Case Report

Anterior Epistaxis

Presentator :
dr. Rifki Zakaria

Moderator :
Dr. Dyah Ayu Kartika Dewanti, M. Sc., Sp. T.H.T.K.L

Departemen Kesehatan Telinga Hidung Tenggorok Bedah Kepala Leher

Fakultas Kedokteran, Kesehatan Masyarakat dan Keperawatan UGM
RSUP Dr. Sardjito
2018

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INTRODUCTION greater. The annual admission rate of adult
epistaxis to otolaryngology wards in the
Anterior epistaxis is defined as
UK is around 30 per 100,000 per year,
bleeding from anterior nasal septum, an
however less than 10% of admitted
area known as the Kiesselbach Plexus.
patients go on to require a surgical
Although epistaxis is rarely a cause of 3
procedure under general anaesthetic.
mortality, it leads morbidity in select
There is neither racial nor gender
patient groups and represents a frequently
1
predilection, excepting that, as men are
encountered otolaryngologic emergency.
more likely to experience trauma, there is
It is rarely life threatening but may cause
some increased likelihood via this
significant concern, especially among
mechanism.6
parenst of little children. Most of epistaxis
are benign, self – limiting, and Nosebleeds occur more frequently
2
spontaneous, but some can be recurrent. in the drier, colder months, and in less
Refferal to ENT is reserved for the humid environments. This is because dry
minority of cases where the epistaxis is air facilitates excoriation and cracking of
severe and or there are other associated the nasal mucosa, vessel trauma, and
patient factors or co – morbid requiring subsequent epistaxis. Ninety percent of
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admission. epistaxis is caused by bleeding originating
from blood vessels in Little's area, located
Epistaxis is one of the most
at the anterior inferior septum. This area
common ENT health problem, affecting
contains a confluence of vessels from the
60% of the population at least once in their
various nasal sources called the
life time.4 Fortunately, only 6 % of these
Kiesselbach plexus.6
people will require medical treatment to
control and stop the hemorrhage.5 There is Causes of epistaxis can be divided
a bimodal distribution of epistaxis into local causes (trauma, mucosal
incidence with peaks in children and older irritation, septal abnormality,
adult. Epistaxis is rare in children under inflammatory diseases, tumors), systemic
the age of 2 years; however it does occur causes (hypertension, arteriosclerosis,
more commonly in childhood with a peak hereditary hemorraghic telangiectasia) and
incidence between the ages of 3 and 8 idiopathic causes. Local trauma is the most
years. The peak incidence of epistaxis in common cause, followed by facial trauma,
adults is in 45 - 65 year old in whom the foreign bodies, nasal or sinus infections,
incidence of severe posterior bleeding is and prolonged inhalation of dry air.

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Children usually present with epistaxis due therefore, investigate the various
to local irritation or recent upper possibilities.2
respiratory infection (URI). 2
In addition to obtaining a head and
Adults with nosebleed often have neck history with an emphasis on nasal
elevated blood pressure (BP), although symptoms, elicit a general medical history
difficulty exists in determining whether concerning relevant medical conditions,
hypertension is a causative factor or current medications, and smoking and
whether the elevated BP is secondary to drinking habits. Inquire about previous
anxiety. Conclusive proof is lacking. Also epistaxis, hypertension, hepatic or other
debated is whether atherosclerotic change, systemic disease, easy bruising, or
secondary to hypertension, increases prolonged bleeding after minor surgical
vessel fragility. In the manner that elevated procedures. A history of frequent recurrent
BP impairs intraoperative surgical nosebleeds, easy bruising, or other
haemostasis, it may be reasonably inferred bleeding episodes should make the
that it would similarly prolong and worsen clinician suspicious of a systemic cause
active nasal bleeding. 6 and prompt a hematologic workup. Obtain
any family history of bleeding disorders or
Controlling significant bleeding or
leukemia.2
hemodynamic instability should always
take precedence over obtaining a lengthy The main goals of treatment are
history. Ask specific questions about the immediate management of the presenting
severity, frequency, duration, and laterality bleeding, treatment of any underlying
of the nosebleed. Determine whether the cause, prevention of recurrence.
bleed occurs after exercise or during sleep Examination and treatment of epistaxis
or is associated with a migraine. often proceeds concurrently. Generally,
Determine whether hematemesis or melena resuscitation is not required in most people
has occurred because posterior bleeding in presenting with epistaxis, but is required in
particular may present in this case. Inquire the rare instance of haemodynamic
about precipitating and aggravating factors compromise. This is more likely if there is
and methods used to stop the bleeding. severe bleeding, the patient is older, the
Most nosebleeds are reported as patient is unwell or frail. Such patients
spontaneous events and are frequently need urgent resuscitation, oxygen
related to nose picking or other trauma supplementation, intravenous access,
urgent FBC, platelets, clotting studies, and

