Holly E.

Stevens,

MD, FRCSC

Epistaxis
SUM
MAR
Y
Good

author
describes
practical
managemen
t of
epistaxis

RESUM
E
II est

essentiel
d'avoir en
sa

equipme ,

possession

nt,

un

particula

readily rly for

availab acute
le, and problems

equipement
approprie et
un plan

therapeutiq

organiz in the
ed
emergency

ue organise

managem room.

reussir a

ent are (Can Fam

essenti Physician

controler

al for

provoquer

success

d'exacerbat

1990;
36:75
7ful
control 760.)
of

si l'on veut

l'epistaxis
sans

ion du
traumatisme
subi par le
patient. On

epistax

subdivise

is

l'epistaxis

without

en deux

exacerb

categories:

ating
the

localise et
systemique.
De

patien

nombreuses

t's

conditions

trauma.

differentes

Epistax
is most

peuvent en
etre la
cause.

commonl

L'auteu

results

decrit

from

un

localiz
ed
causes

plan

de
traitem
ent
pratique

but can

de

reflect

l'epist

systemi

axis,

applica

disease
. The

ble
particu

liere

lemes

salle

ment

aigus

d'urgen

aux

rencontr

ce.

prob

es en

k_
__
_k
~~
~~

Key medi
wordcine
s: ,
episotol
taxiaryn
s, golo
famigy
ly
par
t

D tim
r e,
Dep
. art
men
St
of

t
e Su
v rg
e er
n y,
s Un
iv
er
i si
s ty
of
H Br
e it
a is
dh
Co
o lu
f
mb
t ia
h,

e Va

Di
vi
si
on
of

Ot
ol
ar
yn
go
lo
gy
,
Uni
ver
sit
y
Hos
pit
al,

nc
ou
ve
r.
Re
qu
es
ts
fo
r
rep
rin
ts
to:
Dr.

Ho
ll
y
E.

St
ev
and
is en
Ass s,
ist Sh
ant au
Pro
gh
fes
sor ne
,
ss

e. Good
y
Ot equipmen
t and a
ol
ar calm, organized
yn
go approach
are
lo
essentia
gy
l for
Cl
in successf
ic ul rapid
control
,

ren

'

loc

al

cau

ses

cou

ld

be

cau

sed

by

an

un

trauma to

de

the

rl

yi

ng

bl

t
i
o
n
.

E
t
i
o
with l
450
minimum
0
o
Oak
g
St
., patient.
y
Va Epistaxi
s can re-

nc
ou
ve
r,

sult from

either
localized
or

au
se
s
of

B.C
systemic ep
.

V6
H
3N
1

disease is
and has ta
many xi
causes
that

E should be

s
ca
n

PIST consider
be
AXIS ed in the
is

global

freq

manage-

uent

ment.

ly

This

an

article

u
r

f
r
e
q
u
e
n
t

di
so
rd
er
,
but
thi
s
unu

sua

fi

l.

ed

The

as

un

de

or

xis, em

u
t
o
t
h
e
r

and ant-ly in (T

doct the acute ab

or emergency le
situa-

ng

si

t sy

room

di

is

ent predomin ic

alik

ee

for ofepista st

pati

as

ing practica
l
l
cond
itio managemen

cl

alar discusse
lo
s the
mca

~~~
~~~
~~~
~~~
~i

1)

p
a

rl
yi
ng
dis
ord
er
is
mos
t
lik
ely
a

plat sub

elet tle

usua young

diso clot
rder ting
or a defe

ct,
beca
use

the
more

com
mon
and
seve
re
type
s

-ease of

un

at

be

ca

us

th

are

is

re

ad

il

accompa- os

vi

si

bl

an

P
r
lly males
sugg that can e
est appear
s
the
as
e
dia
epistaxi
n
gno s,
sis should
t
,
be
kept a
es- in
mind
t
peci
when the
i
ally
epistaxi
in a
s
is o
chil
profuse n
d.
A
nas

and

al

nied

usua

or

with

ep

lly

nas nasal

diag

oph obstruc ta

nose

ary tion,

xi

nge even

are

d by
the
time
a
pati
ent
with
epis

is

our very

te

ib

in

ri

le

or

Thi

is

is

es

the

fr

om

an

rare

tumours.

