Epistaxis (Nosebleed)

Definition and Epidemiology

• ROSEN's Emergency Medicine, p. 920

Anatomy and Classification

Blood Supply to the Nose

Little's Area / Kiesselbach's Plexus

Woodruff's Plexus

Anterior vs. Posterior Epistaxis

• ROSEN's Emergency Medicine, pp. 919-920; Bailey and Love's Short Practice of Surgery 28e, p. 788

Causes

Local Causes

• Nose picking (digital trauma) - most common in children
• Nasal trauma / facial injury
• Upper respiratory tract infections (mucosal vasodilation)
• Allergic rhinitis
• Nasal foreign bodies
• Nasal polyps
• Tumours (including juvenile angiofibroma in adolescent boys - can cause massive, life-threatening hemorrhage)
• Granulomatous disorders (sarcoidosis, Wegener's/GPA)
• Low humidity / dry air
• Environmental irritants, cocaine use
• Post-surgical (postoperative epistaxis)

Systemic Causes

• Hypertension - associated with persistent bleeding (though causal link not firmly established)
• Anticoagulants: warfarin, rivaroxaban, other DOACs
• Antiplatelet agents: aspirin, clopidogrel
• Haemophilia
• Von Willebrand's disease
• Leukaemia / thrombocytopenia
• Advanced liver disease
• Chemotherapy
• Hereditary Haemorrhagic Telangiectasia (HHT) (Osler-Weber-Rendu disease) - recurrent multifocal bleeding from thin-walled vessels deficient in muscle and elastic tissue
• Bailey and Love's 28e, p. 788; ROSEN's Emergency Medicine, p. 921

Clinical Assessment

Initial Priorities

1. Airway patency
2. Haemodynamic status / tissue perfusion
3. Identify the bleeding source

History

• Timing, frequency, severity of bleeding
• Laterality (unilateral vs. bilateral)
• Trauma, nasal surgery, or instrumentation
• Medications (anticoagulants, NSAIDs, antiplatelet agents)
• Comorbidities (hypertension, liver disease, haematologic malignancy)
• Family history of bleeding disorders

Examination

1. Have the patient blow the nose, then apply bilateral digital pressure on the cartilaginous septum for 10-15 minutes
2. A nose clip is superior to manual pressure alone
3. Apply oxymetazoline 0.05% (2 sprays) to the affected nostril before pressure - optimises haemostasis and facilitates inspection
4. Examine with a nasal speculum (open vertically, not sideways); floor of nose should be parallel to room floor
5. Rigid nasendoscopy if bleeding source is not obvious anteriorly

Investigations

• Routine labs are not indicated for simple epistaxis
• Reserve coagulation studies for: patients on anticoagulants, severe hemorrhage, underlying liver disease, or haematologic malignancy
• CT or MRI: for suspected tumour (e.g. juvenile angiofibroma)
• ROSEN's Emergency Medicine, pp. 919-920

Management - Step-by-Step

Step 1: First Aid (All Patients)

• Sit upright and lean forward (prevents swallowing blood)
• Pinch the cartilaginous nose for 10-15 minutes continuously
• Oxymetazoline spray as vasoconstrictor

Step 2: Topical Anaesthesia + Vasoconstriction

• Apply 2% lidocaine (mucosal atomisation or soaked gauze) combined with a vasoconstrictive agent to facilitate examination and treatment

Step 3: Chemical Cautery (if bleeding point identified)

• Silver nitrate sticks - applied from periphery to centre, superiorly to inferiorly
• Do not maintain contact longer than 15 seconds (risk of septal necrosis)
• Never cauterise both sides of the septum simultaneously - risks devascularisation and necrosis
• Most effective when bleeding has stopped; not during active haemorrhage

