Indications for Managing Epistaxis in the Office Setting
Epistaxis is a common condition that otolaryngologists should be well-equipped to manage with various strategies. Epistaxis can most often be controlled in an office setting. We describe the indications for managing epistaxis in the office setting, techniques for managing epistaxis in the office, and the outcomes and potential complications associated with managing epistaxis in the office. We conclude the chapter with practical information on billing and coding of office procedures for epistaxis management.
There are various intranasal lesions that can present with epistaxis. Rupture of prominent nasal septal blood vessels is the primary cause of epistaxis in both pediatric and adult populations. The vessels of Kiesselbach plexus along the anterior nasal septum are most frequent cause of epistaxis ( Fig. 11.1 ).
Dilated blood vessels within Kiesselbach plexus along the anterior nasal septum.
Hemangiomas are benign vascular tumors classified as either capillary or cavernous that may also be treated conservatively in the office ( Fig. 11.2 ). Capillary hemangiomas are more often found along the nasal septum. They usually occur in the first few years of life and then spontaneously involute, though they can commonly persist into adulthood. Cavernous hemangiomas are more likely on the lateral nasal wall in the adult population with a traumatic etiology.
Capillary hemangioma of the left anterior inferior turbinate.
Telangiectasias are collections of dilated, thin-walled blood vessels and appear as raised red lesions with a lacy vascular network ( Fig. 11.3 ). Isolated, primary intranasal telangiectasias that are not associated with systemic disease are good candidates for in-office cauterization. Lesions that are numerous and diffusely present are likely to be part of hereditary hemorrhagic telangiectasias (HHT). Epistaxis is one of the most common manifestations of this disease entity. Patients with HHT have both flat and raised intranasal telangiectasias that can be associated with significant blood loss and anemia. In severe cases of recurrent epistaxis, medical treatments such as bevacizumab (Avastin), estriol, or tranexamic acid have been used. Packing agents that cause trauma to the nasal mucosa are generally contraindicated in patients with HHT. It is the current authors’ preference that almost all patients with HHT be deferred to operative intervention under general anesthesia.
Intranasal telangiectasia with a raised, lacy broad base. They can appear singularly but more often occur multiply in the setting of hereditary hemorrhagic telangiectasias.
Anticoagulation and/or antiplatelet therapy is associated with recurrent epistaxis, particularly in patients with concurrent nasal dryness, nasal trauma/manipulation, or intranasal corticosteroid use. These patients should be managed conservatively with nasal moisturization and ointments. Those who fail conservative management should be considered for cautery rather than packing. Nasal packing can further damage the mucosa; thus, it is avoided if possible to prevent intractable bleeding. Importantly, anticoagulation therapy should be continued if the bleeding can be controlled. If bleeding is massive and cannot be stopped, a discussion with a hematologist or cardiologist about possible temporary discontinuation is warranted.
Several other patient populations are more prone to epistaxis. These include pregnant women, in whom the prevalence of epistaxis is up to three times greater due to increased nasal mucosal vascularity. , Patients with nasal septal perforations have increased turbulent nasal airflow, which in turn dries and crusts the nasal mucosa, leading to epistaxis. Patients with autoimmune conditions are also prone to epistaxis due to significant nasal dryness, crusting, and septal perforations. Lastly patients on chronic oxygen via nasal cannula often have epistaxis. The nasal cannula prongs can irritate and traumatize Kiesselbach plexus vessels, and the direct application of oxygen can dry the nasal mucosa. Use of face masks or tents, as opposed to prongs, can eliminate this direct contact with the septum. Humidified oxygen is advised.
In patients presenting with epistaxis, a general algorithm can be used as follows. Patients with a discrete, targetable source of epistaxis can generally be treated with an in-office cauterization. Exceptions include patients who are heavily anticoagulated, have HHT, or have other complex co-morbidities. If the root etiology of epistaxis stems more from nasal dryness and crusting, such patients should aggressively hydrate the nasal mucosa. If there is refractory diffuse, nondiscrete epistaxis, nasal packing should be considered.
Additional Considerations and Technique
Once a patient with recurrent epistaxis is identified, additional considerations should be taken into account before offering an in-office procedure. Age is an important factor to consider; in some children, an office procedure may be challenging. Furthermore, an older patient with comorbid conditions such as dementia, who has difficulty understanding the proposed intervention, may not tolerate an office procedure. Patients who poorly tolerate a nasal endoscopy are unlikely to tolerate an office procedure.
Once an appropriate patient is selected for an in-office procedure, it is prudent to have all supplies, tools, and packing materials set up in advance. Everything should be easily and quickly accessible. The current authors recommend setting up the office procedural room as shown in Fig. 11.4 .
Proposed procedural room setup for in-office cauterization.
While the office room is set up, topical anesthetic should be applied intranasally. The current authors’ preference is to place cottonoids soaked in a mixture of oxymetazoline and 1% lidocaine in the nasal cavities. A heavy disposable absorbent drape is used as a bib. The physician and any assistants should be wearing appropriate personal protective equipment, including a mask, eye shield, gloves, and a gown. A zero-degree rigid endoscope with an associated camera head and light source and a video tower to display the endoscopy are ideal. Various-sized Frazier tip suctions (at least 8-Fr and a 10-Fr) should be connected to a suction canister and suction machine.
If cauterization is likely, chemical silver nitrate, bipolar cautery, or monopolar cautery should be in the room and set up. For silver nitrate, one will simply need the silver nitrate applicators. For bipolar cautery, one will need the machine as well as the associated handpiece and foot pedal. For monopolar cautery, one will need the machine as well as the handpiece and a grounding pad to be placed on the patient. In this latter instance, one should inquire whether the patient has any history of metal implants, to avoid placing the grounding pad in such areas. Packing materials such as Nasopore, Surgicel, Fibrillar, Floseal, Merocel, Rapid Rhino, and other preferred epistaxis packing materials should be readily available and easily accessible ( Fig. 11.5 ).
