Epistaxis
Listen along to our third episode for a concise and comprehensive review of a clinical approach to epistaxis!
Show Notes
Hey everyone and welcome to The Oto Approach, a podcast created by medical students for medical students, to teach you about all things otolaryngology. I'm your host Aileen, and today we're going to talk about an approach to epistaxis. Tag along for a discussion about this common otolaryngology presentation, and stick around to hear some high yield tips at the end.
Introduction:
So what is epistaxis? It is more commonly referred to as a nosebleed and is thought to account for about a third of all otolaryngology-related emergency department visits (Tunkel et al, 2020).
Epistaxis occurs in about 60% of the population. However, only around 6% of those with epistaxis will seek medical attention (Tunkel et al, 2020). It is more common in males (Kucik and Clenney, 2005) and follows a bimodal distribution, which means that it occurs most often in the younger and older populations, in this case being under 10 and over 50 respectively (Kucik and Clenney, 2005).
Epistaxis can be classified as either an anterior bleed, or a posterior bleed (Fried, 2020). Anterior bleeds are by far the more common of the 2, and account for at least 90% of bleeds. Classically, they originate in an area called Kiesselbach's plexus (also known as Little's area) which is on the anterior nasal septum (Tabassom and Cho, 2020).
One of the reasons most epistaxis occurs at the Kiesselbach’s plexus is because it is a “watershed” of the terminal branches of 5 main vessels (Tabassom and Cho, 2020). Another reason is the tight tissue in this area, so there isn’t much room to stress the tissues before they break and bleed (Pasha, 2018). In addition, the Kiesselbach plexus is located at the entrance of the nasal cavity, and is therefore exposed to extreme heat, cold, high moisture, low moisture, and is subject to physical trauma (Tabassom and Cho, 2020). The 5 main vessels include the anterior ethmoidal artery, the posterior ethmoidal artery, the sphenopalatine artery, the greater palatine artery and the superior labial artery (Kucik and Clenney, 2005).
Posterior bleeds are a lot less common, but are more likely to need medical attention (Tabassom and Cho, 2020). They are often more commonly seen in older patients (Tunkel et al, 2020). Posterior bleeds usually originate overlying the vomer bone at the posterior septum, laterally on the inferior or middle turbinate (Fried, 2020) They tend to occur at Woodruffs plexus, which is made up of the sphenopalatine and ascending pharyngeal vessels (Pasha, 2018). Woodruffs plexus is located posterior to the middle and inferior turbinates, on the lateral wall (Pasha, 2018).
Causes:
Firstly, it is important to note that approximately 40% of nosebleeds are considered idiopathic (Smith et al, 2019). However, of the known causes of nosebleeds, the two most common are digital manipulation, (which could include nose blowing and picking), and drying of the mucosa in the nose (Fried, 2020). In fact, a study in the maritime provinces of Canada found that epistaxis episodes vary seasonally, with the highest number of cases occurring during the winter when the weather is colder and less humid, or drier (McMullin et al, 2019). This is thought to be because the thin mucosa of the nasal cavity is more susceptible to drying in less humid weather, and therefore, is more susceptible to micro-abrasions resulting in epistaxis (McMullin et al, 2019).
Causes of epistaxis can be divided into local causes and systemic causes, and the list is quite extensive. As mentioned, digital manipulation is a common cause of epistaxis. Other examples of local causes include a deviated septum, septal perforation, trauma, chronic use of nasal cannulas, chronic sinusitis, rhinitis, intranasal polyps or tumours, or foreign bodies (Tabassom and Cho, 2020; Kucik and Clenney, 2005).
Some examples of systemic causes of epistaxis include hypertension, alcoholism, coagulopathies, and vascular malformations (Tabassom and Cho, 2020). Epistaxis can also be caused by environmental factors, such as cigarette smoke and allergens, or certain medications (which will be discussed in the history taking portion of the episode) (Tabassom and Cho, 2020).
