Epistaxis: how to stop it

Epistaxis: how to stop it

PETER NOYCE, MB BS, FRACS

Most patients with epistaxis can be dealt with ad­

equately by the primary care doctor without specialist assistance. However, there is a small group, particu­

larly in the elderly, where epistaxis can be serious and even life-threatening. Such patients may require hos­

pitalization, intensive care and even surgery. To man­

age epistaxis properly an understanding of the causes of nasal anatomy and physiology is essential.

■ Nasal anatom y and blood supply

The nasal mucosa is endowed with a rich blood supply, from both the external and internal carotid a rteries. T here is confluence of the two systems, particularly at the caudal end of the nasal septum where a number of arteries anastomose with each other, ie Little’s area (Figure 1). The dividing line for the blood supply of the lateral wall of the nose and the nasal septum is approximately at the middle turbinate. The internal carotid artery, via the posterior and anterior ethmoidal artery, supplies above this and the ex­

tern al carotid artery, via branches of the maxillary artery and facial artery, supplies the rest of the nose (Figure 2).

Little’s area is the site of most

Dr Noyce is Visiting Otolaryngologist, Westmead Hospital, Westmead, NSW, Australia. He wrote this article specially for Mo d e r n Me d ic in e.

anterior nose bleeds. Most pos­

terior epistaxis occurs at the entry zone of the sphenopalatine artery just behind the middle turbinate on the lateral wall of the nose.

Why does th e nose bleed?

Why the nasal lining is par­

ticularly prone to bleeding is not exactly known, but the fol­

lowing facts are probably im­

portant:

• The nasal epithelium, espe­

cially that of the cartilaginous septum, has very little cush­

ioning submucosal tissue. Ves­

sels are offered little protection, and the contraction of an injured vessel to close its lumen can be quite limited due to the lack of an elastic submucosal layer.

• The nose is constantly exposed to inspired and expired air;

tem perature and hum idity changes, and external irritants, if ex cessive, can easily

traumatise the lining.

• Histopathological studies of middle, and old-aged, nasal arteries have shown:

—the progressive displace­

ment of muscle tissue in the tunica media by fibrosis. This may cause failure of the blood vessels to contract adequately, leading to lengthy bleeding.

— older nasal arteries tend to have extensive calcification in their lumen, and thereby lack elasticity. This may create a local systolic hypertension and lead to small vessel rupture.

The precise mechanism of bleeding is unclear, although some studies have shown small local dissecting aneurysms in posterior nasal vessels.

Epidem iology

Epistaxis is relatively common, affecting up to 10% or 12% of the population in some studies.

Fortunately, most epistaxis occurs from the anterior septal area, that is, Little’s area. There are generally two groups of patients:

• Children from the age of two to 10 and young adults from 15 to 25 years. This group forms the vast majority of epistaxis patients. Most epistaxis occurs from the an terior septum (Little’s area) in children and young adults. In children, epistaxis is usually associated

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E p is ta x is ■ Most epistaxis occurs from the

continued. | anterior septal area, but posterior

bleeding may occur in older patients.

This is more difficult to control.

Little’s area Posterior

ethmoidal artery

Anterior ethmoidal artery

Greater artery

Superior labial artery

Figure 1. Blood supply to nasal septum. Little ':

site of most anterior epistaxis.

t_»l 1C U l p u o i c i IUI epistaxis

Sphenopalatine Anterior ethmoidal artery

Posterior ethmoidal artery

with no more than mild irrita­

tion or excoriation of the mu­

cosa. Epistaxis in children of­

ten produces parental concern out of proportion to the actual danger. Occasionally, bleeding may herald a serious illness such as n a sop h a ryn gea l angiofibroma or a blood disor­

der. Children with recurrent, prolonged anterior epistaxis may rarely develop chronic anaemia.

• A group of older patients aged 45 to 65 years. In these pa­

tients, bleeding usually occurs posteriorly. It is this group which is most difficult to control and where more intensive treatment may be needed.

D efinite causes

There are only a small number of cases where epistaxis can be attributed to a well defined pri­

mary cause, such as a blood dyscrasia, a blood vessel ab­

normality or local nasal pathol­

ogy. In most cases, bleeding

arises from an artery or vein without any obvious abnormal­

ity. This is termed “spontane­

ous” or “idiopathic” epistaxis.

While anterior epistaxis can quite often be recurrent and

T A B L E 1

Predisposing factors

Trauma Dry air

External injury (eg fractured nose) Foreign body

Patient-induced (nose picking) Postnasal surgery

frequent, the more severe pos­

terior epistaxis fortunately seems to recur no more than once or twice.

