Epistaxis Treatment & Management

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.