1. Project: Ghana Emergency Medicine Collaborative
Document Title: Evaluation and Management of Epistaxis
Author(s): Patrick Carter (University of Michigan), 2008
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3. Evaluation and Management of Epistaxis
Patrick Carter
University of Michigan
Department of Emergency Medicine
July 8, 2008
Dan Keezer 2002 (Flickr)

4. Objectives Epidemiology Review of Anatomy Pathology/Etiology
Evaluation of the patient with Epistaxis
Management
Anterior Epistaxis
Posterior Epistaxis
Alternative Therapies
Complications of Packing

5. Hippocrates – 4th Century B.C.
Nosebleeds occur in those who are beginning to have feelings of lust or who are getting the signs of manliness
History of Epistaxis:
Hippocrates – 4th Century B.C.
“Nose bleeds occur in those who are beginning to have feelings of lust or who are getting the signs of manliness”
Epistaxis is a common medical complaint and has been reported for centuries.
Hippocrates and others believed that disease was caused by an imbalance of the humours and as such – nosebleeds as well as other medical conditions such as vomiting or expectorating were potentially curative measures for any disease above the diaphragm. For example, a patient with a fever who had a nosebleed was an attempt to balance the humors and was a sign that fever was going to resolve.
Hippocrates treated prolonged nasal bleeds with the application of cold towels to the shaven head and packed the nasal cavity with compressed calves rennet or wool soaked in oil of figs.
El Bibliomata 2010 (Flickr)

6. Epidemiology 60% of population with at least one nosebleed
6-10% will require medical treatment
1.6/10,000 will require admission
Bimodal age distribution
High Incidence < 10 y/o
30% of all children 0-5 y/o
56% of all children 6-10 y/o
Second peak: y/o
Bleeding categories
Anterior (90-95%)
Posterior (5-10%)
Epidemiology
60% of population at one point in their lifetime with suffer from some degree of Epistaxis.
Only 6-10% will require medical treatment to control and stop hemorrhage
1.6 in 10,000 patients seeking medical care will require hospitalization for control of epistaxis
Bimodal age distribution – most cases occur before the age of ten and between years of age
Before the age of 49 there is a male predominance attributed to the protective effect of estrogen causing a healthy nasal mucosa and preventing vascular disease in general. After age 49, sexual distribution equalizes.
Epistaxis is divided into anterior and posterior bleeding and 90-95% of epistaxis arises from the anterior vasculature.
Cult Gigolo 2008 (Flickr)

7. Anatomical Considerations
Nasal Cavity
Functions
Respiratory
Protective
Drainage
Olfactory
Anterior Nasal Cavity = Little’s Area
Kesselbach’s Plexus
Anterior/Posterior Ethmoidal Arteries
Sphenopalantine artery
Superior Labial Artery
Greater Palantine Artery
Posterior Nasal Cavity
Sphenopalantine Artery
Woodruff’s Plexus
Anatomy:
Nasal Cavity is divided into three main areas:
Anterior nasal cavity
Posterior nasal cavity
Superior nasal cavity
Functions of Nose
Respiratory – Humidifies, Regulates temperature of air passing through
Protective – Filters air traveling through nasal passages, sneezing reflex as mechanism of clearance
Drainage from sinuses/tear ducts
Olfactory
Anterior Nasal Cavity
Also termed Little’s Area (most common site of bleeding in 90-95% of cases of epistaxis)
Contains Kesselbach’s plexus of vessels in the anteroinferior portion of the nose.
Kesselbach’s plexus is the anastomosis of:
Branches of anterior and posterior ethmoidal arteries (which arise from internal carotid)
Lateral branch of the sphenopalantine artery (off of the internal maxillary, a branch of the external carotid)
Septal branch of the superior labial artery (a branch of the facial artery, which arises from the external carotid)
Greater palantine artery (which arises from the internal maxillary artery and runs through the hard palate)
Posterior Nasal Cavity
Posterior nasal cavity is supplied mostly by several posterior lateral branches of the sphenopalantine artery (branch of internal maxillary off of the external carotid)
Located in the posterior half of the inferior turbinate is a venous network known as Woodruff’s plexus which is the most common source of venous bleeding
Posterior bleeding comprises 5-10% of epistaxis
Gray’s Anatomy 1918 (Wikimedia Commons)

