An update on epistaxis
Stephanie Yau
E
Background pistaxis is a challenging and common palatine and sphenopalatine arteries (SPA).
condition. The lifetime incidence of These contribute to Keisselbachs plexus
Epistaxis is one of the most common epistaxis is difficult to determine, but and supply up to 80% of the nasal vault.
ear, nose and throat (ENT) emergencies has been reported to be as high as 60%. The facial artery is the second major branch
to present to general practitioners However, only a very small proportion of the external carotid to supply the nose,
(GPs). The management of epistaxis has
requires specialist management.1 Many which also contributes to Keisselbachs
evolved significantly in recent years,
patients self-manage this condition as it plexus.
including the use of nasal cautery and
is often spontaneous and self-limiting.
packs. Successful treatment requires
They present to their general practitioner Classification
knowledge of nasal anatomy, and
(GP) only when the condition changes or Epistaxis is most commonly classified into
potential risks and complications of
treatment. worsens. Application of proper first aid is anterior or posterior bleeds. This division
often all that is required. Patients rarely lies at the piriform aperture anatomically.
Objective need to be transferred to a hospital with the More than 90% of episodes of epistaxis
aim of being treated by an ear, nose and occur along the anterior nasal septum,
Epistaxis is often a simple and readily throat (ENT) specialist. As most episodes which is supplied by Keisselbachs plexus
treatable condition. However, given the are minor, the GPs role is important in a site known as the Littles area.2 The
potential consequences of a significant in recognising signs and symptoms Keisselbachs plexus is an anastomotic
bleed, GPs should have an understanding suggestive of more sinister medical network of vessels located on the anterior
of the causes, potential risks and
conditions. cartilaginous septum. It receives blood
emergency management.
The management of epistaxis has supply from both internal and external
evolved significantly in recent years. carotid arteries.
Discussion
Successful treatment requires knowledge Approximately 10% of episodes of
Epistaxis can be classified into anterior of the possible causes of epistaxis and a epistaxis are posterior bleeds. Posterior
or posterior bleeds, the former being detailed knowledge of nasal anatomy. bleeds are most commonly arterial in origin.
the most common. Anterior bleeds can It presents with a greater risk of airway
often be treated with cauterisation with Anatomy compromise, aspiration and difficulty in
silver nitrate sticks, provided there is The nose has a rich vascular anatomy with controlling the haemorrhage.1
good preparation, correct equipment multiple anastomoses. The arterial supply Epistaxis can also be divided into
and assistance close at hand. If there is arises from branches of both the internal primary or secondary. Primary causes
a lack in any of these aspects, prompt and external carotid arteries (Figure 1). account for 85% of episodes and are
use of nasal packing and referral to an
The ethmoidal arteries, branches of the idiopathic, spontaneous bleeds without any
emergency department or a specialist
internal carotid, enter the nose superiorly notable precipitant. Bleeds are considered
ENT service is recommended.
and supply the upper extremes of the secondary if there is a clear and definite
septum and lateral nasal wall. The facial cause (eg trauma, anticoagulant use, post
and the internal maxillary artery are the surgical).3
two branches involved in the supply of the
nasal cavity and are part of the external Aetiology
carotid. The internal maxillary divides into The cause of epistaxis can be divided into
six branches and includes the greater local, systemic, environmental, medications
The Royal Australian College of General practitioners 2015 REPRINTED FROM AFP VOL.44, NO.9, SEPTEMBER 2015 653
CLINICAL AN UPDATE ON EPISTAXIS
or, in the majority of cases, idiopathic.1 bleeding diathesis and alcohol. Epistaxis Other factors, such as alcohol, have
Approximately 714% of the adult can occur in any age group, but also been shown to increase the risk of
population will have experienced epistaxis predominately affects the elderly (5080 epistaxis. Studies found patients who
at some point in their life.3,4 A thorough years of age) and children (210 years of present with epistaxis were likely to
history and examination are vital in assisting age). If an adolescent patient presents with have consumed alcohol within 24 hours
with clinical decisions regarding further epistaxis, it is important to consider other of hospitalisation. This relationship is
investigations and management. causes such as cocaine use or juvenile thought to be related to decreased platelet
nasopharyngeal angiofibroma.6 Juvenile aggregation and prolonged bleeding time.5
Local nasopharyngeal angiofibroma is a benign
Local causes of epistaxis include trauma, tumour that can bleed extensively. Other Environmental
neoplasia, septal abnormality, inflammatory symptoms suggestive of this condition The number of presentations of epistaxis
diseases and iatrogenic causes. Local include nasal obstruction, headaches, has been found to increase during the
trauma is common among children who rhinorrhoea and anosmia.6 dry winter months, often associated with
present with post-digital trauma or irritation. Patients with hereditary haemorrhagic changes in temperature and humidity.7 The
Causes such as neoplasia are uncommon. telangiectasia can present with epistaxis incidence of epistaxis is also related to
However, eliciting significant signs and refractory to usual treatment methods.4 circadian rhythm, with peaks in the morning
symptoms is important. Uncommon causes, It is also common for patients with and late afternoon.4
such as neoplasia, need to be ruled out other bleeding disorders, such as Von
through a thorough history and examination. Willebrands disease, to present with Medications
Red flags for neoplasia include:5 recurrent epistaxis. Further laboratory The use of many over-the-counter
unilateral nasal blockage testing and consultation with a physician and prescribed medications can alter
facial pain may be warranted if a bleeding diathesis is coagulation. Nonsteroidal anti-inflammatory
headaches suspected.4 drugs (NSAIDS), warfarin, clopidogrel
facial swelling/deformity The association between hypertension and the increasingly popular oral factor X
South-East Asian origin (nasopharyngeal and epistaxis is often misunderstood. inhibitors are commonly used medications
carcinoma) Hypertension is rarely the direct cause that can affect clotting. It is imperative,
loose teeth of epistaxis, and is perhaps related to therefore to take a thorough medication
deep otalgia. underlying vasculopathy in this group history. The use of complementary
of patients. It has been suggested that and alternative medicine must also be
Systemic hypertension may be related to anxiety, considered. Their use is increasing and
Examples of the systemic causes of but studies have failed to find conclusive can interfere with regular medications and
epistaxis include age, hypertension, evidence.3 clotting.3
History
What to ask about
Clinical stabilisation, including the control
of significant bleeding, should always take
priority over obtaining a lengthy history.