Rare Causes of Epistaxis:
Hereditary Hemorrhagic Telangiectasia, referred to commonly as HHT or Osler-Weber-Rendu syndrome, is a known genetic bleeding disorder in which some blood vessels develop abnormally (Centers for Disease Control and Prevention, 2020). Epistaxis is the most common sign of this disorder due to the presence of small abnormal blood vessels within the inner layer of the nose (Centers for Disease Control and Prevention, 2020). It is important to be aware of this condition because it can also affect vessels within the brain, lungs, and liver, and there are usually no warning signs before rupturing (Centers for Disease Control and Prevention, 2020). Therefore, if recognized early, such as from frequent episodes of epistaxis, the condition can be diagnosed and treated early (although there is no definitive cure for the condition) (Centers for Disease Control and Prevention, 2020). Usually, this treatment should begin with conservative measures, and then move to medical therapy, followed by surgery if necessary (Chin et al, 2016). Bevacizumab, which is a vascular endothelial growth factor (VEGF) inhibitor, is a recent advance in medical therapy for HHT, and has been shown to decrease both the frequency and severity of epistaxis in HHT patients (Chin et al, 2016). When considering surgical therapies for this condition, a stepwise approach should be taken, which escalates as needed in order to balance the treatment of the patient while minimizing the risk of septal perforation (Chin et al, 2016).
Septal perforation is another somewhat rare cause of epistaxis (Downs and Sauder, 2020). It is a full-thickness, bilateral, defect of the nasal septum, and it usually occurs along the anterior cartilaginous septum (Downs and Sauder, 2020). Symptoms other than epistaxis include, whistling, rhinorrhea, obstruction, crusting chronic rhinosinusitis, pain, and/or a foul smell (Downs and Sauder, 2020). Septal perforation can have autoimmune, iatrogenic, infectious, or neoplastic etiology (Downs and Saunder, 2020). Additionally, steroid or vasoconstrictor nasal sprays, or intranasal drug abuse can also cause septal perforation (Downs and Saunder, 2020). We will touch a bit more on intranasal drug abuse later in this episode!
Juvenile nasopharyngeal angiofibroma, or JNA is an uncommon, locally invasive but benign vascular tumour (Tunkel et al, 2020). These tumours often present with persistent severe or recurrent unilateral epistaxis, essentially exclusively in adolescent males (Tunkel et al, 2020). These tumours are usually managed surgically (Tunkel et al, 2020), and because of their vascular nature, are typically managed by a fellowship-trained surgeon.
Presentation:
Most of the time, this one is going to be pretty obvious. You’ll have a patient with, well, blood coming out of their nose! However keep in mind that some posterior bleeds can be more insidious , and may not present with visible blood (but we’ll get to that a little later). There are some RED FLAGS you should keep in mind when assessing a patient: Hypovolemia, hemorrhagic shock, anticoagulant drug use, cutaneous signs of a bleeding disorder, bleeding not stopped by direct pressure or vasoconstrictor-soaked pledgets, and multiple recurrences with no clear cause (Fried, 2020). These require further investigation (Fried, 2020). And as always, keep in mind that if a patient looks unwell, CALL FOR HELP.
History:
Taking the History of Present Illness, or HPI, should include questions such as i) what was the initial presentation of the bleeding; ii) have there been any previous epistaxis (including time and number), and if so, how were they treated; iii) are there any comorbidities, such as coagulopathies (Kucik and Clenney, 2005)? Some associated symptoms to ask about include symptoms of a URI, sensation of nasal obstruction, and nasal or facial pain (Fried, 2020).
Review of Systems should look for symptoms of excessive bleeding (Fried, 2020). This could include bleeding while brushing teeth, excessive bruising, bloody or tarry stools, hemoptysis, or hematuria (Fried, 2020).
When taking the Past Medical History, known bleeding disorders in the patient or the patient’s family should be identified (Fried, 2020). Additionally, any conditions which can lead to defects in platelets or coagulation, should also be identified (Fried, 2020). This could include cancer, cirrhosis, HIV, and pregnancy (Fried, 2020).
It is especially important to ask about use of medications, including over-the-counter medicines, and herbal and home remedies (Kucik and Clenney, 2005). This is because many medications can be the cause of the nosebleed. It is also important to ask when the patient last took their medications.
Some medications to look out for include, NSAIDs (such as ibuprofen, aspirin), anticoagulants (such as warfarin), platelet aggregation inhibitors (such as clopidogrel), topical nasal steroid sprays, supplements or alternative medications (vitamin E, ginkgo, ginseng), or illicit drugs (such as cocaine) (Tabassom and Cho, 2020). Stay tuned for a clinical pearl about epistaxis and cocaine at the end of the episode!
