epistaxis

MM Carr DDS MD
Reviewed by E.Massoud MD MSc FRCSC,
Assistant Professor, Dept. of Otolaryngology,
Dalhousie University
 
ANATOMY
Blood Supply
1.Internal Carotid Artery
Anterior and Posterior Ethmoidal Aa
2.External Carotid Artery
Internal Maxillary A. gives off
Sphenopalatine A.
 
There are other vessels involved but these are
the most important ones!!
Remember that sensory nerves follow the
general pattern of these vessels. CN V1 and
V2 supply the interior nose (Ant. Ethmoidal N.
and Nasopalatine N. respectively).
 
Little's Area
An area at the anterior inferior nasal septum
where the major vessels anastomose
(Kiesselbach's Plexus) (see diagram). It is an
area of anastomosis for the Sphenopalatine,
Anterior Ethmoid, and Superior Labial Arteries.
This is the MOST COMMON site of epistaxis.
 
ETIOLOGY
1.Local
1.Trauma (*MOST COMMON)
Fractures-facial and nasal
Self-induced-digital trauma,
foreign body
Iatrogenic-nasal/sinus/orbital
surgery
2.Barometric changes
3.Nasal dryness-combination of dry air
(Canadian winters), septal deformities
4.Septal perforation
5.Chemical
Cocaine
Nasal sprays (both steroids and
decongestants)
 Ammonia
Others-gasoline, phosphorus,
chromium salts, sulfuric acid, etc.
6.Tumours
Benign: polyps, inverting
papilloma, angiofibroma
Malignant: squamous cell
carcinoma,
esthesioneuroblastoma
7.Inflammation
Rhinitis-allergic, non-allergic
Infections-bacterial, viral, fungal
2. 
3.Systemic
1.Coagulopathies
Anticoagulant use-Coumadin,
heparin
NSAIDS
Hemophilia
Von Willebrands disease
Hematological malignancies
 Liver failure
Uremia
2.Granulomatous disorders
Wegener's disease
Systemic lupus erythematosis
Periarteritis nodosa etc.
3.Vascular
Hypertension
Atherosclerosis
Osler-Weber-Rendu disease
(hereditary hemorrhagic
telangiectasia)
 
MANAGEMENT
See the Epistaxis Module for complete primary
care management of epistaxis.
I. General Assessment
1.Airway patency
2.Vital signs-BP, pulse, respiration
3.Maintain pressure on nose (patient
pinches anterior nose and leans forward)
 4.Assess blood loss and side of bleeding
(ask patient to quantify blood loss)
5.Important and relevant medical problems:
cardiac, BP, cancer, previous epistaxis,
allergies to medications (ie: local
anesthetics)
6.IV access if indicated
7.Establish rapport with patient. Obtain
consent and cooperation by explaining
what you're going to do
II. Examination
1.Good light
2.Appropriate suction
3.Anesthesia +/- vasoconstrictors
o Use topical 4% lidocaine on cotton

balls inside nose for 7-10 minutes

o Can add topical epinephrine or

decongestant if not contraindicated

o Can use spray topical lidocaine but it

may not stay in place long enough to

work
III. Conservative Treatment
Anterior Epistaxis
a.With patient sitting up, neck slightly flexed,
apply pressure (tell patients to squeeze
anterior (compressible cartilaginous part)
nose for 10 minutes)
 b.Silver nitrate
o Don't cauterize both sides of septum-

potential for perforation

o Don't touch nasal alae, patient's face

or you'll leave burns

o Doesn't work in active bleeding

c. Gelfoam or Surgicel
o Local hemostatic agents which resorb;

place against bleeding site

d.Packing
i. Nasal catheter-"Epistat"
 Anesthetize nose then lubricate

(ie: with polysporin ointment)

epistat before inserting
 Place ports horizontally so patient

can eat/talk
 Inflate balloons with saline

ii. Nasal tampon/sponge- "Merocel"

 Anesthetize nose and lubricate

sponge before inserting (ie:

polysporin)
 Once in, wet with sterile saline

 Rewet prior to removal, check that

none has broken off after removal

iii. Vaseline gauze- use 1/2" by 72" (Don't
use dry gauze!!)
 Leave ends protruding from

anterior nose (don't let them

dangle down pharynx)
  Pack in layers from nasal floor up
 See the Epistaxis Module for
detailed instructions on how to
place a pack
Anterior packs stay in 2-5 days, and
patients require analgesics. Some
clinicians give prophylactic antibiotics (vs.
sinusitis) which can be Amoxil, Erythro etc.
 
If the anterior pack doesn't work, consider:
1. Is the patient hypertensive?
2. Is there a coagulopathy? (NSAID
use?)
3. Is the pack inadequate? (Repack, try
another method)
4. Is the bleed posterior?
o Posterior bleeds usually require
referral to Otolaryngology
 
How Posterior Epistaxis is Managed by
Otolaryngologists
1.Posterior pack
o A Foley catheter is inserted through

the nose and the tip drawn out the

mouth. A gauze roll is tied to it and it is
 withdrawn, bringing the gauze roll up
to the posterior nasal cavity. This acts
as a posterior stop for a tight anterior
pack.
o Some people leave the Foley in the

nose, inflate the balloon, and pack

around the Foley. Then they apply a
clamp to the catheter at the entrance
to the nose, apply pressure to tighten
the pack, and clamp the tube. Foley
posterior packs are not a great idea.
The entire Foley sticks out of the nose
and needs to be controlled somehow,
the Foley tip is long and may irritate
the pharynx, the balloon may leak or
break, and most importantly, the
clamp on the Foley can put pressure
on the nasal ala, causing necrosis.
Still, this method may be used as a
temporizing measure, for example to
transfer a patient.
o Patients with posterior packs require

admission and monitoring for hypoxia,

especially if they're elderly or sick.
Antibiotic prophylaxis is also a good
idea.
2.Embolization
o An interventional radiologist can

occlude the Int. Maxillary Aa, or other

 feeder vessels; there is a risk of CVA
(quoted as 1 in 100)
o Works best in active bleeding (you can

see which artery is involved)

o Considered to be efficacious and of

low morbidity according to the

literature
3.Surgical Treatment
o Ligation of Arteries

 Typically ligate Int. Maxillary A. via

trans-maxillary sinus approach

 Usually also ligate Ant. Ethmoidal

A. through incision near medial

canthus
 Can also ligate Ext. Carotid A. (if

first 2 don't work)

 
SPECIAL CASES
1.Children
a.Toddlers with unilateral recurrent
epistaxis, sometimes with ipsilateral
foul nasal discharge: Think about a
nasal foreign body
b.Adolescent boys with unilateral
recurrent epistaxis who are otherwise
healthy: Think about Angiofibroma (a
benign but locally invasive highly
vascular tumour- they need referral)
 2.Thrombocytopenic patients: Pack with
resorbable materials (ie: Gelfoam), avoid
using vaseline gauze packs (bleeding
restarts when pack is pulled out)
 
Check out Dr. Quinn's Epistaxis Pearls from
the Internet, a collection of clinical secrets
from the otolaryngology community
Back to Table of Contents
 
Page last updated 23 November 2000
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