Questions should focus on the history of
the acute episode and previous episodes,
including duration, severity, frequency and
laterality of bleed.1 Patients with posterior
epistaxis can often bleed from both nostrils
and it can feel as though blood is dripping
down their throat rather than their nose.
The methods they used to control previous
episodes are significant from an education
perspective. It is unfortunate that pinching
over the nasal bones, rather than the soft
cartilaginous tip, remains commonplace.
Figure 1. Blood supply to the nasal septum It is important to ask questions about
haematemesis and malaena. Upper
654 REPRINTED FROM AFP VOL.44, NO.9, SEPTEMBER 2015 The Royal Australian College of General practitioners 2015
AN UPDATE ON EPISTAXIS CLINICAL
The Royal Australian College of General practitioners 2015 REPRINTED FROM AFP VOL.44, NO.9, SEPTEMBER 2015 655
CLINICAL AN UPDATE ON EPISTAXIS
then be packed anteriorly, using materials Risks with this procedure are rare, but escalate into a medical emergency.
such as Kaltostat or ribbon gauze to include blindness, decreased lacrimation, Simple procedures and principles can be
tamponade any potential anterior bleeds. local infection, infraorbital nerve injury, effective in managing epistaxis until the
The clamp and Foleys catheter must be oroantral fistula, sinusitis and epiphoria.9 patient can be treated in hospital. For
regularly reviewed by the nursing staff as most patients, simple first aid is all that
there is a risk of pressure necrosis on the Embolisation is required to control this, often self-
nasal tip. It is recommended that insertion Angiographic embolisation in epistaxis is limiting, condition. However, this requires
of a Foley catheter be performed only by a another method of controlling bleeding. the general public and those prone to
clinician who has been trained in this skill. Access to the vascular system through a nosebleeds to have the correct education
The use of nasal packs can have femoral punch leads to identification of the regarding this condition. Advances in
complications. Oral antibiotics are usually bleeding point. A catheter is then placed the management of epistaxis will allow
prescribed as a prophylactic measure in the internal maxillary artery and the it to continue to evolve to an outpatient
against toxic shock syndrome while the bleeding vessel is embolised. The success managed condition. This therefore leads to
packs are in situ.4 The duration and use of rate of this procedure is high, although not financial and patient benefits.
oral antibiotics is consultant, clinician and without risk. Major complications such as
Author
department dependent. Given that this cerebrovascular accidents and blindness
Stephanie Yau MBBS, ENT Non-training Registrar,
condition is rare, there is little convincing can occur in up to 4% of cases.2 It remains The Townsville Hospital, Townsville, QLD.
evidence in the literature around the a strong alternative to SPA ligation in stephstephyau@gmail.com
use of prophylactic antibiotics. Other posterior epistaxis for patients who are Competing interests: None.
Provenance and peer review: Not commissioned,
complications from the use of nasal packs medically unfit for general anaesthesia, or externally peer reviewed.
include acute sinusitis and obstruction of who have had a failed SPA ligation.
the nasal airway, leading to sleep apnoea References
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Endonasal ligation of the SPA is the hot foods, strenuous activity, digital
most specific and currently the most trauma and nose blowing on discharge
widely used technique.8 Studies have from hospital. Patients should also be
shown that ligation of the SPA can control prescribed a topical ointment such as
98% of posterior epistaxis.10 Patients Kenacomb, Nasalate or paraffin for 7 days.
are placed under general anaesthetic, an This ensures moisturisation of the nasal
incision is made at the lateral nasal wall, mucosa and reduces the risk of bleeding
a mucosal flap is raised, and the SPA recurrence.
is identified. The vessel is then clipped,
divided or coagulated with diathermy. Conclusion
Recognising variations in the anatomy is Epistaxis continues to be a common
important in the success of this procedure. presentation to GPs and can quickly
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