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Epistaxis

Overview
One of the most common consult requests for the Otolaryngologist is nosebleeds. Over 90% are anterior bleeds that typically stem from Kiesselbach’s Plexus in Little’s Area but true posterior bleeds or sinonasal tumor bleeding will be encountered on occasion. While the etiology of epistaxis is most commonly related to factors such as digital trauma, mucosal dryness, and anticoagulants; underlying pathology including autoimmune conditions, foreign bodies, masses, intranasal drug use, familial blood dyscrasias or various coagulopathies must be considered. The management of epistaxis from the simple common variety to the more complex or urgent is discussed here. These consults are usually received after a non-Otolaryngologist provider has attempted some intervention which has failed to stop the bleeding. These patients are therefore frequently frustrated, anxious, and in pain. Thorough investigation of the location and cause of the epistaxis can lead the provider to a solution that stops the bleed in the most comfortable and efficient way for the patient. There are many ways to treat epistaxis, and with time, personal preferences will develop in how to address different types of bleeds. 

Key Supplies for Epistaxis Management 

• Appropriate PPE including mask, eye protection, gloves, and gown

• Chux pad, emesis basin, tissue for patient

• Headlight

• Nasal speculum

• 10 or 12Fr frazier suction

• Oxymetazoline (Afrin), tranexamic acid spray (if available)

• 2% lidocaine , 4% cocaine, or combination Spray (anesthetic/decongestant)

• Cotton pledgets

• Bayonet forceps

• Nasal clamp

• Rigid endoscope, flexible scope may be sufficient if diagnostic visualization is all that is required 

• Silver nitrate application sticks

• Absorbable and nonabsorbable packing:

  • Fibrillar/Surgicel

  • Merocel/Rhinorocket

  • Gauze

  • Vaseline gauze

  • Epistat

Management

• Always ensure cardiopulmonary stability of the patient first following the ABCs (Airway, Breathing, Circulation)

• In case of significant bleeding 

  • Protection of the airway and hemodynamic resuscitation are of primary concern

  • Ensure large bore IV access, and make sure vitals are being monitored.

  • Consider labs including CBC, type and screen, and coagulation panel

• Ask the consulting provider to have the patient sit up and lean forward, liberally spray oxymetazoline in both nostrils, clamp the anterior nose for at least 15 minutes, and get the patient normotensive. This will resolve some nosebleeds and helps manage the epistaxis while you gather supplies

• Complete a history and head & neck physical exam, though this may be delayed until after hemorrhage control depending on the situation

  • Investigate personal and family history of coagulopathy, anticoagulant medications, previous personal history of epistaxis (and what worked before), recent nasal trauma, previous or current nasal/nasopharyngeal malignancy, history of nasal/skull base surgery

• Patient’s nose will likely be filled with blood and clot. Either have the patient gently blow their nose or use headlight, speculum, and frazier suction to carefully suction blood and clot

• Apply topical anesthetic, either lidocaine 2% or 4% or cocaine soaked pledgets if available

  • 4% cocaine is an excellent vasoconstrictor and anesthetic, but it important to use only in patients without cardiovascular disease

• Locate the bleed. The vast majority of nose bleeds occur on the anterior septum and can be identified using a headlight, nasal speculum, and suction

• If the bleeding is still too heavy to complete a proper exam, can repeat the process below up to 3x

  • Have patient blow their nose then apply oxymetazoline spray to bleeding side and apply pressure for 10 minutes without any breaks (may complete a more thorough history and physical during this time). A nasal clip applied over the anterior “soft part of the nose” may be useful to some patients

  • After 10 minutes, release pressure and determine is bleeding continues

  • Local tranexamic acid (TXA) can be effective and can be useful adjunct

• If unable to localize the bleed with anterior rhinoscopy, 0-degree rigid nasal endoscopy will be helpful both for localization of the site and to allow for directed treatments

Nasal Packing

• If a site is visualized with slow bleeding or an area of denuded mucosa, can consider covering with absorbable packing (like Surgicel or Fibrillar). These can then be gently sprayed with Afrin +/- TXA to help them adhere to the mucosa. If the area of bleeding is very localized, you may consider silver nitrate cauterization, although this is usually more painful and there is risk of further damage to the nasal mucosa and even septal perforation with liberal or indiscriminate use

  • Patients not requiring packing or in whom only absorbable packing is used do not require follow up for uncomplicated epistaxis. If there is knowledge or suspicion of an underlying process, follow-up should be scheduled

• If a more profuse bleeding site is seen or arterial bleeding present, consider expandable packing (Merocel, Rhinorocket), gauze, or vaseline gauze (packed in a ribbon/accordion fashion). 