Step 4: Topical Haemostatic Agents

• Absorbable gelatin sponge (Gelfoam)
• Absorbable knitted fabric (Surgicel)
• Topical Tranexamic Acid (TXA) - 500 mg IV solution applied to nasal pledget or atomised - moderate quality evidence supports reduction of bleeding at 10 minutes and re-bleeding at 7-10 days; shown to be superior to anterior packing in patients on antiplatelet drugs

Step 5: Anterior Nasal Packing

• Used if cautery fails or bleeding point not identified
• Options:
  • Polyvinyl acetal sponge (Merocel) - expands on contact with moisture
  • Inflatable balloon devices (Rapid Rhino) - coated in procoagulant material; insert along the floor and inflate with air
  • Vaseline-impregnated ribbon gauze (older technique)
• For uncontrolled bleeding with anterior pack in situ: insert a second pack into the opposite naris
• Prophylactic antibiotics are NOT routinely recommended with anterior packing

Step 6: Posterior Nasal Packing (if anterior packing fails)

• Suggested when bleeding persists despite properly placed anterior pack
• Double balloon catheter device: posterior balloon inflated first, device pulled anteriorly, then anterior balloon inflated
• If unavailable: Foley catheter inserted into nasopharynx, inflated with 5-7 mL water, pulled anteriorly - risk of pressure necrosis if over-inflated
• Patients with posterior packing require inpatient monitoring (risk of pulmonary/cardiac complications, especially in the elderly)

Step 7: Interventional / Surgical Options (Refractory Cases)

• Endoscopic sphenopalatine artery ligation - preferred surgical option for persistent bleeding
• Embolisation (endovascular): catheterisation of internal maxillary and facial arteries; success rate 91-97%, complication rate 0-3%; preferred in patients on anticoagulation or with chronic coagulopathy
• Preferred over surgery in patients who cannot interrupt anticoagulation
• ROSEN's Emergency Medicine, pp. 920-921; Bailey and Love's 28e, p. 788; Grainger & Allison's Diagnostic Radiology

Special Conditions

Hereditary Haemorrhagic Telangiectasia (HHT / Osler's Disease)

• Autosomal dominant disorder
• Thin-walled vessels deficient in muscle and elastic tissue throughout the nasal mucosa
• Recurrent, multifocal epistaxis - standard packing often unhelpful
• Management includes laser coagulation, septodermoplasty, bevacizumab (anti-VEGF)

Juvenile Angiofibroma

• Occurs in adolescent boys (hormonally responsive tumour)
• Can cause massive, life-threatening epistaxis
• Diagnosis: contrast CT or MRI; classical sign: Holman-Miller (antral) sign - anterior bowing of posterior antral wall on CT
• Do NOT biopsy - risk of uncontrollable haemorrhage
• Treatment: endoscopic excision (often with image guidance) by experienced surgeon; preoperative embolisation to reduce intraoperative blood loss
• Bailey and Love's 28e, p. 788

Summary: Management Algorithm

Epistaxis
│
├── First aid: sit forward, pinch nose 10-15 min + oxymetazoline
│
├── Anterior bleeding identified?
│   ├── YES → Silver nitrate cautery ± TXA ± topical haemostatics
│   └── NO → Proceed to packing
│
├── Anterior packing (Merocel / Rapid Rhino / TXA pledget)
│
├── Still bleeding? → Suspect posterior source
│   └── Posterior/double balloon packing → Inpatient admission
│
└── Refractory?
    ├── Endoscopic sphenopalatine artery ligation
    └── Endovascular embolisation

Key Points

• 90% of epistaxis is anterior, from Kiesselbach's plexus in Little's area
• Hypertension is associated with persistent bleeding but its causative role is unproven
• Silver nitrate should never be applied bilaterally on the septum in the same session
• Tranexamic acid (topical) is a well-supported adjunct, particularly in antiplatelet patients
• Posterior epistaxis in the elderly carries risk of cardiac/pulmonary complications from packing
• Routine antibiotics with anterior packs are not recommended
• Embolisation success rate is >91% and is preferred over surgery in anticoagulated patients