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blood type for transfusion are required, stressful for the physician. Also,
along with the maintenance of airway, efficacious pack placement may be
breathing, and circulation (ABC). These compromised if the procedure hurts
patients may present with lightheadedness, excessively and the patient remains
dizziness, syncope, hypotension, uncooperative. Some physicians may
tachycardia, and pallor.6,7 extemporaneously prepare a mixture of
anaesthetic and decongestant in the clinic
As an initial measure the entire
or emergency department. Oxymetazoline
lower compressible cartilage of the nose is
is suggested rather than phenylephrine as
pinched to apply pressure to possible
the latter seems more likely to cause
anterior bleeding sites. Also, liberal
hypertension or possibly angina in
application of a topical vasoconstrictor
susceptible patients. Some physicians
(decongestant), such as oxymetazoline, can
simply remove the top from a spray bottle
be accomplished before the actual
of oxymetazoline, add an equal volume of
evaluation begins. Application of a
the lidocaine, and replace the top;
vasoconstrictor (decongestant) may be
however, consultant advice is
both diagnostic and therapeutic, to help
recommended. The patient blows the nose
visualize the epistaxis site and encourage
to clear blood and clots; suction may be
haemostasis. These agents also shrink
used. Active bleeding may necessitate the
mucosal thickness, allowing more open
rapid alternation between clearing of blood
nasal space should placement of a pack be
and liberal application of the topical
required. This can reduce mucosal trauma
vasoconstrictor and anaesthetic. Next,
incurred during insertion of a pack and
small neurosurgical pledgets or strips of
thereby decrease secondary bleeding sites
cotton are saturated well with the mixture
from disrupted mucous membrane.6
and placed horizontally in the nose with
Initial assessment may reveal an bayonet forceps, and left for 10 to 15
obvious underlying cause or exacerbating minutes. The patient compresses the nose
factor. Active bleeding persistent despite if necessary.6
initial measures Application of a
CASE REPORT
combination of topical anaesthetic, such as
65-year-old male came to the
4% lidocaine, and vasoconstrictor
Emergency Room in Sardjito with the
(decongestant) is useful at this stage.
main complaint of blood out of the left
Topical anaesthetic makes the procedure
nose. Complaints are felt since 2 hours
more humane for the patient and less