  • Electrocautery can be attempted but is painful if not adequately anesthetized and can be difficult if bleeding it too brisk. There is also a risk of causing septal perforation

• Merocels and Rhinorockets are easier to place in awake patients and can tamponade bleeding. Vaseline gauze (the entire 6’ x ½”) can be placed and is very effective at controlling difficult bleeds (HHT, trauma, etc), but is even more uncomfortable for patients

  • Remember that alar necrosis can occur in <24 hrs. Minimize pressure on nasal ala

  • Prescribe antibiotics for patients with non-absorbable nasal packing, risk of toxic shock called into question by recent studies but increased risk of sinusitis and increased pain justify their use. Recommend BID saline irrigation of non-absorbable packing to prevent denuding of nasal mucosa upon removal

  • Remember to secure nonabsorbable packing so that it is easily removed. Taping the ties or a suture passed through the gauze/merocel to the cheek is effective

  • Nonabsorbable packing is often left in place for 4-5 days in patients without coagulopathy and 5-7 days in patients more prone to bleeding

  • Oxymetazoline (Afrin) or a combination spray to the packing prior to removal to prevent denuding and improve comfort

  • Upon removal of nonabsorbable packs, it is important to re-examine the nose for nasal anatomic abnormality or pathologic processes responsible (malignancy, JNA, granulomatous disease, HHT, etc.)

• After you have stopped the bleed, a time period of observation is warranted, depending on patient/situation and volume of the bleed. It is reasonable to watch the patient for an hour in the ED and encourage them to ambulate to ensure adequate hemostasis before discharge

Posterior Epistaxis

• Posterior epistaxis is uncommon, but almost always arterial (sphenopalatine artery (SPA) or, less commonly, anterior/posterior ethmoid arteries (AEA/PEA)) and difficult to control. If a very significant bleed is present that you cannot control with topical sprays and cannot localize anteriorly with headlight, speculum, and suction, you may suspect a posterior bleed. A 0-degree rigid endoscope and 10 French Frazier suction can often help identify the source. If a posterior arterial bleed is present, place a posterior nasal pack

  • Many options including nasal Foley catheter to block the nasopharynx followed by packing the nasal cavity with vaseline gauze or use of an Epistat

  • In many institutions, patients requiring posterior nasal packing require hospital admission. These patients often require a trip to the OR to control the bleeding and perform SPA ligation or treatment through embolization

    • If the source is suspected to be the sphenopalatine artery, endoscopic SPA ligation is often the preferred intervention given its efficacy and safety profile

    • Embolization is a good option for patients that are medically unstable or cannot tolerate general anesthesia 

    • If the source is suspected to be the anterior/posterior ethmoid arteries, surgical intervention is preferred over embolization due to the risk of blindness/stroke (the AEA/PEA arise from the ophthalmic artery, a branch of the internal carotid system)

Aftercare Instructions

• Aftercare/ moisturizing recommendations to decrease frequency of nosebleeds

  • Saline sprays/rinses

  • Nightly application of vaseline or polysporin to anterior nares

  • Room humidification

  • Avoidance of nasal cannula if possible (use face tent, nasal cup, facemask if possible)

  • Management of medical conditions contributing to epistaxis (coagulopathy, hypertension, etc.)

  • Humidification of CPAP appliance if applicable

• It is useful to create a smart phrase in case of re-bleeding to leave instructions for providers (inpatients) or the patient themselves if being discharged home

  • Apply Afrin liberally to both nostrils

  • Apply pressure over the soft part of the nose for 15 minutes (clip or digital pressure, important to have pressure over soft part)

  • Lean forward, avoid swallowing blood. This can cause nausea and vomiting

  • Can repeat steps 1-3 up to 3 times

  • Consult ENT or return to the nearest emergency department if this is unsuccessful

Example Procedure Notes 

• Procedure: Chemical cauterization
  After obtaining verbal consent from the patient, topical anesthetic was applied (Afrin and 2% lidocaine in 1:1 mixture). Silver nitrate was then applied to the right anterior nasal septum for 3 seconds in affected areas. Topical anesthetic was re-applied to de-activate silver nitrate. The patient tolerated the procedure well. The right septal mucosa appeared gray as expected without active bleeding at the end of the procedure.

• Procedure: Anterior/Posterior Nasal Packing

  After obtaining verbal consent from the patient, topical anesthetic was applied (Afrin and 2% lidocaine in 1:1 mixture). An active bleed was identified at the _____. Due to its location, ____ was applied to stop the bleed. At the conclusion of the procedure, active bleeding was noted to be well controlled. 

References

1. Bleier, B.B., Schlosser, R.J. (2013). Epistaxis. In J.J. Johnson, C.A. Rosen. (Eds.), Bailey’s Head and Neck Surgery-Otolaryngology 5e (pp. 501-508). Baltimore, MD: Lippincott Williams & Wilkins.

2. Kuan, E.C., Palmer, J.N. (2020). Epistaxis. In Flint, P.W., et al (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 733-744). Philadelphia, PA: Elsevier.

3. Tunkel, D. E., Anne, S., Payne, S. C., Ishman, S. L., Rosenfeld, R. M., Abramson, P. J., … Monjur, T. M. (2020). Clinical Practice Guideline: Nosebleed (Epistaxis). Otolaryngology–Head and Neck Surgery, 162(1_suppl), S1–S38.