Make sure to ask patients about alcohol and recreational drug use when taking their social history (Tabassom and Cho, 2020).
Physical Exam:
As with all physical exams, begin with reviewing the vital signs, noting hypotension or signs of intravascular depletion (Fried, 2020). When doing a physical exam for epistaxis, you should simultaneously attempt to stop, or at least control, the bleeding (Fried, 2020). Local anesthetic and epinephrine may be used as they cause vasoconstriction, which will help control bleeding (Tabassom and Cho, 2020). In general, the physical exam should look for signs of bleeding disorders (Fried, 2020).
A head lamp is usually used for illumination (Tabassom and Cho, 2020; Fried, 2020).
The patient should be in a seated position, and a speculum can then be carefully inserted, and its blades can be slowly opened to identify the site of bleeding (Tabassom and Cho, 2020). If the bleeding site is anterior, it should usually be apparent on direct examination (Fried, 2020). However, if no site is found, and there have been only few and minor nose bleeds, no further examination is necessary (Fried, 2020). Alternatively, if no bleeding site can be identified, but the bleeds are recurrent and/or severe, nasal endoscopy should be done (Fried, 2020).
As you can imagine, a posterior epistaxis is not as easily visualized as an anterior epistaxis, so it may be assumed based on active bleeding into the posterior pharynx (Tabassom and Cho, 2020). In fact, the diagnosis of posterior bleeding is often made when methods of controlling anterior bleeding have failed (Tabassom and Cho, 2020).
In all cases, a nasal endoscopy greatly increases the chances of identifying the bleeding site (Tabassom and Cho, 2020).
Treatment:
First and foremost, assess the patient’s ABCs (Airway, Breathing, Circulation). Again, if there are signs of airway obstruction or hemodynamic instability (syncope, diaphoresis, skin pallor), notify your staff immediately (Seikaly, 2021)! Treat these patients as a trauma: order a CBC, start an IV to get the patients intravenous fluids and ensure you are wearing a gown, mask, and faceshield before you examine the patient.
Now- the important concept to recognize with epistaxis management is that the majority of anterior bleeds can be managed by pressure! This can be applied externally initially, and if that fails, then more invasive internal means should be considered. Initial management of epistaxis is always very important to discuss with both patients and providers that call for assistance with management of epistaxis. A few things we always discuss for initial management:
Lean forward and pinch the soft part of the nose with direct pressure
Apply this pressure continuously for 20 minutes (don’t release!)
If after 20 minutes the bleeding continues when the pressure is released, apply a topical decongestant such as Otrivin
Lean forward and pinch the soft part of the nose with direct pressure for another 20 minutes
For patients that have not yet come to hospital, if this has not stopped the bleeding, this is when you should come to a hospital (or if you’re unsure and need help!)
For health professionals with experience in managing epistaxis (something all ED docs should be comfortable with), this is when the search for vessels that can be cauterized in the plexus should be considered, followed by local/epi and an anterior pack if necessary
Often this has all been done before otolaryngology is involved, but a big part of the otolaryngologist’s job is patient education including on prevention of further events and how to manage a nosebleed at home. People frequently think they are supposed to hold the hard part of the nose and lean back - this can be very dangerous.
Now we will get into the more otolaryngology specific management of epistaxis. You may not necessarily be the one performing the following procedures. Always ask your staff what they are comfortable with you doing, to help guide your next steps in any clinical encounter.
If the patient is stable, ask for an epistaxis tray, which should include nasal decongestant and local anesthetics, silver nitrate cautery stick, nasal speculum, Frazier suction tip, packing material (gauze, merocel, inflatable balloon), and syringe (Kucik et al, 2005).
