Epistaxis

The nose has a rich vascular supply, with substantial contributions from the internal carotid artery (ICA) and the external carotid artery (ECA).

The ECA system supplies blood to the nose via the facial and internal maxillary arteries. The superior labial artery is one of the terminal branches of the facial artery. This artery subsequently contributes to the blood supply of the anterior nasal floor and anterior septum through a septal branch.

The internal maxillary artery enters the pterygomaxillary fossa and divides into 6 branches: posterior superior alveolar, descending palatine, infraorbital, sphenopalatine, pterygoid canal, and pharyngeal.

The descending palatine artery descends through the greater palatine canal and supplies the lateral nasal wall. It then returns to the nose via a branch in the incisive foramen to provide blood to the anterior septum. The sphenopalatine artery enters the nose near the posterior attachment of the middle turbinate to supply the lateral nasal wall. It also gives off a branch to provide blood supply to the septum.

The ICA contributes to nasal vascularity through the ophthalmic artery. This artery enters the bony orbit via the superior orbital fissure and divides into several branches. The posterior ethmoidal artery exits the orbit through the posterior ethmoidal foramen, located 2-9 mm anterior to the optic canal. The larger anterior ethmoidal artery leaves the orbit through the anterior ethmoidal foramen (see the image below).

The anterior and posterior ethmoidal arteries cross the ethmoidal roof to enter the anterior cranial fossa and then descend into the nasal cavity through the cribriform plate. Here, they divide into lateral and septal branches to supply the lateral nasal wall and the septum.

The Kiesselbach plexus, or Little’s area, is an anastomotic network of vessels located on the anterior cartilaginous septum. It receives blood supply from both the ICA and the ECA.[8] Many of the arteries supplying the septum have anastomotic connections at this site.

Bleeding typically occurs when the mucosa is eroded and vessels become exposed and subsequently break.

More than 90% of bleeds occur anteriorly and arise from Little’s area, where the Kiesselbach plexus forms on the septum.[9, 10] The Kiesselbach plexus is where vessels from both the ICA (anterior and posterior ethmoidal arteries) and the ECA (sphenopalatine and branches of the internal maxillary arteries) converge. These capillary or venous bleeds provide a constant ooze, rather than the profuse pumping of blood observed from an arterial origin. Anterior bleeding may also originate anterior to the inferior turbinate.

Posterior bleeds arise further back in the nasal cavity, are usually more profuse, and are often of arterial origin (eg, from branches of the sphenopalatine artery in the posterior nasal cavity or nasopharynx). A posterior source presents a greater risk of airway compromise, aspiration of blood, and greater difficulty controlling bleeding.

Causes of epistaxis can be divided into local causes (eg, trauma, mucosal irritation, septal abnormality, inflammatory diseases, tumors), systemic causes (eg, blood dyscrasias, arteriosclerosis, hereditary hemorrhagic telangiectasia), and idiopathic causes. Local trauma is the most common cause, followed by facial trauma, foreign bodies, nasal or sinus infections, and prolonged inhalation of dry air. Children usually present with epistaxis due to local irritation or recent upper respiratory infection (URI).

In a retrospective cohort study of 2405 patients with epistaxis (3666 total episodes), Purkey et al used multivariate analysis to identify a series of risk factors for nosebleeds. The likelihood of epistaxis was found to increase in patients with allergic rhinitis, chronic sinusitis, hypertension, hematologic malignancy, coagulopathy, or, as mentioned, hereditary hemorrhagic telangiectasia. The investigators also found increased nosebleeds in association with older age and colder weather.[11]

Similarly, a German study, by Seidel et al, found that the rate of patients receiving a first epistaxis diagnosis at an otolaryngologic practice was lowest in summer, with the rate increasing in fall and winter and peaking in February, March, and April. The study, which involved 114 otolaryngologic practices, reported a rate of 7.22 epistaxis patients per practice in August 2016, the lowest figure that year, compared with a peak rate of 14.89 patients per practice, in February 2016.[12]

Trauma

Self-induced trauma from repeated nasal picking can cause anterior septal mucosal ulceration and bleeding. This scenario is frequently observed in young children. Nasal foreign bodies that cause local trauma (eg, nasogastric and nasotracheal tubes) can be responsible for rare cases of epistaxis.

Acute facial and nasal trauma commonly leads to epistaxis. If the bleeding is from minor mucosal laceration, it is usually limited. However, extensive facial trauma can result in severe bleeding requiring nasal packing. In these patients, delayed epistaxis may signal the presence of a traumatic aneurysm.

Patients undergoing nasal surgery should be warned of the potential for epistaxis. As with nasal trauma, bleeding can range from minor (due to mucosal laceration) to severe (due to transection of a major vessel).

Dry weather

Low humidity may lead to mucosal irritation. Epistaxis is more prevalent in dry climates and during cold weather due to the dehumidification of the nasal mucosa by home heating systems.