adu 2
lt

an

can

ar

app

the

ear

occurs

phy

as

sic

epi

ian

sta

xis

Ifep

but

ista

usu

x-is

all

is

in
th
older e
paan
tients te
with or ri
withou or
in
t

the

acc

ng
sign
ofbl
ood

dys
cra
-sia
or
blee
ding

dis
ord
er,
othe
r
phys
ical
sign

ce

st

enti

ac

are an

though

ts

pres

tum they

al

visi

is

Most
often
epista
xis

taxi

fir

omp
ani
es
oth
er
sym
pto
ms.

Nas
oph
ary
nge
al
ang

of
chr

oni

ant

b
a
c

ten in
pt
winter
al
when
re
poorly
gi
humidi
on
fied
,3
interi
Li
or air tt
dries le
the
's
mucous ar

sit

hypert fe
ension ri
,
of- or
se

ss

eri
or

epi

'

s-

tax

is,

l
e
x
u
s
.

whi
ch
con
sis
ts

of

uni

lat

era

memea
branes
,
ibr
wh
oma .

ic

bi-

lat

re

era

iof

s,
a
dis

Clin
ical

l
or

pr

it

recu spon

sen when the ac

is

rren tane

con

sid

mino
r
blee
ds

that
ofte
n

stop

pre refore

exact

ti

ousl

bet site

is ca

y or

wee not

are

cont

epi ied,

roll

sod is

ed

es. importa es

identif pu
it rp
os

A nt

acu

to

tel

cut careful

e,

by
the

pat
ien
t.
This

ly

pack

oft beneath
en

such

pro obstruct
fus ions.
e,

The

ant ethmoid
eri vessels
cause

or

of

ble epistax

epi

ed- is

sta

ing the

is
most

fre
que

lat
ion
.
The
se

pat
ien
ts
oft
en

ble

ed-

so
ur
ce

r
s

in
g

lar
ger

fro g caused
d
m a by

te

nas

al

sit fracture

bra

nch

es

of

the

in

te

rn

al

max

ill

ary

art

ur

Bleedin

often

ca

af
te
r

th

or
ben these
ou
eat ves-sels
gh
but
can
h a
occur at an

sep

tur

ipu

ior

and

man

ter

di

Pos

ca

lts

ita

ee

or

dig

lo

adu

by

bl

ior

fro

ed

in

vat

be

from

can nasal
occ vault.

spu

ra-

es

tal

agg

ter

th

rs

be

pos

ot

occu

can

be

com

hid occurs
den from

als

to

in

but

nn

dren

ere

nt
chil

if

ng

form

xis

bin
ate
,
mak

any site te
of

ri

direct

or

mucosal

ex

trauma,

am

especia in
lly

to at

the

io

turbi-

n,

nates.

Fortu

ing nately,
direct

vis
ual

posterior

epistaxi
s,

which

is

if
it

n
x
r
a
t
h

pe

rs

is

ts

af

usually

te

more

ad

eq

ua

te

an

te
oss is
also
ri
i- less

iza
tio
n
dif
fic
ult
or

imp

severe
and

al-

ways more
difficult
to
manage,

ble common.
.
For
The

ery
or
fro
m
the
eth
moi
d
art
eri
es.
Thi
s
for
m
is

ge
ne
ra

ll

or

pa

pr

obl em

in

people ar

olde whose

IC Vol. 1
9
IA 36:
N APRIL 9

CA M.
N. PH
FA YS
are

can

arterioscle

severe

rotic

life-

and

be
and

threatenin

brittle.4

to

Failure

g.

good

intravenou

control

epistaxis
with

an

line

should

be

secured and

anterior
pack

can

lead

the

inexperienc
ed

te

physi-

cian

to

diagnose

hemoglobin
sample
drawn.
Rare-ly

patient
will

posterior

require

bleed, when

transfusio

the

n.