8. Etiology of Epistaxis 85% of cases are idiopathic
Four Broad Categories:
Trauma, Infectious, Tumors/Lesions, Disorders of Hemostasis
Traumatic Causes
Digital Trauma
Facial Trauma
Mucosal Drying
Foreign Body
Septal Perforation
Substance Inhalation
Barotrauma
Environmental Irritants
Etiology and Pathology involved in Epistaxis:
Epistaxis results from an interaction of factors that damage the nasal mucosal lining and affect the vessel walls or alter the coagulability of blood.
Despite the identification of multiple factors known to cause epistaxis, 85% of cases have no identifiable cause.
Traumatic Causes
Digital Trauma – Children and psychiatric patients commonly injure the nasal mucosa over Little’s area. The source of bleeding is usually proximal to the mucocutaneous junction where there is little subcutaneous tissue for an excoriated vessel to retract into. Continued trauma devitalizes the perichondrium and leads to exposed cartilage and perforation.
Facial Trauma
Mucosal Drying
Foreign Body – Presence of foreign body should be considered when bleeding is accompanied by purulent discharge
Septal Perforation – Chronic excoriation can lead to small septal perforations that may bleed from surrounding friable granulation tissue.
Substance Inhalation – Chronic Intranasal cocaine also presents similarly. Other inhalation substances are also implicated in the cause of significant inflammation resulting in bleeding.
Barotraumas
Environmental Irritants – One study found that a higher number of patients presented between November-March where humidity is lower.
Infectious Causes – Mucosal hyperemia that accompanies alleric/viral/bacterial infections makes bleeding from minimal local trauma especially profuse.
URI
Sinusitis
Rhinitis
Tuberculosis
Mononucleosis
Scarlet Fever
Rheumatic Fever
Syphilis
Tumor’s/Lesions
Nasopharyngeal neoplasms
Sinus Neoplasms
Benign nasal polyps
Juvenile Angiofibroma – Common cause of bleeding in children
Nasal Hemangioma
HHT (Hereditary Hemorrhagic Telangectasia)
Disorders of Hemostasis
Leukemia
Thrombocytopenia (ITP, TTP)
Hemophilia
Von-Willibrand’s disease – Most common symptom of vWD is epistaxis affecting 60% of patients with this disorder
Aplastic Anemia
Polycythemia Vera
Platelet Inhibition – NSAID’s, Aspirin
Anticoagulation – Warfarin
Aaron Smith 2007 (Flickr)

9. Etiology of Epistaxis Infectious Etiology URI Sinusitis Rhinitis
Tuberculosis
Mononucleosis
Scarlet Fever
Rheumatic Fever
Syphilis
Infectious Causes – Irritation of nasal mucosa as a result of infection or allergic condition is usually the result of hyperemia and inflammation of the mucosa accompanied by forceful nasal blowing that damages friable mucosa. The concurrent use of nasal sprays and drying agents can increase risk of bleeding and direct nasal trauma. Types of infections include:
URI
Sinusitis
Rhinitis
Tuberculosis – Nasal tuberculosis is a rare chronic granulomatous infection that can cause nasal obstruction and epistaxis.
Mononucleosis
Scarlet Fever
Rheumatic Fever
Syphilis – Usually congenital syphilis that causes blood tingled nasal discharge rather than frank epistaxis.
Sevoo (Flickr)

10. Etiology of Epistaxis Tumors/Lesions Nasopharyngeal Neoplasms
Sinus Neoplasms
Benign Nasal Polyps
Juvenile Angiofibrinoma
Metastatic Lesions
Nasal Hemangiomas
HHT (Hereditary Hemorrhagic Telangiectasia)
MathieuMD (WikimediaCommons)
Tumor’s/Lesions – Neoplasms of nasal cavity usually cause unilateral symptoms such as intermittent epistaxis, foul discharge, nasal obstruction or change in sense of small. Severe bleeding is uncommon except in patients with vascular tumors such as juvenile angiofibroma.
Nasopharyngeal neoplasms – (pyogenic granuloma, rhabdomyosarcoma, nasalpharngeal carcinoma, Inverting papillomas)
Sinus Neoplasms
Benign nasal polyps
Juvenile Angiofibroma – Common cause of bleeding in children. A Histologically benign tumor with marked vascularity and can cause severe epistaxis. It occurs primarily in adolescent males. Lesions arise in lateral nasopharynx and are hormonally sensitive. It can cause a large amount of local invasion of adjacent structures and can cause bleeding. The most common presenting signs are the clinical triad of nasal obstruction, epistaxis and nasal drainage. Tumors may be apparent on physical exam and may bulge into the nasal cavity.
Metastatic Lesions – Often from malignant melanoma or squamous cell carcinoma lesions.
Nasal Hemangioma
HHT (Hereditary Hemorrhagic Telangectasia)