Drugs

Topical nasal drugs such as antihistamines and corticosteroids may cause mucosal irritation. Especially when applied directly to the nasal septum instead of the lateral walls, they may cause mild epistaxis. Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) are also frequently involved.

Septal abnormality

Septal deviations (deviated nasal septum) and spurs may disrupt the normal nasal airflow, leading to dryness and epistaxis. The bleeding sites are usually located anterior to the spurs in most patients. The edges of septal perforations frequently harbor crusting and are common sources of epistaxis.

Inflammation

Bacterial, viral, and allergic rhinosinusitis causes mucosal inflammation and may lead to epistaxis. Bleeding in these cases is usually minor and frequently manifests as blood-streaked nasal discharge.

Granulomatosis diseases such as sarcoidosis, Wegener granulomatosis, tuberculosis, syphilis, and rhinoscleroma often lead to crusting and friable mucosa and may be a cause of recurrent epistaxis.

Young infants with gastroesophageal reflux into the nose may have epistaxis secondary to inflammation.

Tumors

Benign and malignant tumors can manifest as epistaxis. Affected patients may also present with signs and symptoms of nasal obstruction and rhinosinusitis, often unilateral.

Intranasal rhabdomyosarcoma, although rare, often begins in the nasal, orbital, or sinus area in children. Juvenile nasal angiofibroma in adolescent males may cause severe nasal bleeding as the initial symptom.

Blood dyscrasias

Congenital coagulopathies should be suspected in individuals with a positive family history, easy bruising, or prolonged bleeding from minor trauma or surgery. Examples of congenital bleeding disorders include hemophilia and von Willebrand disease.[8]

Acquired coagulopathies can be primary (due to the diseases) or secondary (due to their treatments). Among the more common acquired coagulopathies are thrombocytopenia and liver disease with its consequential reduction in coagulation factors. Even in the absence of liver disease, alcoholism has also been associated with coagulopathy and epistaxis. Oral anticoagulants predispose to epistaxis.

Vascular abnormalities

Arteriosclerotic vascular disease is considered a reason for the higher prevalence of epistaxis in elderly individuals.

Hereditary hemorrhagic telangiectasia (HHT; also known as Osler-Weber-Rendu syndrome) is an autosomal dominant disease associated with recurrent bleeding from vascular anomalies. The condition can affect vessels ranging from capillaries to arteries, leading to the formation of telangiectasias and arteriovenous malformations. Pathologic examination of these lesions reveals a lack of elastic or muscular tissue in the vessel wall. As a result, bleeding can occur easily from minor trauma and tends not to stop spontaneously.

Various organ systems such as the respiratory, gastrointestinal, and genitourinary systems may be involved. The epistaxis in these individuals is variable in severity but is almost universally recurrent.

Other vascular abnormalities that predispose to epistaxis include vascular neoplasms, aneurysms, and endometriosis.

Migraine

Children with migraine headaches have a higher incidence of recurrent epistaxis than children without the disease.[13] The Kiesselbach plexus, which is part of the trigeminovascular system, has been implicated in the pathogenesis of migraine.[14]

Hypertension

The relationship between hypertension and epistaxis is often misunderstood. Patients with epistaxis commonly present with an elevated blood pressure. Epistaxis is more common in hypertensive patients, perhaps owing to vascular fragility from long-standing disease.

Hypertension, however, is rarely a direct cause of epistaxis. More commonly, epistaxis and the associated anxiety cause an acute elevation of blood pressure. Therapy, therefore, should be focused on controlling hemorrhage and reducing anxiety as primary means of blood pressure reduction.

A study by Sarhan and Algamal, which included 40 patients with epistaxis and 40 controls, reported that the number of attacks of epistaxis was higher in patients with a history of hypertension, but the investigators were unable to determine whether a definite link existed between nosebleeds and high blood pressure. They did find, however, that control of epistaxis was more difficult in hypertensive patients; patients whose systolic blood pressure was higher at presentation tended to need management with packing, balloon devices, or cauterization.[15]

Excessive coughing causing nasal venous hypertension may be observed in pertussis or cystic fibrosis.

Idiopathic causes

The cause of epistaxis is not always readily identifiable. Approximately 10% of patients with epistaxis have no identifiable causes even after a thorough evaluation.[16]

The frequency of epistaxis is difficult to determine because most episodes resolve with self-treatment and, therefore, are not reported.[17] However, when multiple sources are reviewed, the lifelong incidence of epistaxis in the general population is about 60%, with fewer than 10% seeking medical attention.[8, 18, 17]

The age distribution is bimodal, with peaks in young children (2-10 y) and older individuals (50-80 y). Epistaxis is unusual in infants in the absence of a coagulopathy or nasal pathology (eg, choanal atresia, neoplasm). Local trauma (eg, nose picking) does not occur until later in the toddler years. Older children and adolescents also have a less frequent incidence. Consider cocaine abuse in adolescent patients.

Prevalence of epistaxis tends to be higher in males (58%) than in females (42%).

