– Juvenile nasal angiofibromas (JNA) classically present with heavy epistaxis in a teenage male
7. Vascular anomalies
– Hereditary hemorrhagic telangiectasia (HHT) causes recurrent epistaxis from vascular anomalies in the sinonasal mucosa. These telangiectasias lack elastic or smooth muscle and therefore are prone to bleeding and resistant to topical decongestant medications; HHT may also affect the gastrointestinal and pulmonary tracts.
– Hemangiomas or arteriovenous (AV) malformations can present in the nasal cavity.
– Carotid artery aneurysms and pseudoaneurysms dehiscent into the sphenoid sinus can present with a brief, significant but self-limited, episode of epistaxis as a sentinel bleed.
Vascular Contributions
• The nasal mucosa is rich in vascularity.
• External carotid artery (ECA) contributions
1. Internal maxillary artery
– Enters the pterygopalatine fossa (PPF) and branches into the following arteries:
a. Descending palatine
■ Branches into the greater and lesser palatine arteries
■ Helps to supply lateral nasal wall and anterior septum
b. Infraorbital
c. Posterior superior alveolar
d. Pterygoid canal
e. Pharyngeal
f. Sphenopalatine artery (SPA)
■ Most common source of arterial epistaxis
■ Supplies the turbinates, lateral nasal wall and surrounding sinuses, and the posterior septum
2. Facial artery
– Terminal branch at the superior labial artery
a. Supplies anterior septum and anterior floor of nose
• Internal carotid artery (ICA) contributions
3. Ophthalmic artery
– Enters into the orbit through the superior orbital fissure and branches:
■ Traverses the roof of the ethmoids in a posterolateral to anteromedial direction
■ May be contained within the bony skull base or in a mesentery hanging from the skull base (more prone to injury causing iatrogenic epistaxis and possible orbital hematoma during sinus surgery)
■ AEA can typically be identified on coronal CT scan, one slice posterior to the globe with a bony triangular evagination of the medial orbital wall (Figure 11–1).
b. Posterior ethmoid artery (PEA): enters from the orbit into the nose through the posterior ethmoid foramen (located ~36 mm posterior to lacrimal crest and ~6 mm anterior to the optic canal)
– These two arteries cannot usually be embolized due to risk of blindness and stroke so should be managed with surgical ligation if they are the source of epistaxis.
• Kisselbach’s plexus
1. Located within the septal mucosa covering the anterior cartilaginous nasal septum
FIGURE 11–1. Coronal CT scan demonstrating location of AEA inferior to the skull base (arrows indicate bilateral AEA).
2. Responsible for the majority of epistaxis (>90%)
3. Anastomotic area of vessels with contributions from both the ICA and ECA
• Woodruff’s area
1. Venous plexus located in the posterior nasal cavity along the lateral nasal wall near the root of the inferior turbinate
Anatomic Classification
• The most important step in management of epistaxis is identifying the exact site of bleeding.
• Careful examination with an endoscope will allow for accurate characterization of bleeding in most cases.
1. Suctioning old clots and debris is necessary for proper visualization.
2. This step in work-up will allow for targeted therapy at the site of bleeding, as opposed to an ineffective and complication producing “shotgun” technique of applying cautery or packing to the entire nose.
• Anterior epistaxis
1. Thought to be the source in ~95% of epistaxis cases, with the majority occurring near Kisselbach’s plexus
2. Tend to present as smaller or slower bleeding episodes that respond to anterior pressure unless comorbidities are present
• Posterior epistaxis
1. Although less frequent, posterior bleeds tend to be arterial in nature and result in brisk bleeding.
2. The majority of posterior bleeds are from branches of the SPA.
3. A heavy posterior arterial bleed can quickly lead to airway compromise and significant blood loss.
Classification of Bleeding Type
• Just as important as defining an anatomic location is determining an arterial versus venous bleed.
• Contrary to popular belief, anterior epistaxis may still be arterial, arising from the AEA or greater palatine artery via the incisive foramen.
• Distinguishing arterial bleeding from venous bleeding may significantly alter treatment plans.
Laboratory Tests
• In minor bleeds, no laboratory tests are necessary.
• In heavy or recurrent episodes, a complete blood count and bleeding profile may be warranted.
• In patients on anticoagulation, it is helpful to know their PT/PTT/INR levels, and with newer anti-platelet therapies now on the market, whether their anticoagulant is a reversible or irreversible agent.
• Patients with hematologic malignancies or those undergoing chemotherapy may have thrombocytopenia, thus predisposing them to epistaxis.
• In patients with family history of epistaxis, laboratory tests to evaluate for more rare familial disorders (hemophilia, etc) may be warranted.
Hypertension
• The relationship between hypertension and epistaxis is poorly understood.
• In certain situations, extreme hypertension may manifest itself as epistaxis; more often, however, a patient’s blood pressure tends to become elevated when epistaxis occurs, causing an increase in blood loss.
• If the blood pressure is significantly elevated, treatment is warranted.
Initial Considerations
• The majority of epistaxis episodes are mild and self-limited.