11. Hereditary Hemorrhagic Telangiectasia
Osler-Weber-Rendu Disease
First described in 1864
Mucocutaneous telangiectasias + AV Malformation
U.S. Incidence = 1/16,500
Curacao Criteria
Recurrent Epistaxis (90%)
Treatment
Standard therapies
Surgical intervention
Hereditary Hemorrhagic Telangiectasia (Osler-Weber-Rendu Disease)
An autosomal dominant condition first described in 1864 and characterized by widespread mucocutaneous telangietasias and arteriovenous malformations. Serious bleeding lesions often don’t become fully apparent until the 4th decade of life.
First described in 1864.
Mechanism postulated is that blood vessels are normal until some minor/major insult occurs and during vessel wall repair, abnormal repair occurs (possible an abnormal protein synthesis) leading to weakness in vessel wall that is prone to rupture and bleeding.
Incidence in US has been estimated at 1/16,5000 and all racial groups have been reported to be affected. Men and women are affected equally. European and Asian populations have a higher incidence (1 in ) and small isolated communities (Danish island of Fyn, the Dutch Antilles, and parts of France) have been shown to have a much higher incidence.
Defined by the presence of 3 of following four criteria (Curacao):
Epistaxis – Recurrent, spontaneous nosebleeds
Telangietasias – multiple telangiectasias (dilated spidery blood vessels) present in characteristic sites including lips, oral cavity, fingers, nose.
Presence of visceral lesions: GI telangiectasias, Pulmonary AVM, Hepatic AVM, Cerebral AVM, Spinal AVM
Family History – 1st degree relative with HHT.
Recurrent epistaxis is present in 90% of patients with HHT and typically appears by the age of 12.
Patients with GI/Pulmonary lesions are at increased risk for life threatening bleeding from AV malformations, aneurysms, etc.
Bleeding can be difficult to control and friable lesions may appear to bleed more with treatment than without. Initial treatment measures for epistaxis are the same but patients may easily fail these simple interventions and may require surgical intervention with resection of telangietasias and or dermal septoplasty (excising the affected mucosa and covering with skin graft).
Herbert L. Fred, MD and Hendrik A. van Dijk (Wikimedia Commons)

12. Etiology of Epistaxis Disorders of Hemostasis Platelet Disruption
Leukemia
Thrombocytopenia
Von-Willibrand’s Disease
Medications (Aspirin, Plavix, NSAID’s)
Clotting Cascade Disruption
Hemophilia
Vitamin K Deficiency
Anti-coagulant Medications (Coumadin, Heparin, Lovenox)
Aplastic Anemia
Polycythemia Vera
Systemic Diseases
Hepatic Disease
Uremia
Alcoholism
National Cancer Institute (WikimediaCommons)

13. What about Hypertension?
No clear association between acute hypertensive episode and epistaxis
Chronic Hypertension = Vascular Damage
Increases risk of epistaxis
Acute hypertension = Prolonged Epistaxis
What about Hypertension as a cause of epistaxis?
There is much contradictory evidence surrounds whether hypertension is a cause of epistaxis. Current theory is that chronic hypertension increases the risk of epistaxis but there is no evidence to suggest that acute episode of hypertension causes epistaxis.
Hypertension is currently thought to cause epistaxis by chronic vascular damage that causes degenerative fibrous changes in the tunica medica of arteries. This was confirmed in a post-mortem studies.
Patients with a history of hypertension have also been shown to have an increased number of episodes of epistaxis.
Hypertension is postulated to prolong the episode of epistaxis when present during evaluation.
ML5 (WikimediaCommons)