For most of the general population, epistaxis is merely a nuisance. However, the problem can occasionally be life-threatening, especially in elderly patients and in those patients with underlying medical problems. Fortunately, mortality is rare and is usually due to complications from hypovolemia, with severe hemorrhage or underlying disease states.

Overall, the prognosis is good but variable; with proper treatment, it is excellent. When adequate supportive care is provided and underlying medical problems are controlled, most patients are unlikely to experience any rebleeding. Others may have minor recurrences that resolve spontaneously or with minimal self-treatment. A small percentage of patients may require repacking or more aggressive treatments.

Patients with epistaxis that occurs from dry membranes or minor trauma do well, with no long-term effects. Patients with HHT tend to have multiple recurrences regardless of the treatment modality. Patients with bleeding from a hematologic problem or cancer have a variable prognosis. Patients who have undergone nasal packing are subject to increased morbidity. Posterior packing can potentially cause airway compromise and respiratory depression. Packing in any location may lead to infection.

For patient education resources, see the Breaks, Fractures, and Dislocations Center, as well as Broken Nose.

The following precautions should be imparted to the patient:

• Use nasal saline spray.

• Avoid hard nose blowing or sneezing.

• Sneeze with the mouth open.

• Do not use nasal digital manipulation.

• Avoid hot and spicy foods.

• Avoid taking hot showers.

• Avoid aspirin and other NSAIDs.

The following simple instructions for self-treatment for minor epistaxis should be provided:

• Apply firm digital pressure for 5-10 minutes.

• Use an ice pack.

• Practice deep, relaxed breathing.

• Use a topical vasoconstrictor.

Controlling significant bleeding or hemodynamic instability should always take precedence over obtaining a lengthy history.

Ask specific questions about the severity, frequency, duration, and laterality of the nosebleed. Determine whether the bleed occurs after exercise or during sleep or is associated with a migraine. Determine whether hematemesis or melena has occurred because posterior bleeding in particular may present in this fashion.

Inquire about precipitating and aggravating factors and methods used to stop the bleeding. Most nosebleeds are reported as spontaneous events and are frequently related to nose picking or other trauma; therefore, investigate the various possibilities.

Foreign bodies inserted in the nose may also present with epistaxis, but bleeding may be less and accompanied by foul or purulent discharge if the object has been retained for some time. A unilateral nasal discharge suggests the presence of a foreign body.

Children easily can insert small batteries from electronic devices (eg, calculators, watches, handheld video games) into their nostrils. Not only can local irritation and bleeding result, but these can leak and cause a chemical alkali burn that may result in local tissue necrosis. Severe complications (eg, nasal stenosis) can result from batteries. Removal is a priority; removing the batteries within 4 hours of insertion is best.

In addition to obtaining a head and neck history with an emphasis on nasal symptoms, elicit a general medical history concerning relevant medical conditions, current medications, and smoking and drinking habits.

Inquire about previous epistaxis, hypertension, hepatic or other systemic disease, easy bruising, or prolonged bleeding after minor surgical procedures. A history of frequent recurrent nosebleeds, easy bruising, or other bleeding episodes should make the clinician suspicious of a systemic cause and prompt a hematologic workup. Obtain any family history of bleeding disorders or leukemia.

Children with severe epistaxis are more likely to have required nasal cauterization, an underlying coagulopathy, a positive family history of bleeding, and anemia. Although unusual, children with bleeding disorders (eg, von Willebrand disease) can occasionally have normal coagulation profiles. More than 1 sample may be required to notice the abnormality due to biologic variability throughout the day.

Use of medications—especially aspirin, NSAIDs, warfarin, heparin, ticlopidine, and dipyridamole—should be documented, as these not only predispose to epistaxis but make treatment more difficult. Particularly in children, include investigation of suspicion of accidental ingestion (eg, accidental ingestion of rat poison in toddlers).

Before evaluating a patient with epistaxis, have sufficient illumination, adequate suction, all the necessary topical medications, and cauterization and packing materials ready. Remove all packings, even though bleeding may not be active. The importance of obtaining adequate anesthesia and vasoconstriction if time permits cannot be overemphasized. A comfortable patient tends to be more cooperative, allowing for better examination and more effective treatment.

Perform a thorough and methodical examination of the nasal cavity. Blowing the nose decreases the effects of local fibrinolysis and removes clots, permitting a better examination. Application of a vasoconstrictor (eg, 0.05% oxymetazoline) before the examination may reduce hemorrhage and help to pinpoint the precise bleeding site. A topical anesthetic (eg, 4% aqueous lidocaine) reduces pain associated with the examination and nasal packing. Clots are then suctioned out to permit a thorough examination.

Gently insert a nasal speculum (see the image below) and spread the naris vertically. Begin the examination with inspection, looking specifically for any obvious bleeding site on the septum that may be amenable to direct pressure or cautery. This permits visualization of most anterior bleeding sources. Anterior bleeds from the nasal septum are most common type, and the site can frequently be identified if bleeding is active.

