Epistaxis

Estimated lifetime prevalence of 60% in the US general population.

Few patients seek medical attention: approximately 6% of persons who have nosebleeds seek medical attention.

In most cases the processes self-limited but can cause anxiety and discomfort

Prolonged bleeding may be life threatening, particularly in the elderly or debilitated individuals.

Significant bleeding can, however, lead to hemodynamic instability , especially in older patients with coexisting cardiovascular diseases and complications can include angina and myocardial infarction.

Risk factors include: facial trauma, physical and chemical irritation, rhino sinusitis, allergic rhinitis, nasal tumors, humidity and temperature alterations, impaired hemostasis caused by antithrombotic and antiplatelet agents, herbal supplements, thrombocytopenia, alcohol use, uremia, liver disease and clotting disorders.

Frequent episodes have been observed in patients with von Willebrand’s disease and genetic abnormalities such as hereditary hemorrhagic telangiectasia.

Can be associated with antiplatelet medications including aspirin and clopidogrel.

May be associated with nasal septal abnormalities and hypertension.

There is a significant elevated risk of epistaxes among patients with hypertension.

The presence of long term uncontrolled hypertension predisposes patients to epistaxis via the development of atherosclerosis in vessels of the nasal mucosal.

Recurrent episodes can lead to impaired quality of life and has been linked to premature discontinuance of antiplatelet medications and increased risk of MI from in-stent thromboses.

Long term uncontrolled hypertension can predispose patients to epistaxis by the development of atherosclerosis of vessels in the nasal mucosa.

The most common bleeding occurs in the anterior two-thirds of the nose and can be seen on the nasal septum.

The anterior septum contains the vascular area, the Kiesselbach’s plexus, the site most commonly responsible for nose bleeds.

Anterior bleeding events are the most common types of epistaxis: usually easy to control and have a minimal risk of airway compression or aspiration.

The posterior third of the nose accounts for approximately 10% of cases.

Bleeding from the posterior aspect of the nose can be significant since large blood vessels reside there.

10-20% of epistaxis are attributable to posterior bleeding events that arise from branches of the sphenopalatine and ascending pharyngeal arteries.

Posterior bleeding events are more profuse, more difficult to control than anterior bleeding events and have a greater risk of airway compromise or aspiration.

Such episodes of epistaxis are located on the posterior septum in 67% of cases, the lateral nasal wall in 25%, with the nasal floor in 8%.

The posterior nasal septum has large blood vessels originating from near the sphenopalatine artery.

Posterior nasal bleeding is common in the elderly because of fragility of tissues, the presence of hypertension, arteriosclerotic disease and coagulopathies.

Posterior bleeds require more aggressive management and may require hospitalization.

Stopping anterior bleeding can be achieved by pinching the cartilaginous part of the nose.

Causes include various types of trauma to the mucosa including abrasions from sneezing, blowing, picking of the nose, nasal fracture, and nasal intubation.

In most cases bleeding start spontaneously without a clear precipitant event.

Nasal drying can cause this process and this may result from dry air, cold air, heated environments, nasal sprays, nasal oxygen administration and dehydration.

May be related to irritation from sinusitis, allergic rhinitis, topical decongestants and inhaled drugs.

Risk factors include local and systemic processes.

 Local factors include: lack of humidification, trauma, intranasal medications, infections, inflammation, and tumors.

Systemic factors include: blood dyscrasias, leukemia, atherosclerosis, hypertension, and congestive heart failure and finally idiopathic.

Associated with hereditary hemorrhagic telangiectasia an autosomal dominant process with weakened capillaries.Anterior septum bleeding may occur with Wegener’s granulomatosis, syphilis, tuberculosis and mid-line lethal granuloma.

High association of recurrent epistaxes with congestive heart failure.

Congestive heart failure relationship is probably related to increased venous pressure in nasal vessels.

CHF patients may be at more risk for recurrent nosebleeds of venous origin, in contrast to arterial bleeding from the Kiesselbach plexus on the nasal septum.

There is an association between recurrent epistaxis s in CHF due to undiagnosed hemorrhagic hereditary telangiectasia.

((Hereditary hemorrhagic telangiectasia)),  anautosomal dominant basculatpr disorder  has a prevalence of one in 5000 individuals and is characterized by mucocutaneous telangiectasia  and systemic arterial venous malformations and commonly manifests as spontaneous, recurrent epistaxis which can be debilitating.

The nose is well vascularized from arteries that originate from branches of the internal and external carotid arteries.

Approximately 80-90% of epistaxis  events occur in the anterior nasal cavity, typically from the anterior inferior septum in Little’s area, where the Kiesselbach plexus is found.

There is a known association between high output CHF and HHT due to right-left shunting of blood through systemic arterial venous malformations, particularly in the liver.