14. Clinical Evaluation History Physical Exam Laboratory Studies
Location/Severity
Previous Episodes
PMH/Medications
Facial Trauma
Recent Infections
Recreational Drug Use
Physical Exam
Nasal Speculum
Suction
Adequate Light
Posterior Oropharynx
Laboratory Studies
CBC, PT/INR, PTT, Type and Screen
Evaluation of Patient with Epistaxis
History:
Location and severity of bleeding (one nostril/both), Passage of clots
History of previous epistaxis
Medications (Especially, aspirin, coumadin, NSAID’s, Heparin)
Past Medical History – (Hypertension, ITP/TTP, HHT)
Recent Surgical Interventions (Nasal polyp surgery)
Recent facial trauma
Recent Infection/URI, H/o Allergies
Children – Think about possible foreign body exposure
Recreational Drug use – (Cocaine, Huffing)
Physical Exam:
Adequate exam using nasal (Thudichum) speculum (ideal, otoscope speculum can be substituted but it less effective) and if available, placement of patient in a dental chair so that patient is sitting upright
Remember that the speculum bladed are oriented vertically to expose the vestibule.
Extension of the neck (patients attempt this to help exam) will decrease view of most of the cavity
Clear clots with surgical suction apparatus or blowing of nose.
Examine the kiesselbach’s plexus extensively for any area of active bleeding, ulceration or erosion.
After examination of anterior space, the posterior pharyngeal wall and space should be examined to evaluate for posterior bleeding.
Local anesthesia can be provided with cotton swabs or pledgets soaked in anesthetic and vasoconstrictive agent such as lidocaine with epinephrine, 4% cocaine.
Remember a general examination of the remainder of the patient, evaluating for signs indicating a systemic cause to the patients nasal bleeds – petechia, easy bruising, lymphadenopathy.
Laboratory Investigations:
1. In patients with evidence of extensive bleeding, posterior nose bleeds or elderly patients with suspected significant epistaxis, check CBC, Coagulation studies (especially if on anti-coagulants), type and screen.
sarindam7 (WikimediaCommons)