real

problem

is

an

inadequatel
y

packed

anterior
In

such

cases

the use of a

Foley

Have

epistaxis

(Figure 1).
Replenish

fail.

supplies

Pract
ical
Manag
ement

after every

of

use

regularly
to

of

fol-lowed by

investigati
on
the

often
loss
a

real threat,
but

hemorrhage

vital

for
success,
especially
in

more

bleeds when
calm,

organized

situation.

not

is

clinical

is

This

major

appropriate

blood

complete.

foresight

hemorrhage,

Most

ensure

that it is

involves

to

the

tray

epistax-is
control

or

check

acute

headli
ght or
mirror
;
*

bayone
t
forcep
s;
* #9
Fraser

suction
tip and
suction

source
;

approach is
mandatory.
The
equipment
needed
includes
the

nasal

will

management

following:

scisso
rs;

equipped

catheter

Proper

75
7

nasal
specul
um;

tray

also

es

Epist
axis
Tr-ay
well-

nose.

kidney
basin;

ery

if

used.

nose

Once

available)

for

24

hours.

bleeding

Thereafter,

sufficient.

slows,

the

Al-ways

cauterize

should

the

gently apply

is

often

the

suction

source

patient

with

antibiotic

of clots to

silver

ointment two

identify

nitrate,

or

three

the

pressing

times

daily

firm-ly

for the next

free

nose

exact

bleeding
A

source.

over

the

one

to

two

five-minute

bleeding

weeks.

application

site.

Petroleum

of

Smearing

cotton

jelly

pled-get

the

soaked

over

squeezed

wide

area

with

will

cause

topical

muco-sal

for

anesthetic

trauma

but

term

and

will

not

prophylaxis.

vasoconstri

stop

the

ctor (4% to

hemor-

and

stick

rhage.
Suction

10%

will

cocaine)
will

slow

bleeding
and

should

provide

be

necessary
during
applicatio
n
ifbleeding

adequate
anesthesia
for cautery

is

active.

Suction

(1%

cautery

phenylephri

units

ne

excellent

on

are

cotton

for

followed by

pur-pose.

this

topical

With

xylocaine

electrocau

spray

tery,

can

do
cau-

be used if

not

cocaine

terize

is

not

deeply;

available).

this

Rarely
infiltrat
ion
of
0.5
to
1.0 mL of
xylocaine
with
adrenalin
e
might
be
necessary,
especiall
y
if
electroca
utery
is

cause

too

can

septal
perforatio
n.

Apply

topical
antibiotic
ointment
and
instruct
the
patient
not
touch

to

the

area

or

blow

the

ointment
used

moming

and night is
sufficient
long-

When

10

mg

of

take

specific

morphine

effect,

bleeding

intramuscul

prepare

arly, which

nasal

will

also

ing.

help

to

point

on

the
anterior
septum

pack-

Petroleum

control

jelly

transient

iodoform

or

cannot

be

hyper-

gauze

viewed

or

tension. It

(2.27

is

is

or 1/2") is

bleeding

important

too

to

suction

clotted

profusely
to respond
to

blood

from

the

nose

cm,

thoroughly
coated

with

antibiotic
ointment,

thoroughly

chemical

then

in order to

cautery,

be-tween the

localize

when

or

bleeding

is too far

site

posterior

finger
and

provide
anesthesia.

adequate

Apply

access

cotton

with

pledgets

cautery,

soaked

in

anterior

4%

nasal

cocaine.

to

packing is

They

required.

placed

Anteri
or
Nasal
Pack

along

Reassura
and

10%
are

the

nasal floor
well
posteriorly
, along the
inferior
tur-binate,

calm,

and

well

organized

into

the

approach

nasal roof.

are

very

important
to

instil

pa-tient
confidence
and

co-

They
provide
anesthes
ia
and
topical
va-

be-cause

soconstr
iction,

most

and

patients

help
to
slow
or
even
stop
bleeding
.

operation

are

frightened.
Ex-plain
what you are
doing.
Particularly
anxious

can

given

can

While
allowing

patients
5

time

for

be

the

to

thetic

thumb
that

better

for

nce

index

the

bleeding

drawn

anesto

and
so

* #10 Foley catheter;

