EPISTAXIS

INTRODUCTION

Background

Epistaxis is defined as acute hemorrhage from the nostril, nasal cavity, or nasopharynx. It is a frequent ED complaint and often causes significant anxiety in patients and clinicians. However, more than 90% of patients who present to the ED with epistaxis may be successfully treated by an emergency physician (EP).

Pathophysiology

Epistaxis is classified on the basis of the primary bleeding site as anterior or posterior. Hemorrhage is most commonly anterior, originating from the nasal septum. A common source of anterior epistaxis is the Kiesselbach plexus, an anastomotic network of vessels on the anterior portion of the nasal septum, also referred to as Little's area. It receives blood supply from both the internal and external carotid arteries.¹ Anterior bleeding may also originate anterior to the inferior turbinate. Posterior hemorrhage originates from branches of the sphenopalatine artery in the posterior nasal cavity or nasopharynx.

Frequency

United States

Data may be difficult to obtain on the true incidence of epistaxis due to the fact that not all cases are seen in the emergency department.²  However, when multiple sources are reviewed, the lifelong incidence of epistaxis in the general population is about 60%, with less than 10% seeking medical attention. 

Mortality/Morbidity

• Mortality is rare and is usually due to complications from hypovolemia, with severe hemorrhage or underlying disease states.
• Increased morbidity is associated with nasal packing. Posterior packing can potentially cause airway compromise and respiratory depression. Packing in any location may lead to infection.

Sex

• No sex predilection exists for nosebleeds.

Age

• Bimodal incidence exists, with peaks in those aged 2-10 years and 50-80 years.

Clinical

History

• Controlling significant bleeding or hemodynamic instability should take precedence over obtaining a lengthy history.
• Note the duration, severity of the hemorrhage, and the side of initial bleeding.
• Inquire about previous epistaxis, hypertension, hepatic or other systemic disease, family history, easy bruising, or prolonged bleeding after minor surgical procedures. Recurrent episodes of epistaxis, even if self-limited, should raise suspicion for significant nasal pathology.
• Use of medications, especially aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), warfarin, heparin, ticlopidine, and dipyridamole should be documented, as these not only predispose to epistaxis but make treatment more difficult.

Physical

• Approximately 90% of nosebleeds can be visualized in the anterior portion of the nasal cavity.
• Massive epistaxis may be confused with hemoptysis or hematemesis. Blood dripping from the posterior nasopharynx confirms a nasal source.
• Perform a thorough and methodical examination of the nasal cavity.
  
  • Blowing the nose decreases the effects of local fibrinolysis and removes clots, permitting a better examination. Application of a vasoconstrictor prior to the examination may reduce hemorrhage and help to pinpoint the precise bleeding site. Topical application of a local anesthetic reduces pain associated with the examination and nasal packing.
  • Gently insert a nasal speculum and spread the naris vertically. This permits visualization of most anterior bleeding sources.
• A posterior source is suggested by failure to visualize an anterior source, by hemorrhage from both nares, and by visualization of blood draining in the posterior pharynx.

Causes

• Most cases of epistaxis do not have an easily identifiable cause.
• Local trauma (ie, nose picking) is the most common cause, followed by facial trauma, foreign bodies, nasal or sinus infections, and prolonged inhalation of dry air. A disturbance of normal nasal airflow, as occurs in a deviated nasal septum, may also be a cause of epistaxis.
• Iatrogenic causes include nasogastric and nasotracheal intubation.
• Topical nasal drugs such as antihistamines and corticosteroids, especially when applied directly to the nasal septum instead of the lateral walls, may cause mild epistaxis.
• Children usually present with epistaxis due to local irritation or recent upper respiratory infection (URI).
• Oral anticoagulants and coagulopathy due to splenomegaly, thrombocytopenia, platelet disorders, liver disease, renal failure, chronic alcohol use, or AIDS-related conditions predispose to epistaxis.
• Inherited coagulopathies such as von Willebrand disease, hemophilia A, and hemophilia B.¹
• The relationship between hypertension and epistaxis is often misunderstood. Patients with epistaxis commonly present with an elevated blood pressure. Epistaxis is more common in hypertensive patients perhaps owing to vascular fragility from long-standing disease. Hypertension, however, is rarely a direct cause of epistaxis. More commonly, epistaxis and the associated anxiety cause an acute elevation of blood pressure. Therapy, therefore, should be focused on controlling hemorrhage and reducing anxiety as primary means of blood pressure reduction.  
• Epistaxis is more prevalent in dry climates and during cold weather due to the dehumidification of the nasal mucosa by home heating systems.
• Vascular abnormalities that contribute to epistaxis may include the following:
  
  
  • Sclerotic vessels
  • Hereditary hemorrhagic telangiectasia
  • Arteriovenous malformation
  • Neoplasm
  • Aneurysms
  • Septal perforation, deviation
  • Endometriosis