If an anterior source cannot be visualized, if the hemorrhage is from both nares, or if constant dripping of blood is seen in the posterior pharynx, the bleeding may be from a posterior site. After placement of an anterior pack, and, if bleeding is noted in the pharynx with the anterior pack in place, strongly consider a posterior bleed.

Massive epistaxis may be confused with hemoptysis or hematemesis. Blood dripping from the posterior nasopharynx confirms a nasal source. Approximately 90% of nosebleeds can be visualized in the anterior portion of the nasal cavity.

Fiberoptic endoscopy may be performed with a flexible or (preferably) rigid endoscope to inspect the entire nasal cavity, including the nasopharynx. The rigid endoscope is preferred because of its superior optics and its ability to allow endoscopic suction and cauterization.

Examine the skin for evidence of bruises or petechiae that may indicate an underlying hematologic abnormality.

Assess vital signs. Although high blood pressure rarely, if ever, causes epistaxis on its own, it may impede clotting. Check blood pressure, and complete a workup if high blood pressure is present. Persistent tachycardia must be recognized as an early indicator of significant blood loss requiring intravenous (IV) fluid replacement and, potentially, transfusion.

Complications of epistaxis may include the following:

• Sinusitis

• Septal hematoma/perforation

• External nasal deformity

• Mucosal pressure necrosis

• Vasovagal episode

• Balloon migration

• Aspiration

For the most part, laboratory studies are not needed or helpful for first-time nosebleeds or infrequent recurrences with a good history of nose picking or trauma to the nose. However, they are recommended if major bleeding is present or if a coagulopathy is suspected.

Laboratory tests to evaluate the patient’s condition and underlying medical problems may be ordered depending on the clinical picture at the time of presentation. If the bleeding is minor and not recurrent, then a laboratory evaluation may not be needed.

If a history of persistent heavy bleeding is present, obtain a hematocrit count and type and cross match. If a history of recurrent epistaxis, a platelet disorder, or neoplasia is present, obtain a complete blood count (CBC) with differential. The bleeding time is an excellent screening test if suspicion of a bleeding disorder is present. Obtain the international normalized ratio (INR)/prothrombin time (PT) if the patient is taking warfarin or if liver disease is suspected. Obtain the activated partial thromboplastin time (aPTT) as necessary.

Direct visualization with a good directed light source, a nasal speculum, and nasal suction should be sufficient in most patients. However, computed tomography (CT) scanning, magnetic resonance imaging (MRI), or both may be indicated to evaluate the surgical anatomy and to determine the presence and extent of rhinosinusitis, foreign bodies, and neoplasms. Nasopharyngoscopy may also be performed if a tumor is the suspected cause of bleeding.

Sinus films are rarely indicated for a nosebleed. Angiography is rarely indicated.

When medical attention is needed for epistaxis, it is usually because of the problem is either recurrent or severe. Treatment depends on the clinical picture, the experience of the treating physician, and the availability of ancillary services.

In most patients with epistaxis, the bleeding responds to cauterization, nasal packing, or both. For those who have recurrent or severe bleeding for which medical therapy has failed, various surgical options are available. After surgery or embolization, patients should be closely observed for any complications or signs of rebleeding.

Medical approaches to the treatment of epistaxis may include the following:

• Adequate pain control in patients with nasal packing, especially in those with posterior packing (However, the need of adequate pain control has to be balanced with the concern over hypoventilation in the patient with posterior pack.)

• Oral and topical antibiotics to prevent rhinosinusitis and possibly toxic shock syndrome

• Avoidance of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs)

• Medications to control underlying medical problems (eg, hypertension, vitamin K deficiency) in consultation with other specialists

Also see Anterior Epistaxis Nasal Pack, Posterior Epistaxis Nasal Pack, and Surgery for Pediatric Epistaxis.

Coronavirus disease 2019 (COVID-19)

In May 2020, clinical recommendations out of Italy were published regarding the management of epistaxis during the coronavirus disease 2019 (COVID-19) pandemic.[19]

Personal protection recommendations include the following[19] :

• Disposable equipment use is strictly recommended
• FFP3 (Europe) or N99 (United States) masks are preferred, but if FFP3 masks are unavailable, FFP2 or N95 masks, covered by a surgical mask, can be used
• It is strongly recommended that health-care personnel employ cap and shoe covers, goggles, gowns, and double nitrile gloves

Clinical assessment recommendations include the following[19] :

• Nosebleed risk factors (ie, blood pressure, coagulation factors, ongoing therapies with antithrombotic or anticoagulant drugs) should be controlled
• The patient should be checked for fever, respiratory symptoms, and contacts at risk for COVID-19
• Investigate sudden loss of smell and/or taste
• If allowed, dress patients with a surgical mask
• Promptly assess the nosebleed’s severity
• It is recommended that noninvasive intervention (bidigital compression, administration of antifibrinolytic agents) be employed

Room setting recommendations include the following[19] :

• If conventional operating rooms are unavailable, employ well-demarcated areas within the emergency department complex
• The patient should be treated by a reduced and experienced clinical staff, including a surgeon and a scrub nurse, with proper personal protective equipment (PPE)