* 10-mL syringe;
* #2 silk ties;

* real cotton gauze (7.6 cm * 7.6 cm, or

3" * 3") squares (or lambs-wool);

* cotton pledgets;

* antibiotic ointment;
* silver nitrate cautery sticks;
* paper tape (2.27 cm, or 1/2");
* petroleum jelly gauze packing (2.27
cm, or 1/2") or iodoform gauze (2.27

cm, or 1/2");
* rubber gloves; and

* topical anesthestic and decongestant

agents (4% or 10% cocaine solution

or xylocaine spray and 1% phenyle-

phrine).

These

supplies

should

be

assembled and kept together as a

package.
and

good

Ade-quate
suction

illumination
is

extremely

important.

Cautery

When epistaxis arises from Little's

area, chemical cautery (or electrocaut-

Table 1
Etiology of
Epistaxis
Local
Mucosal disruption
Desiccation
Digital trauma
Spontaneous rupture
Chemical irritation

Systemic
Hematologic disorders
* Vascular;

(hereditary telangiectasia)

* Platelet disorders;

(thrombocytopenic purpura or

drug-induced)
Mucosal inflammation * Coagulation defects;
Acute or chronic infection
(hemophilia,
Allergic congestion
Von Willebrand's disease, or
drug-induced)
Anatomical deformities
Deviated septum or septal spur Blood dyscrasias

Septal perforation

Foreign body
Tumours

Benign (juvenile angiofibroma)

Malignant
Nasal or facial
trauma

Source: Reprinted with

permission of The
Physician and
Sportsmedicina
copyright McGraw-Hill,

Hypertension
Arteriosclerosis

Other chronic diseases

Inc.1
7
5

CAN
.

FAM.
N Vol. 36:
PHYSICIA APRIL 1990

packing

it

is

flatten
ed
and
orderly

in

layers,

e,

and

hemor-

packing

as

rhage

will

far

not

posteriorly

controlled.

as

Alterna-

the

be

for
easiest

bayonet

tively,

forceps

applica
tion.

packing

will

might

reach,

out or into

If

along

bleeding

na-sal

continues

floor.

after

the suction

removing

or

the

the

pledgets,

to

firmly

advance the

and

gently

compress

suction

each lay-er

poste-

riorly

in

the nose to
localize
it.

Try

to

de-termine
whether

it

before

When

it

is

no

longer

possible to
packing,

generally

feed

it

high in the

into

the

nose

nasal roof.

the

Remember

ethmoid

area or more

that

inferiorly

are

(usually

packing

from

the

lateral
wall).

It

the

nose,

pinching
the

nostrils
together.
This

apextra

and

helps

to

main-

tain

you

the

packing.

the

is

from

Always

tape

pressure

next.

layer

x.

plies

applying
the

the

nasopharyn
Use

bayonets

the

slip

Instruct
the

patient
avoid

to

physical
activity,
very

hot

showers,

the

and

bony

nose.

No

amount

of

consumption
of

hot

nasal

beverages

from below a

packing in

until

turbi-nate

the

packing

or

vestibule

removed.

can

arise

septal

spur. It is

will

best to have

effective

the

if

be
the

patient's

posterior

head

nose

inclined
slightly
forward

to

prevent
the

throat,

them

to

cough

and

oral

most

error.

If

nasal

packing
is

too

loosely

placed,
pressure

Begin

will
the

to

common

interpacking.

somewhat

is

choke,
rupting

A
at

bedside

ly packed.

This

is

helps

inadequate

the

causing

the

relieve

the

bleeding
through

is

steamer

the

be

inadequat

Figur
e 1
Epist
axis
Tray

dryness

until

caused

tip

by
breathi
ng
through

seen

the
mouth.
The

the
is

just

below

the

common
cause

of

"posterior"

epistaxis
in the non-

specialist

is clamped
at

the

distal end

palate,

to provide

instilling

tension.
A

approximat
ely 10

most

hemostat

mL

Foley

catheter

ofsaline,

will

and

sometimes

then

pulling

not control

back

the

gently

bleeding.

until

Again

resistance

problem

is

is

met.

often

an

Too

much

saline

the

improperly
placed

's hands is

causes

inadequate

excessive

anterior

pain,

nasal pack-

dysphagia,

ing,

and

anterior
pack.
Altemativel
y,

resulting

possibly

posterior

in

tissue

gauze

ne-

pack

continued

crosis.

can control

bleeding

The

bleeding

down

the

pharynx. In
this case a

posteri-or
pack

will

also

fail.