Anterior Packing: Usually, when otolaryngology is consulted for epistaxis, topical vasoconstrictors and anterior packing has already been attempted and was unsuccessful. However, you should attempt anterior packing again to ensure proper technique. Before packing, ensure adequate anesthesia with topical lidocaine (Seikaly, 2021). If you can identify the source of the bleed, attempt chemical cautery with silver nitrate sticks (Seikaly, 2021). There are various ways to do anterior packing including non-adherent gauze containing petroleum jelly (xeroform), nasal tampon (merocel), or inflatable balloon (Rapid Rhino) (Seikaly, 2021). The type of packing is dependent on resource availability and local practice. The packing should generally be left in place for 2 to 3 days (Seikaly, 2021). Merocels will need to be removed within 72 hours to reduce the risk of toxic shock syndrome. Patients should return to the provider who performed this for removal. A common anterior packing method that is used is a dissolvable method whereby surgi-foam is wrapped in surgicel and applied with vaseline - patients do not need to return for packing to be removed. Similar to Surgicel, FloSeal is a dissolvable hemostatic agent that is very effective for addressing many types of bleeds.
Posterior packing: Although posterior packing theoretically drains into the oropharynx, these patients will very often present with bleeding through the anterior nose. Putting in a posterior pack is the last part of the epistaxis algorithm prior to invasive measures like embolization or surgery. Similar to anterior packing, ensure adequate anesthesia prior to beginning. The various ways to do posterior packing include placement of a foley catheter with gauze, or a commercially available pack, such as an epistat (Simon et al., 2016). Again, the method is dependent on resource availability and local practice. Placement of a foley catheter with gauze is the most commonly used method. It involves advancing a lubricated foley catheter tip through the nose until the tip and balloon are in the nasopharynx. The balloon is then inflated until it is firmly against the posterior nasal choana. The foley is held in place with a metal clamp, so it’s important to remember to place a soft surface such as gauze between the clamp and the nose to prevent pressure necrosis of the nasal ala. However, the foley alone is often not adequate. The inflated foley balloon now allows the Otolaryngologist to pack the nose with ribbon gauze, without it falling posteriorly into the airway. These patients need to be admitted to hospital for 3 to 5 days and be put on antibiotics to prevent toxic shock syndrome from the prolonged placement of nasal packing (Toronto Notes 37th ed.).
If anterior and posterior packing fails, the next 2 options to consider are endoscopic sphenopalatine artery ligation, or embolization by interventional radiology (Seikaly, 2021). Deciding between these two will depend on patient factors, as well as the resources and expertise at your hospital.
Prevention:
When the bleeding is controlled, it is also important to identify and manage the underlying cause of the bleed. This may involve getting other specialists involved such as hematology to manage coagulopathies, cardiology to adjust anticoagulants, and family physicians to manage hypertension. If triggers or irritants are known, such as digital manipulation or vigorous nose blowing, the patients should be instructed to avoid these triggers. Lastly, saline spray, humidifiers, or topical ointments can be given to prevent drying of nasal mucosa (Toronto Notes 37th ed.).
Final Tips and Tricks:
Interestingly, cocaine is both a cause and a cure for epistaxis! Okay well- maybe not so simple! Cocaine is a potent vasoconstrictor and analgesic, which is why 4% cocaine soaked nasal pledgets are sometimes given as a topical treatment for epistaxis (Richards et al, 2017). However, nasal insufflation of cocaine crystals can cause mucosal damage, progressive nasal obstruction, and epistaxis with crusting (Trimarchi et al, 2001). Cocaine induced lesions can even cause destruction of the bone and cartilaginous structures of the nose, sinuses, and palate (Trimarchi et al, 2001). Remember when we talked about septal perforation in the rare causes of epistaxis section in this episode? Cocaine can be a cause of this! By eroding the nasal septum, the nasal cavity can become quite dry which leads to further epistaxis. Therefore, it is extremely important to ask your patients about any illicit drug use. Patients may be hesitant to disclose this information, so it is important to ensure that you ask this in a non-judgmental manner.
It is important to remember some of the important rare causes of epistaxis discussed in this episode, including Hereditary Hemorrhagic Telangiectasia (HHT), Juvenile nasopharyngeal angiofibroma (JNA), and septal perforation! Although they’re rare, it is important to diagnose and treat these conditions!
It is also important to remember that epistaxis can be very dangerous. It can be lethal if not managed properly in patients that are frail or have significant comorbidities. Therefore, a structured algorithm should always be adhered to, and epistaxis should always be taken seriously.
Thank you so much for listening to our podcast!
We would like to extend our sincerest thanks to the Saint John Regional Hospital Department of Surgery within the Horizon Health Network for their generous support. Please head to our website at www.theotoapproach.com for our show notes, and to sign up for our newsletter to stay up to date with our latest episodes.
References
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