Treatment recommendations include the following[19] :

• Avoid unnecessary interventions
• If noninvasive procedures fail, nasal packing or cautery should be performed
• Resorbable packing, if available, is recommended
• If sphenopalatine artery ligation is needed for posterior epistaxis, the procedure should be postponed until COVID-19 testing has been performed
• Avoid using local anesthetic atomized sprays, employing soaked pledgets instead
• During the procedure, a suction system, within a closed system and employing a viral filter, should be used

Postprocedure recommendations include the following[19] :

• To reduce recurrence risk and optimize outcomes, the patient should receive postprocedural instructions on packing removal or antibiotic prophylaxis
• Carefully execute gowning and degowning procedures
• Standard PPE should be employed by personnel engaged in the decontamination of surgical equipment

Initial treatment begins with direct pressure. The nostrils are squeezed together for 5-30 minutes straight, without frequent peeking to see if the bleeding is controlled. Usually, 5-10 minutes is sufficient.

Patients should keep their heads elevated but not hyperextended because hyperextension may cause bleeding into the pharynx and possible aspiration. This maneuver works more than 90% of the time.

If direct pressure is not sufficient, gauze moistened with epinephrine at a ratio of 1:10,000 or phenylephrine (Neo-Synephrine) may be placed in the affected nostril to help vasoconstrict and achieve hemostasis.

If bleeding is caused by excessive dryness in the home (eg, from radiator heating), patients may benefit from humidifying the air with a cool mist vaporizer in the bedroom or, as a simpler alternative, placing a metal basin of water on top of a radiator to humidify the ambient air.

Nasal saline sprays are useful. Oxymetazoline may also be used, with fewer cardiac adverse effects. To minimize the risk of rhinitis medicamentosa and tachyphylaxis, these agents should be used for no more than 3-5 days at a time.

The physician may consider local application of bacitracin or petrolatum ointment directly to the Kiesselbach area with a cotton applicator to prevent further drying (studies recommend 2 wk).

Bleeding from the Kiesselbach plexus (Little’s area) is frequently treated with silver nitrate cauterization.[16] Manage the vessels leading to the site before managing the actual bleeding site. Avoid random and aggressive cauterization and cautery on opposing surfaces of the septum.

Electrocauterization with an insulated suction cautery unit can also be used. This method is usually reserved for more severe bleeding and for bleeding in more posteriorly located sites, and it often requires local anesthesia. The effectiveness of both cauterization methods can be enhanced by using rigid endoscopy, especially in the case of more posteriorly located bleeding sites (see the image below).[20]

After the bleeding has been controlled, instruct the patient to use nasal saline spray and antibiotic ointment and to avoid strenuous activities for 7-10 days. NSAIDs are to be avoided if at all possible. Digital manipulation of the nose is to be avoided. A topical vasoconstrictor may be used if minor bleeding recurs with the dislodging of the eschar.

A retrospective study by Newton et al of emergency department (ED) management of 353 adult cases of primary anterior epistaxis found silver nitrate cauterization to have the highest treatment success rate (80%). The highest rates of patients returning to the ED for recurrence of epistaxis occurred after treatment with nasal clips, Merocel, or petroleum gauze packing. However, the investigators could not say whether the differences in treatment results indicated that certain treatments were more effective or that physicians tended to offer certain treatments in the most severe cases (ie, those most likely to recur).[21]

Nasal packing can be used to treat epistaxis that is not responsive to cauterization. Two types of packing, anterior and posterior, can be placed. In both cases, adequate anesthesia and vasoconstriction are necessary.

A study by Kundi and Raza suggested that in patients with epistaxis, removal of nasal packs after 12 hours leads to a lower incidence of headache and excessive lacrimation than does removal of packs after 24 hours, with no significant difference in bleeding recurrence. The study involved 60 patients with epistaxis, evenly divided between the 12-hour and 24-hour groups.[22]

Anterior

For anterior packing, various packing materials are available. Petroleum jelly gauze (0.5 in × 72 in) filled with an antibiotic ointment is traditionally used (see the image below). Layer it tightly and far enough posteriorly to provide adequate pressure. Blind packing with loose gauze is to be avoided.

Merocel sponges can be placed relatively easily and quickly but may not provide adequate pressure (see the image below). They should be coated with an antibiotic ointment and can be hydrated with a topical vasoconstrictor.

All packings should be removed in 3-4 days. Absorbable materials (eg, Gelfoam, Surgicel, Avitene) may be used in patients with coagulopathy to prevent trauma upon packing removal. Administer prophylactic antibiotics to all patients with packing, and instruct them to avoid physical strain for 1 week.

Also see Anterior Epistaxis Nasal Pack.

Posterior

Epistaxis that cannot be controlled by anterior packing can be managed with posterior packing. Classically, rolled gauzes are used, but medium tonsil sponges can be substituted.