If

the

source

of

bleeding is
very

far

posterior,
however,

catheter

when

should

be

held by an
assistant

pressure

anterior
packing

is

keeping

contour

the

the

catheter

posterior

on

choana bet-

the

be
at

applied

by

the

Use
Posterio
r

bleeding

can

be

controlled

by
a

placing
Foley

catheter
through the
nostril
into

the

nasopharynx

Figur
e 2

nostril,
without
causing
erosion
the

of

alar

rim.

It

is

usually
wrapped
with

gauze
roll

to

protect
the

ala.

An
umbilical

clip
small

of

It

secured

Cathe
ter

the

ter.

floor.
must

pack alone.

it

placed,

be

anterior

because
fits

cannot

an

not,

perhaps

nasal

sufficient

catheter
will

while

Foley

or

Posteri
or Pack

Poste
rior
Nasal

the

force

the

Pack

gauze

pack

difficult,

the

especially

Posterio
r

gauze

packs

are

by

made

folding
7.6

7.6

other

block. It is

hand

is

also

used

to

technically

into

very

nasopharyn

if

x.

The

administrat

silk

ends

or has never

are

then

seen the pro-

used

to

the

secure

the

cedure

demonstrate

cm

(3"*

3'")

real

tying them

gauze

pad,

Therefore,

around

if re-ferral

pack

by
a

tied in the

gauze

middle with

at

#2

-nostril,

silk

the

after

leaving
the

roll

ends

long.

second

inserting
the
anterior

The

strand

of

silk

is

tied to the
first

single
piece

of

silk,

2).

the
A

catheter

is

to

proper

length,
hangs down

placed

in

through the

phar-ynx

nose

to

on the

an

otolaryngol
ogist is an
alter-

native,

it

certainly

oth-er

trimmed

(Figure

to

is

packing.

single

d.

the

recommended.

With

any

type
ofposterior
packing,
hospitalizatio
n

is

necessary.
Whereas

be

topi-cal

side of the

grasped

antibiotics

bleed

with

are

and

brought

forceps

through

for

the

moval

pharynx
into

rior

later.

mouth.
The

with

of

pack

the
the

sufficient
re-

pack

is

or

placement
of

tied to the

posterior

end

packs

of

the

catheter
silk
While

pulling the
catheter
back

through the
the

index

finger

of

oral

antista-

phylococca
l
antibiotics
are

painful
for

strands.

nose,

is

very

with the two

packs,
intravenous

The
gauze

ante-

the

required

patient

with

unless good

posterior

anesthesia

packing.

is

These

achieved,

patients

usually by

also become

greater

palatine
nerve

hypoxic

at

night,

so

40%

Once
catheter is

passed

throug

pack

into

is

nasopha just below

-rynx. palate
to
Trailin be
grasped

nose

hanging

and

tied

brought

to

out

and

mouth,

pulled

of

pack
silkremoval.

is

left

FA
M.

CA
N.
oxygen

piecefor

PHY IAN 36: APRIL

SIC Vol.
1990

by

mask

it

is

always

in

usually

centres

occurs

but

stops

ly.

Swallowing

is

often

After

pack

ointment is

so provide

applied

in-

the
for

fluids

next

as

necessary.
Posterio
r

nasal

to
nose

travenous

the
week.

for 48 to 72

the

nose

hours.

and

the

of

Foley

nasopharynx

catheter can

one to two

be left in,

weeks after

should
deflated

after48
hours

if

there

has

been

no

pack
removal,
when

the

nose

has

healed

and

palatal
edema

further

It

has

settled. It

bleed-ing.
is

is
important

reinflated

to ex-clude

if

underlying

necessary;
other-wise,

disease

it

is

that

removed

24

requires

hours later.

further

Ante-rior

management.

packs

are

usually left
in place for
72

hours.

