EpistaxisLee Jieen Pro,MD, PHD

Departments of Departments of Otolaryngology Head Neck Surgery

First Affiliated Hospital, Guangxi Medical UniversityFirst Affiliated Hospital, Guangxi Medical University

Background

• Epistaxis, or bleeding from the nose, is common in its frequency and varied in its manifestation. The true prevalence of epistaxis is not known because in most cases are self-limited and thus are not reported. When medical attention is needed, it is usually because of either the recurrent or severe nature of the problem. Treatment depends on the clinical picture, the experience of the treating physician, and the availability of ancillary services

Pathophysiology

• The nose has a rich vascular supply with contribution from the internal and external carotid arteries

• The Kiesselbach plexus, or Little area, is located on the anterior septum and is the location of most anterior epistaxis. Many of the arteries supplying the septum have anastomotic connections at this site.

Frequency• Frequency of epistaxis is difficult to

determine because most patients resolve with self-treatment and, therefore, are not reported.

Mortality/Morbidity

• For most of the general population, epistaxis is a nuisance. However, the problem can be life-threatening, especially in elderly patients and in those patients with underlying medical problems

Sex and Age

• Prevalence of epistaxis tends to be higher in males (58%) than in females (42%).

• Distribution is bimodal, with peaks in young children and elderly individuals

CLINICAL History

• Ask specific questions about the severity, frequency, duration, and laterality of the nosebleed.

• Inquire about precipitating and aggravating factors and methods used to stop the bleeding.

• Obtain a head and neck history with an emphasis on nasal symptoms.

CLINICAL

History• In addition, elicit a general medical history

concerning relevant medical conditions (eg, hypertension, arteriosclerosis, liver disease), current medications (eg, warfarin sodium , nonsteroidal anti-inflammatory drugs), and smoking and drinking habits

CLINICAL

Physical• Perform a thorough head and neck

examination if the patient's condition permits.

• Perform anterior rhinoscopy before and after topical administration of medication. A topical anesthetic, such as 1% Dcaine, may be used. They can be applied via aerosolizing spray or cotton pledgets.

CLINICAL

Physical• Remove all packings even if bleeding is not

active.• Finally, perform endoscopy using a

preferably rigid endoscope to inspect the entire nasal cavity, including the nasopharynx. The rigid endoscope is preferred because of its superior optics and its ability to allow endoscopic suction and cauterization

Causes

• Causes of epistaxis can be divided into local causes (eg, trauma, mucosal irritation, septal abnormality, inflammatory diseases, tumors), systemic causes (eg, blood dyscrasias, arteriosclerosis, hereditary hemorrhagic telangiectasia), and idiopathic causes.

Posterior epistaxis from the left sphenopalatine artery

Resolved posterior epistaxis after endoscopic cauterization of the left sphenopalatine artery

Trauma and foreign body

Trauma and foreign body

postoperation

smallpox—nasal septum defects —bleeding

nasal septum deviation and perferation

nasal septum deviation and perferation

Juvenile nasopharyngeal angiofibroma

tumor

tumor

WORKUP

Lab Studies• Lab tests to evaluate the patient's condition and

underlying medical problems may be ordered depending on the clinical picture at the time of presentation.

• If the bleeding is minor and not recurrent, then a lab evaluation may not be needed.

WORKUP

Lab Studies• If bleeding is recurrent or severe, studies may

include a complete blood cell count (including platelet count), prothrombin time, activated partial thromboplastin time, and a chemistry panel (including liver function tests).

• Other more specialized studies, such as bleeding time and various assays for coagulation factors and platelet function.

WORKUP

Imaging Studies

• CT scanning and/or MRI may be indicated to evaluate the surgical anatomy and to determine the presence and extent of rhinosinusitis, foreign bodies, and neoplasms

WORKUP

Procedures

• Diagnostic procedures include angiography and arterial embolization

TREATMENTMedical Care

• Before evaluating a patient with epistaxis, have sufficient illumination, adequate suction, all the necessary topical medications, and cauterization and packing materials ready. Remove all packings even though bleeding may not be active. The importance of obtaining adequate anesthesia and vasoconstriction if time permits cannot be overemphasized.

TREATMENT

Medical Care• Cautery: Bleeding from the Little area is

frequently treated with silver nitrate cauterization. Manage the vessels leading to the site before managing the actual bleeding site.

• Anterior packing: Nasal packing can be used to treat epistaxis that is not responsive to cautery.

TREATMENT

Medical Care• Posterior packing: Epistaxis that cannot be

controlled by anterior packing can be managed with a posterior pack.

Recently, Foley catheters, or specially designed catheters such as Storz and Xomed (eg, Storz

Epistaxis Catheter, Xomed Treace Nasal Post Pac) have become popular because they are easier to place

Posterior packing

TREATMENT

Surgical Care

• In most patients with epistaxis, the bleeding responds to cautery and/or packing. For those who have recurrent or severe bleeding for which medical therapy has failed, various surgical options are available.

Prognosis

• The prognosis is good but variable.

• With adequate supportive care and control of underlying medical problems, most patients may not experience any rebleeding.

Prognosis

• Others may have minor recurrences that resolve spontaneously or with minimal self-treatment.

• A small percentage of patients may require repacking or more aggressive treatments.