Recently, inflatable balloon devices (eg, 12 or 14 French Foley catheters) or specially designed catheters manufactured by companies such as Storz and Xomed (eg, Storz Epistaxis Catheter, Xomed Treace Nasal Post Pac) have become popular because they are easier to place. Avoiding overinflation of the balloon is important because it can cause pain and displacement of the soft palate inferiorly, interfering with swallowing.

A 2010 study by Garcia Callejo et al determined that gauze packing, despite being slower and more uncomfortable, has a higher success rate, produces fewer local injuries, and costs less than inflatable balloon packing.[23]

Regardless of the type of posterior pack used, an anterior pack should also be placed. Admit all patients with posterior packing to the intensive care unit (ICU) for close monitoring of oxygenation, fluid status, and pain control. An antibiotic should also be given to prevent rhinosinusitis and possible toxic shock syndrome.

Also see Posterior Epistaxis Nasal Pack.

Management of packing failure

Packing failure can be caused by inadequate placement resulting either from lack of patient cooperation (especially in the pediatric age group) or from anatomic factors (eg, deviated septum). In cases of packing failure, a careful endoscopic examination with the patient under general anesthesia may be considered. Bleeding sites can be cauterized under endoscopic guidance, a deviated septum can be straightened, spurs can be removed, and meticulous packing can be placed.[24]

If these steps fail to control the bleeding, arterial ligation (see below) may be performed at the same time.

The choice of the specific vessel or vessels to be ligated depends on the location of the epistaxis. In general, the closer the ligation is to the bleeding site, the more effective the procedure tends to be.

External carotid artery

Ligation of the external carotid artery (ECA) can be performed with the patient under local or general anesthesia. A horizontal skin incision is made between the hyoid bone and the superior border of the thyroid cartilage. Subplatysmal skin flaps are then raised, and the sternocleidomastoid muscle is retracted posteriorly.

Next, the carotid sheath is opened and its contents exposed. The ECA is identified by following the internal carotid artery (ICA) for a few centimeters and dissecting the ECA beyond its first few branches. After the ECA has been positively identified, it is usually ligated just distal to the superior thyroid artery. Continued bleeding after ligation may be from anastomoses with the opposite carotid system or the ipsilateral ICA.

Internal maxillary artery

Internal maxillary artery ligation has a higher success rate than ECA ligation because of the more distal site of intervention.

Traditionally, the internal maxillary artery is accessed transantrally via a Caldwell-Luc approach. With the help of an operating microscope, the posterior sinus wall is removed in a piecemeal fashion, and the posterior periosteum is carefully opened. The internal maxillary artery and 3 of its terminal branches (ie, sphenopalatine, descending palatine, pharyngeal) are elevated with nerve hooks, then clipped. The posterior sinus wall is then packed with Gelfoam, and the gingivobuccal incision is closed.

More recently, transoral and transnasal endoscopic approaches have been described. The transoral approach is useful in patients with midface trauma, hypoplastic antra, or maxillary tumors.

In the transoral approach, the buccinator space is first entered through a gingivobuccal incision. The buccal fat pad is removed, and the attachment of the temporalis to the coronoid process is identified. This process facilitates the identification of the internal maxillary artery. The vessel is then doubly clipped and divided. This procedure has a higher failure rate than the transantral approach because the site of ligation is more proximal.

The transnasal endoscopic method requires skills with endoscopic instruments. A large middle meatal antrostomy is made to expose the posterior sinus wall. The middle turbinate can be partially resected to ensure adequate exposure. The remaining steps are similar to those of the traditional transantral approach.

Endoscopic technique can also be used to ligate the sphenopalatine artery at its exit from the sphenopalatine foramen.[25, 26] An incision is made just posterior to the posterior attachment of the middle turbinate. The mucosal flap is then carefully elevated to reveal the sphenopalatine artery, which is then clipped and ligated.

A study by de Bonnecaze et al indicated that transnasal endoscopic sphenopalatine artery ligation (TESPAL) is about as effective as embolization in controlling intractable epistaxis but results in a lower complication rate. Both procedures had a 1-year success rate of 75%, while the minor and/or major complication rate was 18% for TESPAL, compared with 34% for embolization.[27]

Ethmoidal artery

If bleeding occurs high in the nasal vault, consider ligation of the anterior ethmoidal artery, the posterior ethmoidal artery, or both. These arteries are approached through an external ethmoidectomy incision.

The anterior ethmoidal artery is usually found approximately 22 mm (range, 16-29 mm) from the anterior lacrimal crest. If clipping the artery does not stop the bleeding, then the posterior ethmoidal artery may be ligated. This artery is found approximately 12 mm posterior to its anterior counterpart. It should be clipped, not cauterized, because it is only 4-7 mm anterior to the optic nerve.

Bleeding from the ECA system may be controlled with embolization, either as a primary modality in poor surgical candidates or as a second-line treatment in those for whom surgery has failed. Patients considered candidates for embolization should be transferred to hospitals with interventional radiology capability.[24]

Preembolization angiography is performed to check for the presence of any unsafe communications between the ICA and ECA systems. Selective embolization of the internal maxillary artery[28] and sometimes the facial artery may be performed. Postprocedure angiography can be used to evaluate the degree of occlusion. The most common reason for failure is continued bleeding from the ethmoidal arteries.