15. Anterior Epistaxis Management
Sample Algorithm
First Aid Maneuvers
Direct Pressure
Nasal Preparation
Anesthesia
Vasoconstrictors
Cautery
Silver Nitrate Sticks
Electocautery
Treatment
Treatment of epistaxis is dependent on location of the bleeding and the identification of a bleeding source. Treatment is typically divided into treatment of anterior and posterior epistaxis.
Anterior Epistaxis
Typically treated with a combination of direct pressure, vasoconstrictive agents, cautery and nasal packing.
Initial management focuses on A, B, C’s. Epistaxis is a potentially life-threatening event and all patients who are actively bleeding need full assessment and consideration of resuscitation if necessary.
Airway/Breathing – Airway control seldem needs to be established except in massive epistaxis with significant risk of aspiration and depressed mental status, but must be kept in possible treatment algorithm.
Circulation – BP, HR should be monitored and patients with evidence of poor perfusion or hemodynamic instability should be resuscitated with volume and/or blood replacement as necessary.
Treatment Algorithm:
First Aid Measures
Sit the patient up to prevent aspiration and swallowing of blood. Large amounts of blood in stomach promotes nausea/emesis which may dislodge clot.
Direct pressure over the Keisselbach’s plexus for 20 minutes (Close pin) with or without application of icepack to dorsum of the nose.
Nasal Preparation – If no success with direct pressure:
Anesthesia/Vasoconstricion with lidocaine with epinephrine or 4% cocaine or phenylephrine.
Close exam with nasal speculum for identification of possible source of bleeding.
Many nosebleeds with stop with direct pressure and application of vasoconstricor to site.
Cautery – If no success with direct pressure and vasoconstrictor agents, and a single site of bleeding can be identified, cautery may be attempted.
Chemical cautery is achieved by silver nitrate sticks that reacts with the mucosal lining to produce local chemical damage. Firm pressure is applied for 5-10 seconds, until the appearance of a grey eschar. Care should be taken to avoid prolonged application or brushing of silver nitrate sticks against other areas of nose.
Cautery should proceed from the periphery to the central bleeding site and works poorly in a pool of blood, necessitating continuous suction. Resist temptation to cauterize large area of bleeding.
Only one side of the septum should be cauterized b/c bilateral cautery increases the risk of septal perforation.
Electocautery may be performed by ENT to seal vessel.
Nasal Packing – If direct pressure, vasoconstrictor agents do not work and/or the site cannot be visualized, packing is required to stop bleeding.
Nasal Tampons/Balloon Catheters
Merocel – Merocel packing is comprised of a synthetic open-cell foam polymer. The packing should be coated with bacitracin ointment and inserted directly along the floor of the nasal cavity. The tampon is then allowed to absorb cc of NS, which results in expansion to three times the size and compression of bleeding source.
Bacitracin is used to help decreased the risk of toxic shock syndrome and to prevent stripping of of mucosa. The polymer used for merocel packing is a less hospitable medium for staph aureus than traditional packing agents.
Advantage = Technically easier to insert than traditional packing.
Rapid Rhino – A ballon catheter coated in carboxymethylcellulose mesh, which is a hydrocolloid material which acts as a platelet aggregator and forms a lubricant on contact with water or blood. It is inserted similarly to a merocel packing but the cuff is inflated with air or water. The resulting tamponade helps control bleeding along with the gel is supposed to preserve newly formed clot during removal.
Formal Packing – Can be accomplished if other forms of anterior nasal packing fails to stem the bleeding.
Typically, the nose is packed with a ribbon gauze (typically Xeroform or gauze soaked in bismuth iodiform paraffin paste (BIPP)) that comes in 72 inch lengths.
The gauze is placed in an accordion fashion starting on the floor of the nasal cavity until the nose is completely packed. Takes some degree of skill to perform.
Both ends of the ribbon gauze should protrude from the nasal cavity to avoid aspiration, larygospasm.
Failure to control anterior bleeding with traditional packing should prompt consideration of bilateral packing. Bilateral packing causes increased tamponade on nasal septum. If this maneuver doesn’t provide adequate hemostasis, a posterior bleeding source should be considered.
Problems with this method = Degree of skill required, unpleasant smell and taste, discomfort with placement despite use of anesthetic, removal is often uncomfortable.
Comparison of techniques for anterior treatment
Studies have shown no difference in efficacy between Merocel packing and gauze packing although traditional packing requires a higher degree of expertise.
Studies have also demonstrated that the Rapid rhino is significantly superior to conventional packing in patient ease and comfort, however there was no difference between the mesh balloon and Merocel in rebleeding after the packing has been removed.
Antibiotics – Incidence of Toxic Shock Syndrome is 16/100,000 post-operative packings but no known incidence of primary nasal packing has been established.
Studies have not demonstrated any benefit to routine use of antibiotics to prevent toxic shock syndrome or sinus infections although common practice is the use of antibiotics for the duration of the packing placement.
Application of bacitracin or antibiotic ointment to packing helps to decrease the number of bacteria present in nasal cavity.
Disposition
Patients with epistaxis that is controlled by direct pressure, cautery or application of vasoconstrictor agents can be discharged home with outpatient PMD follow-up.
Patients with single nares packing in place should be considered for admission if elderly or poor ability to follow-up. If no significant contraindications to discharge, patients can be discharge with follow-up in hours for packing removal and ENT evaluation.
Bilateral nares packing patients should be considered for admission and ENT consultation because of risk of hypoxia, aspiration and/or treatment failure.
Source Undetermined

16. Digital Pressure (Trotter’s Method)
Application of digital pressure over Kiesselbach’s plexus for at least minutes
Pinch here
SuperFantastic

17. Merocel Packing
Nasal Tampon inserted horizontally after lubrication of pack with bacitracin or KY-Jelly and then allowed to expand after saturation with normal saline.

18. Rapid Rhino
Balloon Catheter coated in carbocymethylcellulose mesh which acts as a lubricant and platelet aggregator.
The catheter is soaked in water for 30 seconds and then inserted into the nose along the base of the nasopharynx.
The cuff is then inflated with air/water until it provides adequate tamponade.
Rapid Rhino – A ballon catheter coated in carboxymethylcellulose mesh, which is a hydrocolloid material which acts as a platelet aggregator and forms a lubricant on contact with water or blood. It is inserted similarly to a merocel packing but the cuff is inflated with air or water. The resulting tamponade helps control bleeding along with the gel is supposed to preserve newly formed clot during removal.