Recurrent episodes related to warfarin and is independent of the INR level.

Recurrent episodes related to diabetes.

Management is straightforward in most cases, but is difficult in patients with cardiovascular disease, impaired coagulation, or platelet dysfunction.

Evaluation of epistaxis is done under blood precautions using personal protective equipment.

Initial management is guided by the assessment of the airway and hemodynamic variables.

Airway compromise or hemorrhagic shock from epistaxes is rare.

History of the quantity and frequency of bleeding, history of nasal official trauma, history of bleeding from other sites, history of recent nasal surgery, current medications and family history of bleeding are all entertained.

During early evaluation the patient should digitally compress the lower nares.

This compression of the lower third of the nose should occur for 15 to 20 minutes, achieving tamponade of the interior nasal blood vessels, preventing aspiration, preventing swallowing of blood and airway compromise.

After digital compression anterior rhinoscopy is performed and if a site is identified, topical vasoconstrictors or cauterization are utilized.

 Electrocautery is associated with greater  efficacy  than  chemical cautery with a  failure rate of 14.5% versus 35.1%,  without a higher incidence of complications or discomfort.

If bleeding is profuse,  and if the bleeding site is not identified,  the anterior  part of the nose is packed.

Packing can control bleeding in nearly all patients with the anterior bleeding events.

If patients  continue to bleed after packing, more aggressive measures need to be taken.

Nasal packing reduces bleeding by direct physical pressure on the mucosa or activation of the clotting cascade.

Packing materials are either resorbable  or non-resorbable.

Contra indications to nasal packing include facial or nasal bone fractures, or basilar skull fractures.

Complications of nasal packing are rare and include obstruction, septal perforations, posterior dislodgment, aspiration, eustachian tube dysfunction, obstructive sleep apnea, foreign body reactions, and toxic shock syndrome.

Resorbable packing is preferred, especially in patients with suspected bleeding disorders or those using anticoagulants or anti-platelet medications.

The use of topical vasoconstricting agents such as oxymetazoline, phenylephrine, epinephrine, or cocaine have demonstrated limited effectiveness.

Oxymetazoline is a selective alpha-adrenergic-receptor agonist, and an alpha2 adrenergic receptors partial agonist and would be the preferred outpatient treatment.

Using topical vasoconstrictors may be associated with increased risk of cardiac complications.

Tranexamic acid administered orally or more commonly topically to control epistaxis shoes moderate quality evidence of lower risk of recurrent bleeding.

Trials suggest tranexamic acid has a greater frequency of hemostasis in the first 10 minutes of use than other topical agents.

Cauterization can be utilized if the bleeding site is identified.

Cauterization techniques include topical application of chemicals, such as silver nitrate, or electrical energy.

Extracellular matrix based biomaterials derived from collagen or hyaluronic acid can improve hemostasis by means of tamponade or activation activation of the coagulation cascade, if augmented with thrombin.

Fibrin sealants are coagulation cascade precipitants associated with rapid hemostasis.

Freeze dried polyurethane foam can reduce patient discomfort and bleeding.

Polyvinyl acetate foam tampons can provide hemostasis.

The duration of packing typically ranges from 48 to 72 hours.

Non-resorbable packing materials can cause significant pain while in place and during removal.

if bleeding persist despite the above measures treatment options include posterior packing, arterial ligations, and endovascular embolization.

Posterior packs occlude the posterior choana with gauze, a Foley catheter, an inflatable nasal balloon catheter in conjunction with non-resolvable anterior nasal packs.

Posterior packing is extremely uncomfortable and associated with a higher risk of complications of otitis media, sinusitis, necrosis of nasal tissues, airway obstruction, hypoxemia due to stimulation of the nasal pulmonary reflex, toxic shock syndrome, than  anterior packing.

Arterial ligation or embolization can be used for persistent or recurrent epistaxis refractory to initial treatments.

Transnasal endoscopic sphenopalatine artery ligation and ethmoidal artery ligation is effective for intractable epistaxis, with low rates of failure and complications.

Arterial embolization occludes blood flow in the terminal branches of the external carotid artery and is performed by means of interventional radiology.

Arterial embolization may be associated with transient facial pain, facial numbness, altered mental status in 25 to 59% of patients.

Rarely arterial embolization is associated with serious complications including cerebral vascular accident, hemiplegia, ophthalmoplegia, facial nerve palsy, seizures and soft tissue necrosis.

Ligation and embolization have similar results, with 75% of the patients have a treatment success at one year and a similar incidence exists of complications.

Antiplatelet drugs and anticoagulants should be held during active bleeding.

The risk for recurrent bleeding can be minimized by decreasing digital manipulation and vigorous nose blowing and by using proper nasal hygiene, such as moisturizing and lubricating with saline  and gels, and the use of a humidifier.