There are a group of common predisposing factors which

Blood vessel disease

Hypertension and artherosclerotic vascular disease Hereditary haemorrhagic telangiectasia

Blood dyscrasias Anticoagulant drugs

Platelet abnormality (eg ITP, aspirin ingestion)

Coagulation defect (eg von Willebrand’s disease, haemophilia, alcoholic)

Neoplasm

Juvenile nasopharyngeal angiofibroma Carcinoma

Inflammation

Upper respiratory tract infection (viral, bacterial) Allergic rhinitis

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E p is ta x is I While anterior epistaxis is often

continued | frequent and recurrent, the more

serious posterior epistaxis seems to recur but once or twice.

seem to occu r m uch m ore frequently with epistaxis. It is essential that the treating d octor look for all these factors (Table 1).

M anagem ent of

spontaneous ep istaxis

Anterior epistaxis Initial first aid

These patients can usually be managed on an out-patient ba­

sis and rarely require admis­

sion to hospital. The bleeding patient is instructed to sit up­

right, leaning forward over a bowl. The patient or parent pinches the front of the nose,

just at the edge of the alae nasi, between the flat edge of the fingers (thumb and forefinger), often with a damp cloth between the fingers. Quite often pres­

sure maintained for 10 to 15 minutes will stop bleeding from Little’s area. Some patients can take a large cotton ball, soak it in hydrogen peroxide, squeeze the peroxide out and insert the cotton ball just into the front of the nose for one to two hours to ensure complete haemostasis.

Nasal cautery

Nasal cautery of the anterior septal area can be very useful, either during a bout of epistaxis,

or to cauterize vessels which have been causing recurrent bleeding. Simple instruments required include a head mir­

ror, a nasal speculum, nasal packing forceps, and metal ap­

p lica tor (F igu re 3). The patient’s nose is examined for bleeding, local disease or any local abnormalities. If a child, it is best the patient sits on the parent’s lap facing the exam­

iner. Cotton wool pledgets soaked in local anaesthetic, usually topical lignocaine 4%

(Xylocaine), are placed in the nasal vestibule against the anterior septal area. These are left in for 10 to 15 minutes. The

Figure 3 (above left). Basic instruments for nasal packing.

From left to right clockwise: head mirror, nasal speculum, nasal forceps for packing, applicator with cotton wool on top (ASKO Swabbing Broach), nasal sucker.

Figure 4 (left). Basic nasal endoscopy equipment.

Figure 5 (above). Nasal packing. From left to right clock­

wise: Vaseline gauze, inflatable balloon, postnasal pack, Foley’s catheter.

1 '

ft

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E p is ta x is I In anterior epistaxis, cautery o f

continued. | the bleeding area can be very useful.

Use a local anaesthetic and then a chemical agent.

TVeatment of anterior epistaxis

Anterior nasal pressure - 10 minutes Cotton wool with H20 2

I

Nasal

\

cautery

Nasal packing Lubricating ointment

\

bleeding site, or the vessels of Little’s area, are then cauter­

ized with trichloroacetic acid or a silver nitrate stick. Electrical cautery of the anterior septal area can be carried out in adults, but even for them it can be very unpleasant and painful. In-sur­

gery electrocautery under local anaesthetic is rarely used in children as it can be very fright­

ening and dangerous if the child is struggling.

Post-cautery treatment

The cautery may often initiate a bleed and a firm cotton wool pack soaked in local anaesthetic is usually inserted into the na­

sal vestibule and left there for up to an hour to ensure full haemostasis. It is essential that the patient is given a moisturiz­

ing ointment to apply to the anterior nose at least two or three times a day (eg Kenacomb ointment) while the cauterized area heals. Patients should be warned that there may be some

bleeding from the cauterized area for up to two weeks, while the area heals and the crusts come away. If there has been bleeding from the other side of the anterior septum, the pa­

tient should return in four to six weeks for a second cautery.

Never cauterize both sides of the nasal septum at the one sitting for fear of septal perfo­

ration.

Nasal packing

In the rare case where copious bleeding continues, the ante­

rior nose will need to be packed firmly with gauze impregnated with antibiotic ointment or vaseline. It is not necessary in these cases to insert deep nasal packing but, usually, only into the anterior nasal vestibule.

Such patients should be admit­

ted to hospital for observation for 24 to 48 hours and then the pack removed. It is not recom­

mended that cotton wool or other packs soaked in adrena­

line are placed in the nasal passage. There is no way of knowing the amount of adrena­

line which may be absorbed into the highly vascular nasal mu­

cosa and this can be quite dangerous in an elderly patient.

It is also essential that dry gauze is not used for packing as this can be locally traumatic.

Gauze well lubricated with vaseline, antibiotic ointment or bismuth iodine petroleum paste must be used.

Posterior epistaxis Elderly population

Posterior epistaxis usually oc­

curs in middle-aged and eld­

erly people. It is commonly seen in those with systemic medical disorders, particularly hyper­

tension and arteriosclerotic vascular disease. There is often regular ingestion of aspirin and alcohol. Large quantities of blood can be lost from the back of the nose and swallowed. This can be associated with a signifi­

cant morbidity and occasional mortality.