A literature review by Hoffman et al found that in patients with epistaxis, the pooled procedural success rate for endovascular embolization was 87%. The odds of success were lower in association with age and the presence of HHT.[29]

A retrospective study by Wang et al indicated that transarterial embolization (TAE) can safely and successfully be used in patients with intractable epistaxis, even when etiology and angiographic findings differ among patients. TAE was effective in all 43 of the study’s patients, despite the fact that both malignant and benign etiologies and positive and negative angiographic findings were present.[30]

Management of hereditary hemorrhagic telangiectasia (HHT) is palliative because the underlying defect is not curable. Options include coagulation with potassium-titanyl-phosphate (KTP) or neodymium:yttrium-aluminum-garnet (Nd:YAG) lasers, septodermoplasty, embolization, and estrogen therapy.[31]

A study by Wirsching et al indicated that in patients with HHT, supplementing Nd:YAG laser therapy with temporary nasal occlusion with hypoallergenic tape can reduce the Epistaxis Severity Score by a significant amount over laser therapy alone.[32]

Research by Contis et al suggested that the beta blocker propranolol is effective against epistaxis in patients with HHT. In a retrospective study, the investigators found that the Epistaxis Severity Score significantly improved in nine out of 10 patients with HHT who received the drug, while in a second, prospective study, of 11 patients, they found that the median duration of epistaxis per month, as well as the monthly number of epistaxis episodes, significantly decreased after 3 months of propranolol therapy.[33]

Potential treatment complications include the following :

• Cauterization - Synechia, septal perforation

• Anterior packing - Synechia, rhinosinusitis, toxic shock syndrome, eustachian tube dysfunction, scarring of the nasal ala and columella

• Posterior packing - Synechia, rhinosinusitis, toxic shock syndrome, eustachian tube dysfunction, dysphagia, scarring of nasal ala and columella, hypoventilation, sudden death

• Transantral internal maxillary artery ligation - Anesthetic risks, rhinosinusitis, oroantral fistula, infraorbital numbness, dental injury

• Transoral internal maxillary artery ligation - Anesthetic risks, cheek numbness, trismus, tongue paresthesia

• Anterior or posterior ethmoidal artery ligation - Anesthetic risks, rhinosinusitis, lacrimal duct injury, telecanthus, blindness

• Embolization - Facial pain, trismus, facial paralysis, skin necrosis, blindness, stroke, groin hematoma

Few dietary measures are indicated. Patients should avoid hot and spicy foods and drink plenty of fluids.

Patients should avoid strenuous activities, hot showers, and digital trauma. They should use nasal saline spray liberally and should employ digital pressure and ice packs as needed for minor recurrences.

To the extent possible, patients should avoid the following:

• Strenuous activities - Protection from direct trauma from some sports activities is afforded by the use of helmets or face pieces.

• Hot and dry environments – The effects of such environments can be mitigated by using humidifiers, better thermostatic control, saline spray, and antibiotic ointment on the Kiesselbach area.

• Hot and spicy foods

• Digital trauma – In children, nose picking is difficult to deter and should probably be considered inevitable. Keeping the child’s nails well trimmed may be helpful.

• Nose blowing and excessive sneezing - Instruct patients to sneeze gently with the mouth open.

• Inappropriate or careless use of drugs - Consider drug education relating to use or accidental ingestion of aspirin, warfarin (eg, rat poison in toddlers), or drug abuse in adolescents.

A hematologist may have to be consulted. Consultation with an interventional radiologist may also be appropriate.

Use supportive measures to prevent recurrence (eg, nasal saline spray, Bactroban nasal ointment). Arrange for follow-up care to remove packing in 3-4 days.

Guidelines on coronavirus disease 2019 (COVID-19)

In May 2020, clinical recommendations out of Italy were published regarding the management of epistaxis during the coronavirus disease 2019 (COVID-19) pandemic.[19]

Personal protection recommendations include the following[19] :

• Disposable equipment use is strictly recommended
• FFP3 (Europe) or N99 (United States) masks are preferred, but if FFP3 masks are unavailable, FFP2 or N95 masks, covered by a surgical mask, can be used
• It is strongly recommended that health-care personnel employ cap and shoe covers, goggles, gowns, and double nitrile gloves

Clinical assessment recommendations include the following[19] :

• Nosebleed risk factors (ie, blood pressure, coagulation factors, ongoing therapies with antithrombotic or anticoagulant drugs) should be controlled
• The patient should be checked for fever, respiratory symptoms, and contacts at risk for COVID-19
• Investigate sudden loss of smell and/or taste
• If allowed, dress patients with a surgical mask
• Promptly assess the nosebleed’s severity
• It is recommended that noninvasive intervention (bidigital compression, administration of antifibrinolytic agents) be employed