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before hospitalization . Blood came out
slightly but continuously and the patient
pressed and gagged his left nose with a
tissue but the blood still flowed out.
Patients didn’t feel any swallowed blood,
nasal congestion or nose pain. Before the
patient bleeding was not fever, cough
,runny nose and no trauma.
Examination of patient's vital signs,
blood pressure 160/104 mmHg, pulse 100
x/min, respiration 20 x/minute, saturation
o
99 %, temperature 36.9 C, patient's
general condition was good, calm and
stable. From the physical examination of
the ear was obtained auricula dextra and
sinistra within normal limit, from otoskopi
examination obtained membran tympani
dextra and sinistra intact with positive
reflex cone of light. On
rhinoscopic examination the
appeared out of the left septum, the outer
location of the bleeding was difficult to
assess, on posterior rhinoscopy
examination bleeding did not appear from
the posterior wall of the nasal cavity. On
oropharynx examination
appeared. There was no history of double
vision, tinnitus, and decreased hearing.
Neck examination showed no palbable
lump or lymphnode enlargement.
Patients claimed to have had a
nosebleed once in 2 years ago. History of
Hypertention since 10 years ago. Patient
take amlodipin 5 mg when he felt his
blood pressure was rising. The patient
denies any history of blood clotting
disorders, diabetes mellitus and liver
disease. Patients were diagnosed with
anterior epistaxis.
In these patients given an anterior
tampon was observed for 2-3 day. Patient
was hospitalized. Patient were given
Infusion Ringer Laktat 20 rpm, hemostatic
injection (tranexamic acid 500 mg per 8
hours) and consulted with interna. The
problem in this case was recurrence.
DISCUSION
Epistaxis (nosebleed) may be defined
as acute bleeding from the nasal cavity or
nasopharynx. Epistaxis is bleeding from
the nose, which varies cause and
anterior
manifestation. Epistaxis is bleeding from
blood
the nose that can occur as a result of a
variety of causes, both trauma and
malignancy, with the amount of bleeding
varying from a few to many.13,17
Epistaxis or nasal bleeding is a
bleeding relatively common case in both the child
and the elderly, with an incidence rate of
7% -14% of the total population per year.
Epistaxis is often a symptom or a
manifestation of another disease. Most are
mild cases and can often stop themselves
without the need for medical help.2,8
The anterior epistaxis often originates
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from the front of the septum, which is rich
in anastomosis from the branches of the
sphenopalatine artery, the anterior etmoid
artery, the superior labial artery and the
major palatine artery called the Plexus
Kiesselbach (Little's Area). The
Kiesselbach Plexus is superficial and is
easily injured by trauma, so it is often a
source of epistaxis in children. Patients
with anterior epistaxis will see bleeding
coming out of the nose with varying
amounts of bleeding, may be slight or
continuous resulting in harm.13
The two most important factors of
epistaxis are 1) Minor Trauma such as
nose, sneezing, coughing or straining. 2)
Fragile nasal mucosa such as upper
respiratory tract infections, mucosal
dryness.13 Congenital abnormalities that
often cause epistaxis are Rendu-Olser-
Weber disease. In addition epistaksis can
occur in the diver due to changes in
atmospheric pressure. Besides other causes
of epistaxis is the presence of foreign
objects in the nasal cavity, nasal polyps,
Blood disorders, blood vessel disorders
and tumors in the nasopharyngeal region
and patient with hypertension.9
Epistaxis is more common in
hypertension patients, perhaps owing to
vascular fragility from long-standing
disease. epistaxis was more difficult to
control in hypertensive patients.11
Recurrences that occur in this patients
perhaps patient do not take medication
regularly so that uncontrolled blood
pressure may be the triger of epistaxis.
Therefore patients are educated to take anti
hypertension drug regularly, changing diet
and lifestyle.
Management of anterior epistaxis is
adjusted to the patient's condition.When
hypertension is suspected in the setting of
epistaxis, it should be investigated and
managed appropriatley. Improvement of
the patient's general condition. In mild
epistaxis bleeding can be stopped by
sitting, head up and then nostrils pressed
with the finger towards the septum for 15
minutes. After determining the location of
the bleeding, the installation of adrenaline
tampons and lidocaine 15 If the bleeding
soureces difficult to assess used anterior
tampon is recomended.18
SUMMARY
It has been reported that 65 year-old
male patients with an anterior epistaxis
diagnosis. In these patients given an
anterior tampon was observed for 2-3 day.
Patients are hospitalized. Patient were
given Infusion Ringer Laktat 20 rpm,
hemostatic injection (tranexamic acid 500
mg per 8 hours). Patient removed anterior
tampon after 2 day in hospital and
sugessted to control one more week. Take
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home message for the patient are
educated to take anti hypertension drug
regularly, changing diet and lifestyle.

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