Other
Tools

Special

Pack removal

ly

is
unpleasant,

designed

and

nasal

an

analgesic is
recommended
before-hand.

Warn

the

patient that

always

applied
certain

to
ar-

eas, such as
inferior

or a

nation

be

not

to

turbinate

thorough

exami-

but

adequate

pres-sure is

should have

is

Unfortunatel

usually left

packing

spe-cialist.

Patients

and

can be used

removal,
antibiotic

difficult,

some

by the non-

spontaneous

given.

759

some oozing

catheters
or

sponges

(Figure

3)

are
preferred

Figure
3
Nasal
Balloo
ns

septal
spur, so
that
bleeding
persists
or
recurs.

mucosa

cover-age

with

while nasal

secondary

packing is

dysphagia.

in place.

In
elderly

patients,
nocturnal
confu-sion
suggests
hypoxia.

Comp
lica
tion
s

Check
blood
gases

and

provide an
appropriat
e

An

con-

centration

overfilled

of oxygen.

balloon

Later

causes

complica-

exces-sive

tions

pain,
dysphagia,

mucosal

and
dysarthria.
If

patient
of a lot of
re-

move I to 2
mL

of

saline.
Dislodgemen
t

trauma
from gauze
packing or
pressure

complains
pain,

can

include

or

necrosis
of

the

nasal

or

nasopharyn
geal
mucosa
from

an

overfilled

posterior

catheter.

slippage

Bad ulcer-

ofan

ation

anterior

the

pack

skin

into

of
alar
can

the pharynx

occur from

may

an

occur.

After

incorrectl

spraying

the pharynx

catheter

with

and

xylocaine

re-sult in

to

permanent

prevent

simply
cut

ary
and

offthe

strand
Mouth

drying

sinusitis
an

obstructed
ostium

breathing
can

maxillary
from

ofpacking.

the

Second

can

grasp

can

scarring.

gagging,
one

secured

cause
of
oral

and
pharyngeal

should

be

pre-vented
by
appropriat
e
antibiotic

~~~~~
~~~~~
~~~~~
~~~~~
~~~~~
~~~~~
~~~~~
~~~~~
~~~~.
.....

Delayed

The

or

Med 1988;

prolonged

successfu

symptoms,

such

as

management

foul

of

postnasal

epistaxis

discharge,

requires

can

good

indicate

equipment

this

problem. X-

understan

ray

ding

examination

nasal

anatomy

will

not

always

be

acute

an

of

and blood

beneficial

supply,

because

and

there

could

still

be

organized

blood

in

ap-

the

sinus,

which

will

create

an

calm,

al-though

tube

when

orifice can

does,

(rarely)

arterial

become

ligation

obstructed

is

it

4. Shaheen
MacKay

IS,

necessary.
U

Conc
lusi
on

1968:281
(Head and
neck; vol
1).

Epistaxi
s.
In:

causing

loss.

Anatomyfor

OH.

from edema,

hearing

WH,

and Row,

fails,

conductive

3. Hollings
head
ed.

packing

eusta-chian

and

1977;
6(3):22432.

Hagerstown,
MD:
Harper

rarely

otitis

Otola)yn-gol

Nasal

level.

serous

2.

Doyle
PJ, Riding
K.
The
management
of
nasopharyn
geal
angiofibro
ma.
J

sur-geons.

proach.

air-fluid
The

16(12):31
-40.

Bull
eds.

TR,

Rhinology.

Refe
renc
es
1. Stevens

H.
Epistaxi
s in the
athlete.
Phys

Spor-ts
~ ~

London:
Butter-

worths
Co.,

and

1987:272-82

(Kerr

AG,

ed.

ScottBrown's
otolaryngo
logy; vol
4).
~~~~..
.....

..

CAN. FAM.
PHYSICIAN Vol. 36:
APRIL 1990

76