Room setting recommendations include the following[19] :

• If conventional operating rooms are unavailable, employ well-demarcated areas within the emergency department complex
• The patient should be treated by a reduced and experienced clinical staff, including a surgeon and a scrub nurse, with proper personal protective equipment (PPE)

Treatment recommendations include the following[19] :

• Avoid unnecessary interventions
• If noninvasive procedures fail, nasal packing or cautery should be performed
• Resorbable packing, if available, is recommended
• If sphenopalatine artery ligation is needed for posterior epistaxis, the procedure should be postponed until COVID-19 testing has been performed
• Avoid using local anesthetic atomized sprays, employing soaked pledgets instead
• During the procedure, a suction system, within a closed system and employing a viral filter, should be used

Postprocedure recommendations include the following[19] :

• To reduce recurrence risk and optimize outcomes, the patient should receive postprocedural instructions on packing removal or antibiotic prophylaxis
• Carefully execute gowning and degowning procedures
• Standard PPE should be employed by personnel engaged in the decontamination of surgical equipment

AAO-HNSF guidelines

Guidelines on the management of epistaxis were published in 2020 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF). They include, but are not limited to, the following[34] :

• Upon initial contact, the clinician should determine whether a nosebleed patient does or does not require prompt management
• In patients who require prompt management, active bleeding should be treated with firm, sustained compression to the lower third of the nose, with or without the patient or caregiver’s help, for at least 5 minutes
• If, owing to bleeding, the bleeding site cannot be identified (despite nasal compression), nasal packing should be used to treat ongoing, active bleeding
• In patients with a suspected bleeding disorder or in those who are on anticoagulation or antiplatelet medications, resorbable packing should be used
• In any patient with a nosebleed, factors that lead to more frequent or severe bleeding, including personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, or intranasal drug use, should be documented
• In patients with nosebleeds, anterior rhinoscopy should be carried out to identify a bleeding source (although any blood clot, if present, should first be removed)
• To identify the bleeding site and guide further management in patients who, despite prior packing or cautery, have recurrent nasal bleeding, the clinician should either perform nasal endoscopy or make a referral to a clinician who can perform it; this should also be done in patients with recurrent unilateral nasal bleeding
• In patients whose epistaxis is difficult to control, as well as in those for whom concern exists that the epistaxis is associated with an unrecognized pathology, the clinician may examine the nasal cavity and nasopharynx with nasal endoscopy or make a referral to one who can
• Patients with an identified bleeding site should be treated with appropriate interventions; these may include one or more of the following: topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents
• When employing nasal cautery, the bleeding site should be anesthetized, and the cautery should be restricted only to the active or suspected bleeding site(s)
• Patients in whom packing or nasal cauterization fails to control persistent or recurrent bleeding should be evaluated as candidates for surgical arterial ligation or endovascular embolization; the clinician should either perform the evaluation or make a referral to one who can
• If bleeding is not life-threatening, first-line treatments should be initiated before transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications from patients using these agents
• In patients with a history of recurrent bilateral nosebleeds or a family history of recurrent nosebleeds, the clinician should assess, or make a referral to a specialist can assess, whether nasal telangiectasias and/or oral mucosal telangiectasias are present, in order to diagnose hereditary hemorrhagic telangiectasia (HHT) syndrome

Most patients with epistaxis who seek medical attention are likely to be treated with cauterization, anterior packing, or both. Those with severe or recalcitrant bleeding may need posterior packing, arterial ligation, or embolization. Pharmacotherapy plays only a supportive role in treating the patient with epistaxis.

Class Summary

Topical vasoconstrictors act on alpha-adrenergic receptors in the nasal mucosa, causing vessels to constrict.

Oxymetazoline 0.05% (Afrin)

Oxymetazoline is applied directly to mucous membranes, where it stimulates alpha-adrenergic receptors and causes vasoconstriction. Decongestion occurs without drastic changes in blood pressure, vascular redistribution, or cardiac stimulation.

Oxymetazoline can be used in combination with lidocaine 4% to provide effective nasal anesthesia and vasoconstriction.

Class Summary

When anesthetics are used concomitantly with vasoconstrictors, their anesthetic effect is prolonged and the pain threshold increased.

Lidocaine 4% (Xylocaine)

Lidocaine decreases permeability to sodium ions in neuronal membranes. This results in the inhibition of depolarization, blocking the transmission of nerve impulses.

Lidocaine can be used in combination with oxymetazoline 0.05% to provide effective nasal anesthesia and vasoconstriction.

Class Summary

Antibiotic ointments help prevent local infection and provide local moisturization.

Mupirocin ointment 2% (Bactroban nasal)

Mupirocin ointment inhibits bacterial growth by inhibiting RNA and protein synthesis. It is a compounded medication.

Class Summary

Cauterizing agents coagulate cellular proteins, which can in turn reduce bleeding.

Silver nitrate

Silver nitrate coagulates cellular protein and removes granulation tissue. It also has antibacterial effects.