Epistaxis

Conditions of the Nose and Paranasal Sinuses » Epistaxis

Type

  • ANTERIOR
    • Almost always from nasal septum.
    • Confluence of blood vessels (rich supply) to anterior nasal septum called Little’s
      area or Kieselbach’s plexus.
    • Site of 99% of childhood (and most adults) epistaxis
  • POSTERIOR
    • Almost always lateral nasal wall.
    • Blood supply is sphenopalatine artery from sphenopalatine foramen. Just below
      posterior end of middle turbinate insertion.
    • Common site of elderly hypertension related epistaxis.

The most common epistaxis is in a healthy child or adult without risk factors who bleeds from the septum. Most likely cause is the cycle of mucosal dryness ? mucosal cracking/crusting ? bleeding.

 

Rick factors

  • Hypertension
  • Anti-coagulants (eg. ASA, Plavix, Coumadin)
  • Trauma (including nose picking)
  • Nasal surgery (first 2 weeks post operative)
  • Nasal septal perforation
  • Hereditary Hemorrhagic Telangiectasias
  • Bleeding diatheses
  • Rarely, sinonasal tumors

 

Treatment (mild to moderate epistaxis)

  • Educate patient/caregiver on proper application of nose pinching (pressure).
  • Apply Vaseline or other ointment to anterior nasal septal areas. Preventive effect to break cycle of mucosal dryness leading to bleeding.
  • If specific localized bleeding source seen, may cauterize with silver nitrate under topical anesthesia.
  • For more diffuse mucosal bleeding, gentle insertion of ointment impregnated packing. Leave in 2-3 days.

Treatment (moderate to severe epistaxis)

  • As above for mild to moderate epistaxis.
  • If severe , initial treatment options consist of assessment, ABC’s, manage hypertension, measure hemoglobin, type and screen.
  • Clean nose, i.e.) clear all blood/clots from nose. Patient nose blowing or suction. Apply topical anesthesia. Try to visualize bleeding.
  • Then if localized bleeding, try silver nitrate cautery or electrocautery.
  • Then if diffuse bleeding, try anterior and/or posterior nasal packing.
  • If still refractory to nasal packing or as an alternative to packing for severe bleeding, consider arterial ligation or embolization.

Additional Resources

Epistaxis Management Case