AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 10  

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• Clinical
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• Treatment
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• Miscellaneous
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• References

Background

Epistaxis, or bleeding from the nose, is common in its frequency and varied in its manifestation. The true prevalence of epistaxis is not known because most episodes are self-limited and thus are not reported. When medical attention is needed, it is usually because of either the recurrent or severe nature of the problem. Treatment depends on the clinical picture, the experience of the treating physician, and the availability of ancillary services.

Pathophysiology

The nose has a rich vascular supply with contribution from the internal and external carotid arteries.

The external carotid 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 internal carotid artery contributes to the nasal vascularity through the ophthalmic artery. This artery enters the bony orbit via the superior orbital fissure and divides into several branches. The posterior ethmoid artery exits the orbit through the posterior ethmoid foramen, located 2-9 mm anterior to the optic canal. The larger anterior ethmoid artery leaves the orbit through the anterior ethmoid foramen. Both of these vessels cross the ethmoid 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 area, is located on the anterior cartilaginous septum and is the location of most anterior epistaxis. Many of the arteries supplying the septum have anastomotic connections at this site.

Frequency

United States

Frequency of epistaxis is difficult to determine because most episodes resolve with self-treatment and, therefore, are not reported.

Mortality/Morbidity

For most of the general population, epistaxis is a nuisance. However, the problem can be life-threatening, especially in elderly patients and in those patients with underlying medical problems.

Sex

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

Age

Distribution is bimodal, with peaks in young children and elderly individuals.

CLINICAL

Section 3 of 10  

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• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

History

• Ask specific questions about the severity, frequency, duration, and laterality of the nosebleed.
• Inquire about precipitating and aggravating factors and methods used to stop the bleeding.
• Obtain a head and neck history with an emphasis on nasal symptoms.
• In addition, elicit a general medical history concerning relevant medical conditions (eg, hypertension, arteriosclerosis, coagulopathies, liver disease), current medications (eg, warfarin sodium [Coumadin], nonsteroidal anti-inflammatory drugs [NSAIDs]), and smoking and drinking habits.

Physical

• Perform a thorough head and neck examination if the patient's condition permits.
• Remove all packings even if bleeding is not active.
• Perform anterior rhinoscopy before and after topical administration of medication. A topical anesthetic, such as 4% aqueous lidocaine, and a vasoconstrictor, such as 0.05% oxymetazoline, may be used. They can be applied via aerosolizing spray or cotton pledgets.
• Finally, perform fiberoptic endoscopy using 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.

Causes

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.

• Trauma
• • Self-induced trauma from repeated nasal picking can cause anterior septal mucosal ulceration and bleeding. This scenario is frequently observed in young children.
  • 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).
• Mucosal irritation: Dry, hot weather and topical nasal sprays can also cause mucosal irritation and epistaxis.
• Septal abnormality
• • Septal deviations 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.
• Inflammatory disease
• • 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.
• 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.
• 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.
  • 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.
• Arteriosclerosis: Arteriosclerotic vascular disease is considered a reason for the higher prevalence of epistaxis in elderly individuals.
• Hereditary hemorrhagic telangiectasia
• • Hereditary hemorrhagic telangiectasia (Osler-Rendu-Weber disease) 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.
• Idiopathic causes: Approximately 10% of patients with epistaxis have no identifiable causes even after a thorough evaluation.

WORKUP

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• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
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• References

Lab Studies

• Lab 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 lab evaluation may not be needed.
• If bleeding is recurrent or severe, studies to evaluate the fluid status, coagulation profiles, and relevant systemic diseases are needed. These may include a complete blood cell count (including platelet count), prothrombin time, activated partial thromboplastin time, and a chemistry panel (including liver function tests).
• Other more specialized studies, such as bleeding time and various assays for coagulation factors and platelet function, may be considered if warranted.

Imaging Studies

• CT scanning and/or MRI may be indicated to evaluate the surgical anatomy and to determine the presence and extent of rhinosinusitis, foreign bodies, and neoplasms.

Procedures

• Diagnostic procedures include angiography and arterial embolization¹ (see Embolization).

TREATMENT

Section 5 of 10  

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Medical Care

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. Topical anesthetics and vasoconstrictors, such as 4% lidocaine and 0.05% oxymetazoline, are applied via aerosolizing spray or cotton pledgets. Clots are then suctioned out to permit a thorough examination.

