Epistaxis—A Review

By Jacquelyn Reilly, MD

Epistaxis—otherwise known as nose bleeds—make up one of the most common problems seen in the emergency room. It occurs in one of every seven people and affects all age groups. Patients who seek medical attention for epistaxis typically fall into two general categories: those who have multiple minor episodes and those who have a single severe prolonged episode that will not stop. In most cases, it is simply secondary to the cold dry air, nasal trauma, or blood thinners. However, in some cases it can relate to more serious diseases, such as cancers of the nasal cavity, sinuses, or nasopharynx. In this article, we will explore the anatomy, etiology, diagnosis, and treatment of epistaxis.

Anatomy. Nose bleeds are classified into either anterior (most common ~ 90%) or posterior epistaxis. To truly understand epistaxis, we must explore the vascular anatomy of the nose. The nose has a very rich vascular supply from both the internal and external carotid artery. The majority of the blood supply comes from the sphenopalatine artery, which is a terminal branch of the external carotid artery. This artery enters the posterior aspect of the nose and supplies both the posterior and anterior mucosa. The internal carotid artery gives off the anterior and posterior ethmoidal artery off the ophthalmic artery, which enters the nose superiorly and supplies the anterior nasal mucosa. The rich anterior septal plexus (also known as Kiesselbach’s plexus) is located in Little’s area, where branches from the external carotid artery meet the branches from the internal carotid artery. This is the most common site (anterior epistaxis) for nose bleeds, especially in the pediatric population, often from frequent digital trauma. The nasopharyngeal plexus (or Woodruff’s plexus, which involves the posterior lateral nasal wall) is the most common site for posterior epistaxis.

Etiology. The etiology of nosebleeds is very diverse. As stated above, digital trauma in the pediatric group is common. Some other causes involving trauma are nasal fractures and other facial injuries, nasal foreign bodies, or simply cold dry air going across a deviated nasal septum. This dry, turbulent air causes breakdown of mucosa, leaving a friable bleeding surface. Turbulent air occurs more significantly at areas or irregularity such as septal deflections and spurs.  A nasal septal perforation, which can be secondary to the use of intranasal illicit drugs (i.e. cocaine) or previous trauma, can cause nose bleeds. So can topical nasal steroids, which can irritate the nasal septum.

Patients in the hospital with nasal cannulas placed for supplemental oxygen frequently have nosebleeds (especially those on heparin for cardiac reasons). Traumatic placement of nasogastric tubes, or simply prolonged use of NG tubes, can cause nose bleeds as well. Infectious causes of epistaxis include acute or chronic rhinosinusitis resulting in inflammation and bleeding. A simple upper respiratory infection can result in epistaxis.

Coagulopathy is a major etiology of epistaxis. Not only are the nose bleeds sometimes profuse, but they also are very difficult to control as long as the patient remains coagulopathic. Some common etiologies of coagulopathy in epistaxis patients include the use of heparin, coumadin, aspirin, or NSAIDS. Systemic etiologies include liver disease, splenomegaly, thrombocytopenia, and leukemia. A positive family history, easy bruisability, history of prolonged bleeding from lacerations, dental extractions or minor trauma should make one consider a congenital coagulopathy.  Von Willebrans’s disease is a congenital bleeding disorder wiwth epistaxis as a frequent (60%) feature.

Hypertension is commonly seen in patients with epistaxis. The cause-versus-effect issue has been debated. However, controlling the blood pressure in patients with epistaxis has certainly been shown to help.

Neoplastic diseases also cause epistaxis. Benign nasal disease (such as nasal polyposis) sometimes presents with epistaxis. Also, an inverting papilloma can present with epistaxis. Cancers of the nasal cavity or nasopharynx (such as squamous cell carcinoma, adenocarcinoma, esthesioneuroblastoma, mucosal melanoma or adenoid cystic carcinoma) are in the differential. In a teenage boy, a juvenile nasopharyngeal angiofibroma can present with unilateral nasal obstruction and epistaxis. Other presenting complaints (such as nasal congestion or sinus-like symptoms) are also features of neoplastic diseases of the sinonasal cavity. Rare disease such as Osler-Weber-Rendu, or hereditary hemmorhagic telangiectasia, should also within the differential.

Diagnosis. Nasal endoscopy has played a major role in not only localizing the site of bleeding but also directly treating the nose with minimal discomfort and trauma. Since the majority of nose bleeds are anterior, simple anterior rhinoscopy can make the diagnosis in the majority of cases. However, if the site of bleeding is not seen, a thorough endoscopic exam of the nasal cavity is warranted. Topical nasal spray decongestants can slow down profuse bleeding so that an adequate exam can be performed. In cases where bleeding is so profuse that endoscopy cannot be performed, an anterior nasal pack can be placed. If this controls the bleeding, the source is most likely anterior. However, if it does not control the bleeding, it may be either a posterior bleed or an ineffective anterior pack.

Routine blood work (including a CBC, PT, and PTT) will be helpful in ruling out underlying coagulopathies. If nasal endoscopy reveals an intranasal mass or polyps, further imaging studies (such as a CT scan or MRI) should be performed.

Treatment. Treatment of epistaxis, like other diseases, starts with prevention. Use alternatives to nasal cannulas, such as a face mask with humidified oxygen, in patients on anticoagulation therapy. Avoid traumatic placement of NG tubes. In patients who are prone to nose bleeds in the winter, recommend daily use of saline nasal spray and nasal lubricants or gels. Hypertension should be closely followed and controlled. Patients on coumadin or heparin should be closely monitored and kept in therapeutic range, particularly when new medications are begun that can alter bleeding times.

In the acute treatment of epistaxis, simple digital pressure of the nose with the patient sitting and leaning forward often proves effective. Topical decongestants (i.e., Afrin, Neosynephrine) have vasoconstrictive properties which may help. If this is not successful, cautery (either chemically with silver nitrate or with electrocautery) can control the bleed. This can be done with anterior rhinoscopy alone or with the aid of endoscopic visualization. If the bleeding site cannot be isolated or the bleeding is too profuse, anterior nasal packing can be tried. This can be done with traditional merocel sponges (which get larger when moistened), or inflatable packs.

If the above measures still do not control the bleed, the source may be posterior, and a posterior pack may need to be placed. Traditionally, posterior packs are placed with an Epistat balloon, which tamponade the choana of the posterior nasal cavity. It is important to understand that bleeding into the nasopharynx does not specifically indicate a posterior bleed.

Packs are typically left in the nose for at least two to three days, and sometimes longer. Antibiotic therapy is used so that a sinusitis (or even worse, toxic shock syndrome) does not occur. If a posterior pack is placed, the patient is typically monitored in the hospital. Any underlying coagulopathy should be controlled unless it is medically contraindicated secondary to a concomitant cardiac issue.

If the packing doesn’t work, or the patient continues to bleed despite long-term use of packing, there are other options to explore. One is embolization of the sphenopalatine/internal maxillary artery. Other options include transantral internal maxillary artery ligation and anterior ethmoidal artery ligation. A newer alternative to transantral internal maxillary artery ligation is an endoscopic ligation of the sphenopalatine artery. These options are generally very effective as the last resort.  Septoplasty can also be considered to decrease the extent of turbulent flow and allow for healing.