Clinical Pearls & Morning Reports
The management of epistaxis is straightforward in most cases but can be challenging in patients with cardiovascular disease, impaired coagulation, or platelet dysfunction. Read the NEJM Clinical Practice article here.
Q: What are the risk factors for epistaxis?
A: In most cases, bleeding starts spontaneously, without any obvious precipitant. The underlying causes of and risk factors for epistaxis are classified as being local (e.g., lack of humidification, trauma, intranasal medication application, infection, inflammation, and tumors), systemic (e.g., blood dyscrasias, leukemia, atherosclerosis, hypertension, and congestive heart failure), or idiopathic. Recurrent epistaxis may be the first sign of systemic or local neoplastic disease.
Q: How do anterior and posterior bleeding events differ?
A: The nose is well vascularized, with arteries that originate from branches of the internal carotid and external carotid arteries. Approximately 80 to 90% of epistaxis events occur in the anterior nasal cavity, typically from the anteroinferior septum in Little’s area, where the Kiesselbach plexus is found. This plexus is a rich confluence of vessels from the internal carotid (anterior ethmoidal) and external carotid (sphenopalatine, greater palatine, and superior labial) arteries. Anterior bleeding events are the most common types of epistaxis, are usually easy to control, and pose a minimal risk of airway compromise or aspiration. Approximately 10 to 20% of cases of epistaxis are attributable to posterior bleeding events that arise from branches of the sphenopalatine and ascending pharyngeal arteries. Such cases of epistaxis are usually located on the posterior septum (in 67% of patients), the lateral nasal wall (in 25%), or the nasal floor (in 8%). Posterior bleeding events are more profuse and harder to control than anterior bleeding events, and they pose a greater risk of airway compromise or aspiration.
A: Epistaxis is appropriately controlled in a systematic and escalating fashion. Initially, patients in the medical setting are advised to apply continuous digital compression to the lower third of the nose for 15 to 20 minutes while leaning forward. A directed history and a cursory physical examination, including vital signs, should be performed while the patient digitally compresses the lower nares. History taking should involve attention to the quantity and frequency of bleeding, history of nasal or facial trauma, other sites of bleeding or bruising, history of nasal surgery, coexisting conditions, current medications, and family history of bleeding. After compression, anterior rhinoscopy is performed with the use of a nasal speculum and a headlight. If the bleeding continues and a site of bleeding is identified, topical vasoconstrictors or cauterization are used. If the bleeding site is not identified or if profuse bleeding precludes the identification of a distinct site, the anterior part of the nose is packed.
A: Resorbable packing is generally preferred over nonresorbable packing, especially in patients with a suspected bleeding disorder or those using anticoagulants or antiplatelet medications. Resorbable packing material is more comfortable during insertion and avoids the prolonged recurrent bleeding from the irritated nasal mucosa associated with the removal of packing material, but it may be more costly. Failure to control bleeding with this packing may result in the advancement to treatment with nonresorbable packing. Posterior packing is very uncomfortable and is associated with a higher risk of complications (e.g., otitis media, sinusitis, necrosis of nasal tissues, airway obstruction, hypoxemia due to stimulation of the nasopulmonary reflex, and toxic shock syndrome) than anterior packing. The duration of packing typically ranges from 48 to 72 hours.