20 Epistaxis: Surgical and Nonsurgical Management

The nose receives its vascular supply from branches of both the internal and external carotid systems. The anterior and posterior ethmoid arteries are branches of the ophthalmic artery from the internal carotid system (Fig. 20.1). The superior labial artery is a branch of the facial artery that, along with the sphenopalatine artery (SPA), originates from the external carotid system.

Distal branches of the anterior ethmoid artery and the superior labial artery anastomose with branches of the SPA to form Kiesselbach plexis, a vascular region of the anterior septum (Fig. 20.1). The majority of anterior nasal bleeds, which account for greater than 90% of all nasal bleeds, arise from this anastomotic region. Bleeds from this area are typically easier to manage than posterior bleeds and may be treated with targeted cautery, direct pressure, and nasal moisturization regimens.

The majority of posterior epistaxis arises from branches of the SPA, the terminal branch of the internal maxillary artery (IMA), which is the primary vascular supply to the posterior nasal cavity. Identification of the bleeding site is more difficult with posterior epistaxis and bleeds from this area are more frequently refractory to conservative treatment.

The anterior and posterior ethmoid arteries supply the superior portion of the nasal cavity. Overall, these vessels are less common sources of epistaxis, except in patients with recent facial trauma or recent sinonasal surgery.

Evaluation of Epistaxis

Appropriate treatment for epistaxis depends on the cause and severity of the bleed. Most patients suffer from primary epistaxis or spontaneous bleeds without a clear cause. Primary epistaxis may be exacerbated by medications, herbal supplements, and underlying medical conditions such as hypertension and atherosclerosis. Some patients presenting with epistaxis will have a clear identifiable cause for their bleeding such as a tumor or blood dyscrasia.

Medical History

Initial evaluation of patients requiring treatment for epistaxis should focus on the possible underlying disorders that may result in secondary epistaxis or exacerbate primary epistaxis. Patients with unexplained refractory bleeds should be evaluated for the use of anticoagulant medication (see “Medications”) and the presence of leukemia, liver disease, or myelosuppression, all of which can present as epistaxis. Bleeding from other sources such as hematuria and easy bruising can indicate a systemic source for a coagulopathy. A thorough history will also guide laboratory testing, which typically includes a hemoglobin level, platelet count, prothrombin time, and partial thromboplastin time.

A history of nosebleeds including descriptions of the most recent and most severe bleeds will clarify the severity of epistaxis. Anterior epistaxis is commonly related to digital manipulation, blowing the nose, and a drying environment. These episodes are typically unilateral, recurrent, and self-limited lasting less than 5 minutes, though episodes of prolonged bleeding are occasionally seen. Patients will report that bleeding occurs through the anterior nose first and will readily identify the side that commonly bleeds. With posterior epistaxis, bleeding is often noted initially in the back of the throat and episodes are more commonly severe. Although these episodes are frequently profused and prolonged, they stop suddenly related to vascular spasm, only to resume hours later with similar severity.

Medical comorbidities may exacerbate bleeding and increase concern for complications of blood loss. Patients with hypertension may have more difficulty controlling epistaxis. Vascular disease associated with diabetes may result in a loss of vessel contractility and result in prolonged bleeds. Patients with coronary artery disease are at an increased risk of cardiac complications from epistaxis-associated blood loss, and transfusion thresholds should be considered for patients with significant blood loss.

The presence of epiphora (tearing), facial numbness, or diplopia in association with epistaxis should raise concern for tumors of the nose or paranasal sinuses. Patients with nasal tumors or nasopharyngeal carcinoma typically report a more indolent course of bleeding and may have other characteristics of malignancy such as cachexia, weakness, and posterior triangle neck adenopathy. Unilateral ear effusion in an adult can be a sign of a nasopharyngeal mass. Family history may be helpful in identifying coagulopathies or other bleeding disorders such as hereditary hemorrhagic telangiectasias.

Figure 20.1 Vascular supply to the nasal cavity. Vessels supplying the (A) medial and (B) lateral nasal walls originate from both the internal and external carotid systems.
Printed with permission from: Thieme Publishers. Schuenke M, Schulte E, Schumacher U, Ross LM, Lamperti ED. Thieme Atlas of Anatomy: Head and Neuroanatomy. New York and Stuttgart: Thieme; 2007:116; Fig. 7.2 A. Illustrated by Wesker K.

Medications

Medications that interrupt clotting pathways commonly exacerbate epistaxis. Platelet inhibitors such as aspirin, nonsteroidal anti-inflammatory drugs, and clopidogrel have all been implicated as contributors. A study of 10,241 patients in primary care clinics demonstrated an increased frequency of epistaxis in patients taking aspirin or clopidogrel.1 Patients taking aspirin have also been demonstrated to experience more severe epistaxis, more frequently require surgical intervention, and have a higher rate of recurrent bleeds.² Warfarin treatment, which prolongs the partial thromboplastin time, significantly increases the risk of epistaxis. Although the risk of epistaxis in patients taking warfarin is similar to that of patients taking both aspirin and clopidogrel, nose-bleeds in patients taking warfarin are more likely to require hospitalization.³ Many patients taking warfarin who present to the emergency department with epistaxis have an international normalized ratio above their recommended range.⁴

Along with traditional medication history, patients should be queried regarding their use of complementary and alternative medications or supplements. Many alternative treatments have the potential to directly impair clot formation or alter pharmacokinetics of other medications that impair clotting.⁵ Fish oil, gingko biloba, ginseng, ginger, and garlic all inhibit platelet aggregation.

Physical Examination

Vital signs should be taken with specific attention on blood pressure, pulse, and fluid status. Bleeding sites are easier to identify in patients with current or recent bleeding. The extent of blood loss should be evaluated by both the patient’s history and ongoing bleeding. Patients with brisk bleeding and significant blood loss should be evaluated and monitored in the emergency department. Fluid resuscitation and transfusions may be required for patients with extensive blood loss.

A close examination of the anterior nasal septum will often identify an area of bleeding. Mucosal prominences and prominent vasculature can be lightly manipulated with a suction or similar device to unmask bleeding sites and identify a target for treatment. Because manipulation of this nature can initiate a bleeding episode, it is helpful to anticipate such bleeding and have appropriate equipment available.

Stay updated, free articles. Join our Telegram channel

Join