Initial Assessment

The amount of blood loss should be estimated (the physician should ask about whether the patient has lost enough to soak a handkerchief, a facecloth, or a towel; the last would indicate a significant loss), and over what period (a regular minor bleed can cause anemia). A clinical assessment of the patient’s cardiac status and circulating blood volume should include looking to see if the patient is pale, sweating, or cool, or has tachycardia; any of these findings would indicate significant hypovolemia. A reduction in blood pressure is often a late sign, particularly in young people, who can maintain blood pressure until the circulatory volume is critical.

Obtaining intravenous access, checking for and correcting any clotting abnormalities, and taking blood for “group and save” and/or crossmatching may be required. In our unit patients admitted via the emergency department can be “fast-tracked” to the otorhinolaryngologic emergency unit if stable (Box 45-1). This practice helps avoid unnecessary and counterproductive nasal packing in the emergency department as well as transfer of patients before they are fit enough to travel.

First aid measures include asking the patient to apply constant firm pressure over the lower (non-bony) part of the nose for 20 minutes and to lean forward with the mouth open over a bowl so that further blood loss can be estimated. Otherwise, blood dripping postnasally will be swallowed, and the next warning sign of a serious loss could be several hundred milliliters of blood being vomited up.

It is important to establish both the site and the cause (Box 45-2; Figs. 45-6 to 45-12) of bleeding. The philosophy of this approach can be summarized as follows:

Figure 45-6. Endoscopic view in Wegener’s granulomatosis.

Figure 45-7. Postoperative severe epistaxis that has not been stopped by packing. Endoscopic investigation has determined that bleeding is coming from the septal branch, which was cut by sphenoidotomy performed on the right side.

Figure 45-8. Pyogenic granuloma on the septum, right side nasal vestibule.

Figure 45-9. Endoscopic view of an angiofibroma occluding the right nasal cavity and choana.

Figure 45-10. Squamous cell carcinoma of the right nasal cavity originating from the septum and occluding the olfactory cleft and middle meatus.

Figure 45-11. Septal perforation causing epistaxis and crusting.

Figure 45-12. Total septal perforation causing epistaxis and crusting in a patient with cocaine abuse.

The clinician must remember that epistaxis is frequently idiopathic but can be a manifestation of a possible underlying pathology (see Fig. 45-12). Your patient should undergo further investigation according to the history.

Headlamp Examination Using Local Anesthesia—Initial Overview

The key to controlling most epistaxis is to find the site of the bleeding, and although chemical cautery with silver nitrate can be used, bipolar diathermy is more effective for stopping the bleeding. Protection from blood contamination is important. A plastic apron for both parties is helpful in order to avoid staining of clothes, and eye protection is advisable if there is active bleeding because some patients have a reflex to blow away any fluid dripping down the upper lip, which can create a bloody aerosol. Once the clots have been sucked out, the nasal airway should be inspected, initially with a headlamp and then, if the bleeding point cannot be located, with an endoscope.

Epistaxis in Children

Young children usually bleed from a vessel just inside the nose at the mucocutaneous junction on the septum, and the bleeding invariably stops spontaneously. In children with epistaxis in whom no prominent vessel can be seen, the regular local application of a cream can help,¹² but petroleum jelly (Vaseline) alone does not.¹³ A Cochrane Collaboration systematic analysis of the efficacy of topical treatments for idiopathic epistaxis in children concluded that the best treatment still must be defined.¹⁴ As many as 5% to 10% of children with recurrent nosebleeds may have undiagnosed von Willebrand’s disease.^15,16 Children who have leukemia or are undergoing chemotherapy often have epistaxis associated with thrombocytopenia. Older children, adolescents, and adults often bleed from Little’s area or a maxillary spur.

Epistaxis in Adults

The caudal end of the septum, where several branches of the external and internal carotid anastomose in Little’s area or Kiesselbach’s plexus, is the most common site of bleeding in adults.¹⁷ Less commonly bleeding, comes from further back on the septum, and a septal deviation may make it difficult to visualize (Fig. 45-13). Some patients with seasonal allergic rhinitis complain of more nosebleeds in the hay fever season, and topical nasal steroids aggravate the bleeding in approximately 4% of users. Many people believe that a nosebleed signifies a release of pressure and may herald a stroke, and it is important for the clinician to address these anxieties for the patient. Although many patients are found to be hypertensive during nosebleeds, few remain so on follow-up. The association between hypertension and epistaxis is disputed.¹⁸ Many clinicians report that hypertension is not related to nosebleed.^19–21 However, nosebleeds in patients with hypertension are more likely to lead to admission and to be associated with comorbidity.²²

Figure 45-13. Endoscopic view of the bleeding site on the septum in epistaxis, just opposite the left middle turbinate in the olfactory cleft.

Bleeding disorders can manifest de novo as nosebleeds, although this situation is rare. A range of drugs has been linked with epistaxis, warfarin being one of the most common.^3,23 Nearly a third of patients admitted with epistaxis who were taking warfarin had an international normalized ratio (INR) value above the upper limit of the therapeutic range.²⁴ The need to reverse anticoagulation is uncertain as long as the INR value is within the therapeutic range.²⁵ In over-anticoagulated patients, fresh frozen plasma, clotting factor extracts, and vitamin K help. Vitamin K takes more than 6 hours to work, however, and it can delay anticoagulation for 7 days after warfarin is started. If the INR value is greater than 4, the warfarin should be stopped, and fresh frozen plasma given.²³ Clotting factor extracts should be given with extreme caution because of the risk of thromboembolic complications. Tranexamic acid, an antifibrinolytic agent, has not been shown to help.²⁶ Other drugs associated with bleeding are aspirin, which interferes with platelet function for up to 7 days, clopidogrel, and nonsteroidal anti-inflammatory drugs.^27,28 In patients who do not have a history of a bleeding disorder or undergoing anticoagulant therapy, routine clotting studies do not add to the management.^22,24 There is a higher incidence of epistaxis in patients with a high alcohol intake, even when there is no laboratory evidence of a coagulation abnormality.^29,30

Topical Treatment

A randomized controlled trial of silver nitrate cautery with topical antiseptic nasal carrier cream versus topical alone showed both to be effective.³¹ A study of patients applying weekly triamcinolone 0.025% and daily petroleum jelly reported that 89% of patients had no further bleeding.³² Various hemostatic compounds have been used but without consistent evidence of their efficacy. Collagen-derived particles with bovine-derived thrombin have been found to be better than nasal packs.³³

Cautery

Most anterior epistaxis can be controlled with identification of the bleeding point and cautery using a headlamp. The vast majority of posterior bleeding sites can be identified by endoscopy without the use of general anesthesia.³⁴ The majority of posterior idiopathic bleeds are from the septum, usually from the septal branch of the sphenopalatine artery as it runs submucosally (Fig. 45-14

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