• Cautery: Bleeding from the Little area is frequently treated with silver nitrate cauterization. Manage the vessels leading to the site before managing the actual bleeding site. Avoid random and aggressive cautery and cautery on opposing surfaces of the septum. Electrocautery using an insulated suction cautery unit can also be used. This method is usually reserved for more severe bleedings and for bleedings in more posteriorly located sites, and it often requires local anesthesia. The effectiveness of both cauterization methods can be enhanced by using rigid endoscopes, especially in the case of more posteriorly located bleeding sites. 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 not to be used 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.
• Anterior packing: Nasal packing can be used to treat epistaxis that is not responsive to cautery. Two types of packing, anterior and posterior, can be placed. In both cases, adequate anesthesia and vasoconstriction are necessary. For anterior packing, various packing materials are available. Petroleum jelly gauze (.5 in X 72 in) filled with an antibiotic ointment is traditionally used. 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. 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 avoid trauma upon packing removal. For all patients with packing, administer prophylactic antibiotics and instruct them to avoid physical strain for 1 week.
• Posterior packing: Epistaxis that cannot be controlled by anterior packing can be managed with a posterior pack. Classically, rolled gauzes are used, but medium tonsil sponges can be substituted. Recently, inflatable balloon devices, such as 12F or 14F 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. Regardless of the type of posterior pack, an anterior pack should also be placed. Admit all patients with posterior packing to the ICU. Close monitoring of oxygenation, fluid status, and adequate pain control is essential in these individuals. They should also be given an antibiotic to prevent rhinosinusitis and possible toxic shock syndrome.

Surgical Care

In most patients with epistaxis, the bleeding responds to cautery and/or packing. For those who have recurrent or severe bleeding for which medical therapy has failed, various surgical options are available.

• Examination under general anesthesia and septoplasty: Packing failure can be caused by inadequate placement from either lack of cooperation by the patient (especially those in the pediatric age group) or from anatomic factors such as a deviated septum. In these patients, 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. In addition, arterial ligation may be performed at the same time if these steps fail to control the bleeding.
• Arterial ligation: The specific vessel(s) 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: Ligation of the external carotid artery 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 external carotid artery is identified by following the internal carotid for a few centimeters and dissecting the external carotid beyond its first few branches. After the external carotid 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 internal carotid artery.
  • Internal maxillary artery ligation: This procedure has a higher success rate than external carotid artery 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 using nerve hooks, and then they are 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. The buccinator space is first entered through a gingivobuccal incision. The buccal fat pad is removed, and the attachment of the temporalis muscle to the coronoid process is identified next. 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 because the site of ligation is more proximal than in the transantral approach.
    • The 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 the traditional transantral approach. Endoscopic technique can also be used to ligate the sphenopalatine artery at its exit from the sphenopalatine foramen. 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 clipped and ligated.
  • Ethmoid artery ligation: If bleeding occurs high in the nasal vault, consider ligation of the anterior and/or posterior ethmoid arteries. These arteries are approached through an external ethmoidectomy incision. The anterior ethmoid artery is usually found 22 mm (range, 16-29 mm) from the anterior lacrimal crest. If clipping the artery does not stop the bleeding, then the posterior ethmoid 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.
• Embolization: Bleeding from the external carotid 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. Preembolization angiography is performed to check for the presence of any unsafe communications between the internal and external carotid systems. Selective embolization of the internal maxillary artery 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 ethmoid arteries.
• Management of hereditary hemorrhagic telangiectasia: Management of this disease 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, or estrogen therapy.

Consultations

• Hematology
• Interventional radiology

Diet

• Patients should avoid hot and spicy foods and drink plenty of fluids.

Activity

• Patients should avoid strenuous activities, hot showers, and digital trauma.
• Patients should use nasal saline spray liberally.
• Digital pressure and ice packs are to be used as needed for minor recurrences.

MEDICATION

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Most patients with epistaxis who seek medical attention are likely to be treated with cautery and/or anterior packing. 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.

Drug Category: Topical vasoconstrictors

Act on alpha-adrenergic receptors in the nasal mucosa, causing vasoconstriction.

Drug Category: Anesthetics

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

Drug Category: Antibiotic ointments

Help prevent local infection and provide local moisturization.

Drug Category: Cauterizing agents

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

FOLLOW-UP

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Further Inpatient Care

• Admit patients with posterior packing to the ICU for close monitoring of oxygenation, fluid balance, and pain control.
• Closely observe patients postsurgery and postembolization for any complications and signs of rebleeding.

Further Outpatient Care

• 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.