19. Formal Anterior Packing
Pack the nasal cavity with xeroform ribbon gauze from the floor upwards in an accordion fashion using a bayonet forceps leaving a four inch tail on each end out of nares

20. Posterior Epistaxis Foley Catheter Specialized products
Brighton Balloons
Simpson Balloons
Formal Posterior Packing
Posterior Epistaxis Treatment (5% of epistaxis originates from a posterior source)
- Tends to be in elderly patients and is usually associated with arterial degeneration.
Anterior Packing may be insufficient to control bleeding, which should prompt the consideration of a posterior bleed. These bleeds often require a balloon packing or formal posterior packing. Posterior packing is designed to provide a buttress when used in conjunction with anterior packing causes tamponade of the entire nasal cavity. Thus, the purpose of a posterior pack is to stabilize the anterior packing and the combination of the two packs leads to tamponade of the space.
Foley Catheter
A 14 French Foley catheter is utilized for posterior packing. The tip is cut off to minimize irritation of the posterior structures. The catheter is inserted into the nares and advanced back to posterior oropharynx until it is visible in the mouth.
The balloon is filled with 5-7 cc of sterile saline and then retracted through the nose until well opposed to the posterior nasopharynx. The balloon is then completely filled with another 5 cc of normal saline. Pain or distension of the soft palate indicates that the balloon is overfilled. Some practitioners utilize air for inflation 2/2 risk of aspiration of saline with balloon rupture but there is increased risk of early deflation 2/2 use of air rather than saline.
The Foley catheter is clamped in place with a umbilical clamp or small c-clamp.
The anterior nose is then packed with either traditional packing or merocel/rhino packing.
Brighton Balloon/Simpson plug/Epistat nasal catheter
a. Specially designed packing devices with both a anterior and posterior nasal balloon that are independently inflated.
Formal Posterior Packing
Often performed under general anesthesia 2/2 uncomfortable nature of the procedure, a red rubber hose is fed through the nose and into the oropharynx, where it is grabbed with a ring forceps. A gauze roll is then sutured to the end of the catheter and the catheter is pulled through the nose to lodge the gauze roll in the posterior nasopharynx and tamponade posterior bleeding source.
The anterior nasal region is then usually packed with xeroform traditional packing so that both anterior and posterior regions are packed.
A second cotton packing is then sutured to the end of the catheter coming out of the nares to secure the tube placement.
These patients need to be admitted to the hospital due to risk of hypoxia and aspiration of packing material.
saf

21. Traditional Posterior Packing
Catheter through affected nostril and through the nasopharynx is drawn out the mouth by ring forceps.
A gauze pack is secured to the end of the catheter with umbilical tape or suture material, and long tails protrude from the mouth.
The gauze pack is guided through the mouth and around the soft palate
The gauze pack in the posterior nasal cavity maintaining tension on the catheter with a padded clamp or firm gauze roll placed anterior to the nostril.

