Epistaxis

 

• Background

  Aka nosebleed.

  Anatomy

  90% occur in Kiesselbach's plexus (Little's area), where the 5 vessels that supply the septum anastomose:

  • From the internal carotid artery: the anterior and posterior ethmoidal arteries.
  • From the external carotid artery: the greater palatine, sphenopalatine, and superior labial arteries.

  Causes

  • Idiopathic
  • Trauma or anatomical: nose-picking, assault, fall, polyps, nasal surgery.
  • Infection or inflammation: chronic rhinitis, granulomatosis with polyangiitis (Wegner's), TB, syphilis.
  • Tumour: squamous cell, juvenile angiofibroma (recurrent nosebleed in teenage boys).
  • Coagulopathy: warfarin, leukaemia, Von Willebrand disease, haemophilia, hepatic coagulopathy, hereditary haemorrhagic telangiectasia.
  • Hypertension can exacerbate it, but does not itself cause nosebleed.

• Presentation

  • In anterior bleeds, blood runs out of the nostrils, while in posterior bleeds (less common), it runs down the throat.
  • Bleeding may co-present with septal perforation or nasal fracture.

• Investigations

  • Generally only indicated if severe or recurrent.
  • Bloods: FBC, coag, LFT.

• Management

  Achieving haemostasis

  Stepwise approach, proceeding until bleeding stops.

  1. Evaluate for severe haemorrhage and attempt conservative measures:

  • ABC assessment if suspected hypovolaemia.
  • Trotter's method: pinch lower nostrils, sit up, lean forward. Continue 10 minutes.

  2. Topical therapy:

  • Vasoconstriction with adrenaline (via spray or soaked pleget/gauze) ± lidocaine. Also facilitates examination at next step. Oxymetazoline spray is another option, sometimes given in step 1 before initial external compression.
  • Antifibrinolysis with tranexamic acid via soaked pleget/gauze if adrenaline unsuccessful.

  3. Cautery or packing:

  • Look for bleeding vessel – a small red dot – by examining the nose with thudicum's speculum or by lifting the tip with your thumb. Clots should be blown or gently suctioned out, even if this causes re-bleeding.
  • If bleeding vessel identified, cauterise. Topical lidocaine then chemical cautery with silver nitrite sticks (1st line), which cause a chemical burn on reacting with the mucosa, or thermal cautery with uni/bipolar diathermy (2nd line). If there is bilateral bleeding (rare), do not cauterise both sides at once due to the risk of impaired septal supply and perforation.
  • If bleeding vessel not identified or cautery ineffective, insert packing. Packs may contain material which expands (Merocel), or an antiseptic-astringent combo (bismuth iodine paraffin paste, BIPP). May require air or saline inflation.

  4. Further invasive treatments:

  • Foley catheter.
  • Surgical ligation of artery.
  • Embolisation via interventional radiology.

  Post haemostatsis

  If bleeding resolves with initial steps, monitor for re-bleed for 30 mins, then discharge with advice to avoid the following for 24 hours:

  • Blowing or picking nose. If sneezing, keep mouth open.
  • Heavy lifting or straining.
  • Lying flat.
  • Alcohol or hot drinks.

  Patients with prolonged, severe, or recurrent bleeds may require ENT follow up and/or hospitalisation.