In/Out Patient Meds

• Adequate pain control in patients with nasal packing, especially in those with posterior packing
• Oral and topical antibiotics to prevent rhinosinusitis and possibly toxic shock syndrome
• Avoidance of aspirin and other NSAIDs
• Medications to control underlying medical problems (eg, hypertension, vitamin K deficiency) in consultation with other specialists

Transfer

• Patients considered candidates for embolization should be transferred to hospitals with interventional radiology capability.

Deterrence/Prevention

• Patients should avoid the following:
• • Strenuous activities
  • Hot and dry environments
  • Hot and spicy foods
  • Digital trauma
  • Nose blowing and excessive sneezing (Instruct patients to sneeze gently with the mouth open.)

Complications

• Cautery - Synechia, septal perforation
• Anterior packing - Synechia, rhinosinusitis, toxic shock syndrome, eustachian tube dysfunction
• 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/posterior ethmoid artery ligation - Anesthetic risks, rhinosinusitis, lacrimal duct injury, telecanthus
• Embolization - Facial pain, trismus, facial paralysis, skin necrosis, stroke, groin hematoma

Prognosis

• The prognosis is good but variable.
• With adequate supportive care and control of underlying medical problems, most patients may not 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 hereditary hemorrhagic telangiectasia tend to have multiple recurrences regardless of the treatment modality.

Patient Education

• Epistaxis precaution
• • 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.
• Self-treatment for minor epistaxis
• • Apply firm digital pressure for 5-10 minutes.
  • Use an ice pack.
  • Practice deep, relaxed breathing.
  • Use a topical vasoconstrictor.
• For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article, Broken Nose.

MISCELLANEOUS

Section 8 of 10  

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• Clinical
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• Follow-up
• Miscellaneous
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• References

Medical/Legal Pitfalls

• Failure to recognize the severity of the bleeding, especially in patients with posterior epistaxis in whom most of the blood may be swallowed
• Failure to diagnose serious underlying causes (eg, neoplasm, aneurysm, systemic coagulopathies)
• Failure to prescribe antibiotic therapy to prevent rhinosinusitis and possibly toxic shock syndrome

Special Concerns

• Need of adequate pain control has to be balanced with the concern over hypoventilation in the patient with posterior pack.
• Recurrent epistaxis in children could be caused by a foreign body, especially if the nosebleeds are accompanied by symptoms of unilateral nasal congestion and purulent rhinorrhea.
• Delayed epistaxis in a trauma patient may signal the presence of a traumatic aneurysm.

MULTIMEDIA

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Media file 1a:  Posterior epistaxis from the left sphenopalatine artery.
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Media file 1b:  Resolved posterior epistaxis after endoscopic cauterization of the left sphenopalatine artery.
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Media type:  Image

REFERENCES

Section 10 of 10

• Authors and Editors
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• References

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2. Abdelkader M, Leong SC, White PS. Endoscopic control of the sphenopalatine artery for epistaxis: long-term results. J Laryngol Otol. Aug 2007;121(8):759-62. [Medline].
3. Abelson TI. Epistaxis. In: Schaefer SD. Rhinology and Sinus Disease 1st ed. ed. New York: Mosby; 1998:43-50.
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6. Emanuel JM. Epistaxis. In: Cummings CW. Otolaryngology-Head and Neck Surgery. 3^rd ed. St. Louis: Mosby; 1998:852-865.
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8. Juselius H. Epistaxis. A clinical study of 1,724 patients. J Laryngol Otol. Apr 1974;88(4):317-27. [Medline].
9. Maceri DR, Makielski KH. Intraoral ligation of the maxillary artery for posterior epistaxis. Laryngoscope. Jun 1984;94(6):737-41. [Medline].
10. McGarry GW, Gatehouse S, Vernham G. Idiopathic epistaxis, haemostasis and alcohol. Clin Otolaryngol. Apr 1995;20(2):174-7. [Medline].
11. McQueen CT, DiRuggiero DC, Campbell JP, Shockley WW. Orbital osteology: a study of the surgical landmarks. Laryngoscope. Aug 1995;105(8 Pt 1):783-8. [Medline].
12. Padgham N. Epistaxis: anatomical and clinical correlates. J Laryngol Otol. Apr 1990;104(4):308-11. [Medline].
13. Pope LE, Hobbs CG. Epistaxis: an update on current management. Postgrad Med J. May 2005;81(955):309-14. [Medline].
14. Wormald PJ, Wee DT, van Hasselt CA. Endoscopic ligation of the sphenopalatine artery for refractory posterior epistaxis. Am J Rhinol. 2000;Jul-Aug:14(4):261-264.

Article Last Updated: Nov 29, 2007