CHAPTER 78 Management of Epistaxis

Nosebleed is a common complaint with an incidence of approximately 1 per 1000 patients annually in the United States. Ninety percent of nosebleeds resolve, either spontaneously, with the aid of pinching the outer soft tissue of the nose (Fig. 78-1), or by applying an ice pack to the bridge (Fig. 78-2). Managing the other 10% is the topic of this chapter.

Figure 78-1 Apply pressure by pinching the nose to stop the bleeding.

Figure 78-2 An ice pack can be applied to the bridge of the nose.

The most common cause of minor nosebleed is dry nasal mucosa (i.e., low-humidity environment such as in the desert or in a cold climate where heating is used). Moderate nosebleed is usually caused by nasal trauma; severe nosebleed is often a complication of a medical condition such as a coagulopathy caused by medications, cancer, or cirrhosis. Although hypertension is often seen in patients with nosebleeds, studies have been unable to confirm this condition as a cause. Rather, it appears that nosebleeds are associated with anxiety, and anxiety leads to hypertension. Localized causes of nosebleeds also include inflammation from colds and allergies, foreign bodies, nasal septum deformities, and sinonasal neoplasms. Systemic causes include coagulopathies, Osler-Weber-Rendu disease (hereditary hemorrhagic telangiectasia), and use of nonsteroidal anti-inflammatory drugs or anticoagulants. Osler-Weber-Rendu disease is an autosomal dominant condition in which the vascular walls lack contractile elements; consequently, prolonged and heavy bleeding can occur despite a normal coagulation profile. The diagnosis can be suspected when there is a family history compatible with the disease.

Nosebleeds can be divided into three groups: anterior, posterior, and mixed. Anterior bleeds account for approximately 90% of epistaxis. Posterior and mixed bleeds can be clinically suspected in patients who have brisk, bilateral, nontraumatic bleeding that does not abate with anterior packing. Posterior bleeding can be life-threatening and is more common in patients older than 40 years of age. Usually the patient can tell you which side of the nose started bleeding. With posterior bleeding, blood also usually runs down the back of the throat.

Understanding the anatomy of the nasal cavity is useful for obtaining efficient and effective control of bleeding. The blood supply for the nasal septum arises from both the internal and external carotid arteries. A primary source for the posteroinferior septum is the sphenopalatine artery, a branch of the internal maxillary artery, which in turn is a branch of the external carotid system. The uppermost part of the nasal septum is supplied by the anterior and posterior ethmoid arteries, which arise indirectly from the internal carotid system. The blood supply for the anterior nasal septum is the superior labial artery, which is also indirectly a branch of the internal carotid system. All of these arteries anastomose in the anterior central portion of the nasal septum, an area known as Kiesselbach’s plexus (Fig. 78-3). It is estimated that 95% of anterior nasal bleeds occur there. An occasional source of anterior bleeding is an exposed edge from a perforated nasal septum. Anterior bleeding from the lateral nasal cavity is rare, although telangiectases from Osler-Weber-Rendu disease can be seen here. Trauma can also result in lateral bleeding.

Figure 78-3 Anatomy of the septal blood supply.

The clinician treating epistaxis must understand the normal anatomy of the nose and be familiar with the nasal septum and its appropriate midline position. He or she should be able to identify the inferior and middle turbinates. With an understanding of normal anatomy, when a patient has a nosebleed, the examiner should quickly notice if there are any anatomic abnormalities (e.g., deviated nasal septum, a nasal polyp, a mass). Bleeding is not unusual on either side of a deviated nasal septum.

Equipment

Preparing a “nosebleed tray” in advance is useful.

• Headlight

• Tongue depressor

• Yankauer suction catheter

• Frazier suction catheters, no. 5 and no. 7

• Nasal speculums, short and medium length

• Bayonet or offset forceps (see Chapter 76, Removal of Foreign Bodies from the Ear and Nose, Fig. 76-1)

• Fine Adson forceps

• Emesis (kidney) basin

• Cotton balls

• Cotton-tipped swabs (wooden handle preferred if applying Gelfoam or Surgicel)

• Gelfoam or Surgicel (Surgicel may be better for coagulation but may delay healing, so it is often reserved for when Gelfoam is not effective or available)

• 4 × 4 gauze sponges

• Silver nitrate sticks

• Petroleum impregnated gauze, -inch wide, up to 72 inches long

• Nasal sponges/tampons (Fig. 78-4) or Rhino Rocket (Fig. 78-5)

• Nasal balloon devices (Fig. 78-6)

• 12- to 14-Fr Foley catheter with 30-mL balloon, umbilical clamp and padding

• Red rubber (in and out or Robinson) soft catheter(s)

• Bite block

• 3-inch dental gauze roll

• Umbilical tape or heavy silk (nonabsorbable) sutures, two pieces at least 18 inches long each

• Petroleum jelly (Vaseline) or other lubricant

• Phenylephrine 2% or oxymetazoline 0.05%

• Epinephrine 1 : 1000

• Local anesthetic such as lidocaine 2% to 5%, benzocaine 14% spray or 20% solution, or tetracaine 2%

• Gowns, gloves, and face shield as necessary for clinician to follow universal blood and body fluid precautions

• Chux or towels

Figure 78-4 Nasal sponges. A, Pope pack. B, Nasal sponge with airway (Merocel 2000 4.5 cm).

(A and B, Courtesy of Medtronic Xomed ENT, Inc., Jacksonville, Fla.)

Figure 78-5 Rhino Rocket nasal sponge system.

(Courtesy of Shippert Medical Technologies, Centennial, Colo.)

Figure 78-6 Nasal balloon device. The Medtronic Xomed EpiStat I (pictured) is a double (anterior and posterior) balloon catheter. The EpiStat II is a posterior balloon catheter with anterior soft packing attached. It also contains an airway and can be used for bleeding from an indeterminate site, whether posterior, anterior, or both. If posterior bleeding stops, the balloon catheter and airway can be removed, leaving the anterior packing in place.

(Courtesy of Medtronic Xomed ENT, Inc., Jacksonville, Fla.)

Technique

Patient and Clinician Preparation

1 Obtain vital signs and address any significant vital sign abnormalities. Apply pulse oximetry (vasoactive drugs will be used; packing can provoke the nasopulmonary reflex with subsequent decreases in oxygen saturation).

2 Have the patient sit back on a procedural chair or gurney with the head elevated approximately 45 degrees. Gown and drape the patient appropriately; the patient can also be given an emesis basin. While getting the patient positioned, ask which side started bleeding first and which side is currently bleeding the most. Have the patient continue to apply ice or pressure while the equipment is being assembled.

3 Connect the suction tubing and catheters to wall suction. Don the headlamp. Good lighting is critical to the procedure.

4 Inspect the oropharynx for trauma, or any other abnormality. Plan to inspect the nasal cavity that is not actively bleeding first. If both are bleeding, and the patient cannot state which side started bleeding first, inspect the side of the patient’s dominant hand. Many nosebleeds are caused by nose-picking, and people are less clumsy with their dominant hands. This side will generally be easier to examine.

5 Have the patient blow his or her nose gently to remove any loose clots that may obstruct the examination. Insert the short nasal speculum and open it vertically. Suction any blood or clots and inspect the nasal cavity, specifically looking at the floor, vestibule, turbinates, and septum. Forceps may be helpful for manual removal of large clots.

NOTE: If you are able to get behind the source of the bleeding with the suction tip, the condition can be managed in the office.

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