with airway obstruction, pressure necrosis of the palate, alar or columellar skin, and sinus infection or toxic shock syndrome. The latter is caused by staphylococcal exotoxin TSST-1, and presents with fever, diarrhea, hypotension, and a rash.26 Staphylococcus aureus can be isolated in one-third of patients, of which 30% produce the exotoxin.28
Ankaferd Blood Stopper Is More Effective Than Adrenaline Plus Lidocaine and Gelatin Foam in the Treatment of Epistaxis in Rabbits
2011, Current Therapeutic Research - Clinical and ExperimentalCitation Excerpt :Approximately 60% of the population have nosebleeds at least once in their lifespan, and some of them require medical intervention.2 However, in a minority of the patients, persistent and recurrent bleeding may lead to aspiration, hypotension, hypoxia, and even severe and mortal cardiovascular complications (eg, myocardial infarction).3 Several methods or techniques have been described to control epistaxis.
Address reprint requests to Karen H. Calhoun, MD, Department of Otolaryngology, University of Texas Medical Branch, Galveston, TX 77555-0521