Epistaxis

Etiology

There are multiple causes of epistaxis, which can be divided into local, systemic, environmental, and medication-induced.

Local Causes

Local causes of epistaxis include:

• Digital manipulation
• Deviated septum
• Trauma
• Chronic nasal cannula use

Systemic Causes

Local causes of epistaxis include:

• Alcoholism
• Hypertension
• Vascular malformations
• Coagulopathies (von Willebrand disease, hemophilia)

Environmental Factors

Environmental factors in epistaxis include:

• Allergies
• Environmental dryness (more common in winter months)

Medications

Medications that can cause epistaxis include:

• Nonsteroidal anti-inflammatories (NSAIDs; ibuprofen, naproxen, aspirin)
• Anticoagulants (warfarin)
• Platelet aggregation inhibitors (clopidogrel)
• Topical nasal steroid sprays
• Supplements or alternative medications (vitamin E, ginkgo, ginseng)
• Illicit drugs (cocaine)

While epistaxis is a widespread spontaneous problem, rarer etiologies such as neoplasms or vascular malformations must always be in the differential diagnosis, particularly if additional symptoms such as unilateral nasal obstruction, pain, or other cranial nerve deficits are noted.[4][5][6]

Epidemiology

Nosebleeds are rarely fatal, accounting for only 4 of the 2.4 million deaths in the United States. About 60% of people have experienced a nosebleed, and only 10% are severe enough to warrant treatment or medical intervention. They occur most commonly in children aged 2 to 10 years old and older people between 50 and 80. 

Pathophysiology

The rupture of a blood vessel within the nasal mucosa causes nosebleeds. Rupture can be spontaneous, initiated by trauma, use of certain medications, and secondary to other comorbidities or malignancies. An increase in the patient's blood pressure can increase the episode's length. Anticoagulant medications, as well as clotting disorders, can also increase the bleeding time.

Most nosebleeds occur in the anterior part of the nose (Kiesselbach plexus), and an etiologic vessel can usually be found on careful nasal examination. Bleeding from the posterior or superior nasal cavity is often termed a posterior nosebleed. This is usually presumed due to bleeding from the Woodruff plexus, the rear, and fine terminal branches of the sphenopalatine and posterior ethmoidal arteries. These are often difficult to control and are associated with bleeding from both nostrils or into the nasopharynx, where it is swallowed or coughed up, presenting as hemoptysis. This can generate a greater blood flow into the posterior pharynx, and there is a higher risk for airway compromise or aspiration due to increased difficulty controlling the bleeding.

History and Physical

The history should include duration, severity, frequency, laterality of the bleeding, inciting event, and interventions provided before seeking care. Inquire about anticoagulants, aspirin, NSAIDs, and topical nasal steroid use. Obtain a relevant family history, particularly relating to coagulopathy and vascular/collagen disease, as well as any history of drug and alcohol use.

Prepare proper equipment and proper personal protective equipment before beginning the physical examination. Equipment may include a nasal speculum, bayonet forceps, headlamp, suction catheter, packing, silver nitrate swabs, cotton pledgets, topical vasoconstrictor, and anesthetic. Have the patient seated in an exam chair in a room with suction available. Carefully insert the speculum and slowly open the blades to visualize the bleeding site. A headlight is essential for hands-free illumination, and the clot may need to be suctioned from the nasal cavity to identify the bleeding source. A posterior nosebleed is not easy to visualize and may be suggested by active bleeding into the posterior pharynx without a visualized vessel on nasal examination. Nasal endoscopy dramatically increases the success rate of identifying the bleeding source.

Evaluation

Differentiating an anterior or posterior nosebleed is critical in management. Diagnosis of anterior bleeding can be made by direct visualization using a nasal speculum and light source. A topical spray with anesthetic and epinephrine may be helpful for vasoconstriction to help control bleeding and to aid in the visualization of the source. Usually, posterior bleeding is diagnosed after measures to control anterior bleeding have failed. Clinical features of posterior bleeding can include active bleeding into the posterior pharynx without an identified anterior source; high-flow posterior bleeds may cause blood to emanate from both nares. Labs may be obtained if necessary, including a complete blood cell count, type and cross match, and coagulation studies, though they should not delay treatment of an active bleed. Imaging such as x-rays or computed tomography have no role in the urgent or emergent management of active epistaxis.

Treatment / Management

Start with a primary survey and address the airway, ensuring it is patent. Next, assess for hemodynamic compromise. Obtain large-bore intravenous access in patients with severe bleeding and obtain labs. Reverse blood clotting as necessary if there is a concern with medication use.[7][8][9] All patients with moderate to severe nose bleeding should have 2 large-bore intravenous lines and an infusion of crystalloid. Monitoring oxygen and hemodynamic stability is vital.(A1)

Treatment for anterior bleeding can be started with direct pressure for at least 10 minutes. Have the patient apply constant direct pressure by pinching the nose over the cartilaginous tip (instead of over the bony areas) for a few minutes to control the bleeding. Vasoconstrictors such as oxymetazoline or thrombogenic foams or gels can be employed if that is ineffective. Remove all clots with suction before any attempt at treatment is made. The reasons are 2-fold:

1. Clot prevents any medication from reaching the vessel.
2. If packing becomes necessary, the clot can be pushed into the nasopharynx and aspirated.

If topical treatments are unsuccessful, proceed with nasal examination to identify and cauterize the vessel with silver nitrate. If this is unsuccessful, anterior nasal packing is necessary. This can be performed with absorbable packing material such as surgical or fibrillar or with devices such as anterior epistaxis balloons or nasal tampons. If silver nitrate is used to cauterize a septal blood vessel, only use it on 1 side of the septum to prevent septal perforation. Thermal coagulation is painful and should rarely be attempted in an emergent setting.

Traditional petrolatum gauze can be used if one does not have access to balloons or tampons. If none of this is successful, the bleeding may be from the posterior or superior nasal cavity. Symptoms can include active bleeding from both nostrils or active bleeding present in the posterior pharynx. Longer (7.5 cm) nasal tampons provide more posterior pressure and can be employed in this situation. Formal posterior nasal packing should only be performed by experienced personnel as it requires admission, telemetry monitoring, and sometimes intubation; this is associated with higher rates of complications like pressure necrosis, infection, or hypoxia. A nasal-cardiac reflex may be triggered (ie, sudden bradycardia after nasal packing); if this occurs, remove the pack immediately). Foley catheters can be used by experienced personnel to tamponade a posterior bleed. If a rear pack is placed, a formal petrolatum gauze anterior pack must also be set to create a closed, tamponaded space in the nasopharynx. If these measures are unsuccessful, the patient should be intubated for airway protection, and interventional radiology should be consulted emergently for embolization. If this service is unavailable, an otolaryngologist can perform operative ligation of the sphenopalatine and ethmoid arteries in the operating room.

Differential Diagnosis

The differential diagnoses for epistaxis include the following:

• Nasal tumor
• Disseminated intravascular coagulation
• Hemophilia
• Von Willebrand disease
• Rhinitis
• Foreign body in the nose
• Drug toxicity (warfarin, NSAIDs)