• When heavy uncontrolled bleeding occurs, prompt treatment is vital.
1. Airway protection is paramount.
2. If an arterial nosebleed causes airway compromise, strong consideration should be given to securing the airway prophylactically.
3. Early vascular access and intravenous fluid administration is important.
4. A type and screen should be obtained.
• The patient should be seated with a forward lean to prevent blood from entering the airway and also to prevent the patient from swallowing a large amount of blood, which will lead to eventual emesis.
1. A Yankauer suction should be provided to evacuate clots from the oropharynx.
2. Topical decongestant medication should be applied and hard pressure held over the cartilaginous portion of the nose for at least 5 to 10 minutes.
• Universal protective clothing should always be worn, including a facemask; the risk of bloody contamination from patient coughing or suctioning is high.
Evaluation
• Examination should be carried out with both a speculum and headlight, as well as endoscope.
1. Simple anterior sites of bleeding may be visualized and treated with a speculum.
2. Endoscopes are useful for more posterior bleeds and to ensure that other etiologies or sources are not missed.
– Endoscopic exam is crucial in young males with epistaxis to rule out the presence of a JNA.
3. Old clots should be carefully evacuated with a nasal suction to allow adequate visualization.
– Identifying the specific site of bleeding is the most important step in treating epistaxis.
4. If bleeding is too brisk to identify the exact site accurately, the suspected area may be temporarily packed with a cottonoid, soaked in decongestant, to slow the bleeding; it can then be removed and the area re-examined.
Nasal Cautery
• In simple anterior bleeds, silver nitrate cautery may be carried out under headlight or endoscopic guidance.
• Cautery should be focal.
1. Cauterizing multiple opposing sites in one nasal cavity may lead to synechiae formation.
• In general, bilateral cautery on opposing sides of the nasal septum is avoided due to risk of perforation from lack of vascularity to the cartilaginous septum.
• Avoidance of accidental cautery of skin of the ala or nasal sill should be avoided by visualizing the silver nitrate stick entering the nose with the endoscope.
• If available, electrocauterization may also be considered but is generally less tolerable in the awake patient.
Nasal Packing
• If bleeding is uncontrolled or too brisk for cautery, nasal packing is an option.
• If possible, packing should also be directed at the specific site of bleeding.
• Absorbable packing
1. A number of commercially available products are available for use.
2. Many products are designed to stimulate the coagulation cascade to control bleeding as opposed to traditional packing techniques largely designed simply to apply direct pressure.
– Available products include microfibrillar collagen, oxidized cellulose, and human-derived thrombin solutions.
• Non-absorbable packing
1. Non-absorbable packing is useful when cautery and/or absorbable packing has failed.
2. Again, the packing should be directed at the site of bleeding whenever possible.
3. The traditional material of choice was layered ribbon petroleum-impregnated gauze; this has largely fallen out of favor, however, due to its time-intensive nature and patient discomfort.
5. A variety of balloon-type packing is also available; these products tend to be easily inserted but cause significant patient discomfort when expanded; designs are available for anterior or anterior/posterior balloon packs.
– Another option for posterior bleeding is a Foley catheter balloon. It is passed through the nasal passage and inflated in the nasopharynx and seated forward towards the choanae; it is then secured anteriorly. If necessary, an additional pack can then be placed anterior to it.
– It is imperative to protect the nasal ala from pressure necrosis while the Foley is in place and secured with an anterior clip.
– A posterior balloon pack carries the risk of stimulating the nasopulmonary reflex causing hypercarbia and hypoxia; therefore, hospital admission, with continuous pulse oximetry and telemetry, is recommended.
6. Although controversial as to the necessity of this measure, most physicians prescribe prophylactic antibiotics while packing is in place to help prevent secondary sinusitis and theoretically reduce the risk of toxic shock syndrome.
Medical Interventions
• Control blood pressure and control pain that could cause elevation in blood pressure.
• If patient is on a reversible anticoagulant and is experiencing life threatening bleeding, a reversing agent should be given.
• If significant blood loss has been sustained, whole blood and platelet or clotting factor transfusion should be given based on respective laboratory values.
• If patient is undergoing treatment such as chemotherapy that is causing recurrent life threatening epistaxis, modulation of therapeutic course should be considered.
Surgical Management
• Endoscopic SPA ligation (ESPAL)
1. This technique has been shown to be very effective in managing posterior arterial epistaxis.
– A mucosal flap is elevated back to the crista ethmoidalis.
– The SPA is identified and ligated with a clip or electrocautery.
a. It is crucial to ensure that all branches are addressed (Figure 11–2).
b. Some authors recommend entering the medial PPF to ensure the artery has not branched before entering the SPA foramen.
– The use of ESPAL as first-line treatment for posterior arterial epistaxis has been shown to increase patient comfort and reduce cost compared to posterior packing with hospital admission.
• AEA and PEA ligation
1. If the site of bleeding is suspected to arise from the AEA or PEA, endoscopic or open approaches can be utilized.
– Lynch incision
FIGURE 11–2. Endoscopic view of two branches of SPA exiting the sphenopalatine foramen.
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