Epistaxis Overview and Pathophysiology

Epistaxis

• Epistaxis is a common complaint and often benign
• Most nosebleeds are self-limiting and spontaneous, some are recurrent
• Epistaxis is divided into two categories: anterior bleeds and posterior bleeds
• Anterior bleeds are more common (over 90%) and arise from Little’s area on the septum
• Posterior bleeds arise in the back of the nasal cavity, are usually more profuse, and are often of arterial origin
• Posterior bleeds present a greater risk of airway compromise, aspiration of blood, and greater difficulty controlling bleeding

Pathophysiology

• Bleeding typically occurs when nasal mucosa is eroded and vessels become exposed and break
• The Kiesselbach plexus is located on the septum, where vessels from the internal carotid artery (ICA - anterior and posterior ethmoidal arteries) and the external carotid artery (ECA - sphenopalatine and branches of the internal maxillary arteries) converge
• Anterior bleeds often have a capillary or venous origin and ooze, rather than the profuse pumping of blood observed with an arterial origin
• Posterior bleeds likely originate from branches of the sphenopalatine artery

Contributing Factors

• 90% of epistaxis is due to spontaneous rupture of blood vessels in the Kiesselbach plexus
• Systemic causes include arteriolosclerosis, hematological disorders, and hereditary hemorrhagic telangiectasias
• Local causes include trauma, irritants (e.g., smoking), inflammation of the nasal mucosa, a septal defect, intranasal foreign bodies, paranasal tumors, medications like NSAIDS, anticoagulants, and antiplatelets
• 10% of nosebleeds are idiopathic
• Epistaxis is more frequent in young children and elderly persons, and in males compared to females

Signs and Symptoms

• Most epistaxis has no signs or symptoms other than external bleeding or blood dripping down the posterior nasopharynx

Diagnostic Testing

• No laboratory studies are indicated for minor and nonrecurring nosebleeds
• For substantial or recurring nosebleeds, CBC, including platelet count, bleeding time, prothrombin time, and partial thromboplastin time may be helpful
• INR may be needed for patients on Coumadin
• Type and Cross may be needed for patients anticipated to need a blood transfusion due to blood loss

Differential Diagnosis

• Trauma
• Inflammation due to rhinitis or infection
• Vascular disorders
• Clotting disorders and blood dyscrasias
• Intranasal foreign bodies
• Hereditary telangiectasia
• Tumors

Treatment

• Most episodes of epistaxis are mild and self-limited and resolve spontaneously
• Control can be achieved by pinching the nostrils together for 5-10 minutes, keeping the patient in an erect position with the head tilted forward
• Anterior bleeds not controlled by manual pressure may be controlled with two sprays of Oxymetazolone 0.05% applied directly to the bleeding site followed by 10-15 minutes of manual pressure
• Nares may be packed, if necessary
• Have suction available

When to Refer to ENT

• Bleeding not controlled after 15 minutes of compression
• Evidence of massive bleeding
• Recurrent bleeding within the first hour
• Second episode of epistaxis within 1 week
• Uncontrolled bleeding from the posterior nasopharynx

Patient Teaching

• Avoid NSAID use
• Sneeze with the mouth open
• Avoid hot and spicy foods
• Do not pick at nose
• Avoid hot showers

Considerations for the Geriatric Population

• Patients older than 50 years often have more serious bleeding that requires medical attention
• Anemia can be a complication of frequent or excessive bouts of epistaxis
• Severe blood loss can exacerbate existing diseases
• Assess older patients for dyspnea, chest pain/pressure, and syncope
• Epistaxis in older adults can be a sign of arterial hypertension, cardiovascular disease, or a coagulation disorder