22. Alternative Treatments
Surgical Therapies
Electrocautery
Septal Surgery
Arterial Ligation
Alternative Treatments
Angiographic Embolization
Fibrin Glue
Laser Therapy
Hot Water Irrigation
Surgical Options
Any bleeding that fails to stop despite an escalation of emergency room management techniques will likely require surgical intervention. Surgical interventions include diathermy, septal surgery or arterial ligation.
Diathermy = Electrocautery under general anesthesia after localization of bleeding source usually through use of endoscopic equipment.
Septal Surgery =
Arterial Ligation
Typically proceed with sphenopalantine artery ligation performed under direct endoscopic where the vessel can be clipped or ligated. This is often followed by anterior or posterior ethmoidal artery ligation if sphenopalantine artery ligation is unsuccessful.
Posterior ethmoid artery is avoided if possible because of close proximity to the optic nerve and risk of damage.
Rarely performed arterial ligations include maxillary artery but is effective in 87% of cases. In addition, previously external carotid artery ligation was performed but this is has failure rate of 45% and is seldom used and is reserved only for when all other methods fail.
Alternative treatments
Angiographic Embolization (Now the treatment of choice)
Angiographic Embolization was first attempted in 1972 for epistaxis.
The external carotid artery or femoral artery is cannulated and then the bleeding point is located. Coils, gel foam, can then be used to embolize the causative artery.
Success rate is as high as 87%.
Limiting factors: Presence of specialized radiologists to perform procedure.
Complication rate = 17-27%
Fibrin Glue – Developed from human plasma cryoprecipitate and bind to damaged vessels. A thin layer of glue is spread over the bleeding site. Similar bleeding control efficacy when compared to electrocautery but a higher incidence of local swelling, pain, slow healing of bleeding site and atrophy of nasal mucosa. Complications include nasal mucosa atrophy, excessive nasal discharge. Rebleeding rate = 15%.
Endoscopic Electrocautery – ENT procedure first used in 1960’s but now being used by ENT to treat refractory epistaxis through close examination of nasopharynx and identification of bleeding point. Electrocautery is then used to identify and cauterize the site of bleeding.
Laser – Laser therapy is starting to be used especially in cases of recurrent epistaxis, such as from patients with HHT.
Hot water Irrigation – Posterior nasopharynx is irrigated with 45 degree to 50 degree centigrade water to help clear blood clots and promote mucosal edema which decreases local blood flow.

23. Complications of Packing
Failure to control bleeding
Toxic Shock Syndrome
Blockage of Duct drainage
Nasovagal Reflex (Controversial)
Obstructive Sleep Apnea
Airway obstruction
Removal can cause re-bleeding
Pressure necrosis
Complications of Nasal Packing:
Failure to Control Bleeding
Toxic Shock Syndrome
Incidence of Toxic shock syndrome with nasal packing is estimated at 16 per 100,000 post-operative packings but the incidence in primary nasal packing is not been truly established.
No significant difference in complications when patients randomized to receive antibiotics with their packing or just topical bacitracin but the group that did not receive antibiotics had a higher proportion of gram negative colonization of the nares post-removal of packing material and heavy gram negative growth was associated with an offensive odor.
Most authors recommend first generation cephalosporin (Keflex) administered with packing placement despite the lack of effective evidence to support usage as prevention of TSS, but will help prevent sinusitis.
Note: Toxic Shock syndrome is characterized by over infection with staph aureus and release of dangerous exotoxin which results in symptoms such as fever, rash, hypotension, GI disturbances and mental status changes. The use of antibiotic ointment to prevent colonization of staph aureus and hopefully limit risk of TSS.
Blockage of:
Nasolacrimal duct – leading to epiphora
Sinus drainage – leading to acute sinusitis
Nasal Airway – leading to hypoxia
Nasovagal Reflex – A reflex that occurs with placement of a pack of instrumentation of the nasal cavity leading to vagal stimulation and consequently resulting in hypotension and bradycardia. Studies have been unable to attribute physiologic changes to packing but sample sizes of the studies were small and the risk is still reported in many reviews of epistaxis treatment.
Obstructive sleep apnea
Displacement of packing into posterior oropharynx, with risk of acute airway obstruction
Removal of packing may induce bleeding
Pressure necrosis from prolonged application of tamponade against tissues. Prevention is key. Packing should not be left in place for longer than hours and unreliable patients should be admitted if follow-up is a concern. Also, care should be taken to cushion the nostrils with the anterior portion of the posterior packing.
** Posterior packing has a higher degree of morbidity and mortality, especially hypoxia in patients with chronic underlying lung disease. Hypoxia is thought to be due to intrapulmonary shunting through stimulation of nasovagal reflex.

24. Summary
Epistaxis is common complaint affecting 60% of population at some point in lifetime
Key to evaluation is differentiation between anterior and posterior bleeding source
Anterior = % (from Kiesselbach’s plexus)
Posterior = 5-10% (from sphenopalantine artery)
Consider possible causes for epistaxis with recurrent or difficult to control nosebleeds
Non-invasive techniques will stop the majority of epistaxis (Trotter’s method, cautery, vasoconstrictive compounds)
Difficulty to control epistaxis may require nasal packing
Consider antibiotics while packing in place
Posterior nasal bleeds should all be hospitalized

25. Questions

26. References
Alter, Harrison. Approach to the adult with epistaxis. Accessed 6/29/08.
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