Epistaxis

Gordon H. Sun and Allen M. Seiden

History

A 39-year-old man arrived in the emergency department complaining of intermittent epis-taxis over the past 2 days. These episodes previously resolved on their own with a moderate amount of pressure applied to the anterior nose for about 5 to 10 minutes, with occasional use of oxymetazoline applied by nasal spray. However, this particular episode was much more severe; anterior nasal pressure reduced but did not completely staunch the flow of blood, and the patient could feel blood trickling down the back of his throat. He reported having had this episode of epistaxis for more than 2 hours before arrival in the emergency department.

His medical history was significant for recently diagnosed mild hypertension, not yet medically treated by his primary care provider. He also carried a diagnosis of idiopathic thrombocytopenic purpura (ITP), although the patient could not recall how he was discovered to have that condition initially. He denied a personal history of stroke, peripheral vascular disease, or previous episodes of easy bruising or bleeding, other than the recent epistaxis. There was no history of trauma to the nose, nor did he have a previous surgical history. He was a nonsmoker. The patient denied a family history of epistaxis or bleeding diatheses. He was not taking any medications.

On physical examination, the patient was awake, alert, and able to speak clearly, although he reported feeling increasingly light-headed during the examination. He was tachycardic, but his blood pressure was within normal limits. Oxygen saturation levels were normal. The patient was not stridulous. Rhinoscopy revealed active bilateral epistaxis, with a moderate amount of fresh blood and clots in the anterior nasal cavity, precluding visualization of the posterior nares despite repeated suctioning. The source of the epistaxis could not be identified anteriorly. Oral cavity and oropharyngeal examination demonstrated significant amounts of blood coursing down the posterior pharyngeal wall. No friable or hypervascular lesions were seen within the oral mucosa, lips, or face.

Differential Diagnosis—Key Points

1. The blood supply to the nose originates from both the external and internal carotid systems. The external carotid artery supplies the facial and internal maxillary arteries, the latter of which terminates in the sphenopalatine artery. The sphenopalatine artery enters the nasal cavity through a foramen on the posterior lateral nasal wall. This artery is well known as a major potential source of posterior epistaxis. The internal carotid artery feeds into the ophthalmic artery, which itself branches into anterior and posterior ethmoidal arteries that supply the upper lateral nasal wall and septum. The source of most nose bleeds is the Kiesselbach plexus or the Little area, found on the anterior nasal septum, and supplied by the sphenopalatine, greater palatine, superior labial and anterior ethmoid arteries.

2. Epistaxis has a lifetime incidence of up to 60% in the general population, with less than 10% of all cases requiring medical attention. The condition has a bimodal distribution, peaking in children younger than 10 years of age and adults over 50 years old. Roughly 80% of all cases of epistaxis are anterior. Minor bleeds, which are usually found in the anterior nares, are more frequently encountered in the pediatric population. Severe episodes of epistaxis requiring major intervention, more often originating posteriorly, are seen more often in adults. The distinction between anterior and posterior epistaxis has blurred recently with the introduction of various endoscopic methods of controlling severe epistaxis. Traditionally, anterior epistaxis can be seen on anterior rhinoscopy or controlled with anterior packing. Posterior epistaxis might not be seen easily even with rigid nasal endoscopy because of its tendency to be more severe; thus posterior nasal hemorrhage might be identified only by the necessity for posteriorly based packing to gain control.