Posterior epistaxis is a serious medical condition and must be trea ted as such. U su ally adm ission to hospital and undergoing extensive prolonged pack in g are n ecessary.

O cca sion a lly , su rgery is required.

Initial first aid

The patient leans forward and allows blood to run out of the nose into a bowl so that an esti­

mate of blood loss can be made.

The patient should remain calm so as to reduce stress and to help reduce possible raised

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E p is ta x is continued

blood pressure. There is no evi­

dence that ice packs on, and around, the nose and the back of the neck help. Their use is not recommended.

Initial hospital treatment Initial accurate assessment of the amount of previous blood loss and current blood loss is essential. Medical problems, p a rticu la rly h yp erten sion , should be reviewed and treated appropriately. An intravenous line for fluid volume mainte­

nance and close monitoring of vital signs are essential. In all cases a full blood count, blood cross match, full coagulation screen and platelet count should be performed immediately. If the patient has a history of alco­

hol ingestion, it can often be helpful to give an immediate injection of vitamin K.

Nasal cautery

Using the appropriate instru­

ments (Figure 3), blood is sucked from the nasal passage and an effort made to estimate the bleeding site (high or low in the nose). Occasionally, a bleeding site may be seen and electrocauterized. This is usu­

ally extremely difficult to carry out in the posterior part of the nose, not only because it is diffi­

cult to get at, but because of the copious bleeding. Recent litera­

ture has described the use of nasal endoscopy — small tele­

scopes with suction are inserted into the nose to visualize the bleeding sites which can then be cauterized (Figure 4). These nasoendoscopy techniques are still being developed. Rarely,

upon nasal examination, the bleeding may have stopped and the bleeding site cannot be seen.

Occasionally, if the nasal sep­

tum is rubbed with a blunt in­

strument (eg a cotton wool ap­

plicator) the irritated dilated vessels become obvious and can then be cauterized.

Nasal packing

In most posterior epistaxis, na­

sal packing is essential.

• Emergency packing. In a pa­

tient with massive bleeding, an initial attempt may be made to stop the bleeding by inserting a Foley urinary catheter into the nasopharynx, inflating the bal­

loon in, and then pulling the catheter into the nasal passage, and attempting to wedge it to the posterior part of the nose.

Vaseline gauze or an inflatable balloon (Figure 5) is then packed onto the inflated Foley catheter balloon.

• Anterior nasal packing. This is usually done in a calm and orderly manner with lubricated gauze (vaseline gauze). The pa­

tient needs to sit upright, lean­

ing slightly forward, and the appropriate instruments (Fig­

ure 3) are essential. The patient should be very sedated and the nasal passage anaesthetized with local Xylocaine spray or topical liquid. Usually vaseline gauze (1,8m long) is inserted in the nose, starting inferiorly

along the entire nasal length and then extended superiorly.

The vaseline gauze is placed in the nose in a pleated fashion, with closed loops coming out the front and going to the back of the nasal passage. It should be emphasized that proper an­

terior nasal packing can be very painful for the patient and ad­

equate local anaesthetic and sedation is essential. The ante­

rior nasal packing is left in for at least three to four days. The p atien t shou ld con tin u e bedrest, sedation, a soft diet, and the appropriate systemic antibiotics. It is felt that nasal packing stops epistaxis initially by pressure closing the vessel.

Inflammatory swelling of the nasal vessel occurs after some days and seals it permanently.

• C on tin u ed b leed in g or rebleeding. If anterior packing does not control the initial bleeding, or the nose bleeds once the packing is removed, the next step is an examination under general anaesthesia in the op­

erating room. Few patients come to this, and in most, bleeding can be com pletely stopped by thorough packing under anaesthesia.

• Posterior nasal packing. A posterior nasal pack may rarely be needed initially for massive posterior bleeding, or with con­

tinued bleeding once packs have been removed. The posterior

C O M I N f i Classification of ventricular arrhythmias and implications for their

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Posterior epistaxis is serious: usually hospitalization, extensive prolonged packing and occasionally surgery

are needed.

A b d o m i n a l p a i n . . .

pack is usually inserted under general anaesthesia and essen­

tially consists of a large gauze pack in the nasopharynx with tapes out of the oral cavity and the anterior nasal passage (Fig­

ure 5). An anterior nasal pack or balloon is then inserted in the front of the nose onto the posterior nasal pack.

• Further surgical treatment.In a few patients, bleeding cannot be controlled by both anterior and posterior nasal packing, or the nose keeps rebleeding once the packing is removed. In these circumstances, surgical treat­

ment may be necessary, the details of which are beyond the

scope of this article. Further treatment can include:

— Ligation of the ethmoidal a rteries. T his in volves dissection of the medial orbital wall to cauterize and ligate the ethmoidal artery supplying the top of the nose.

— Ligation of the maxillary artery. This involves surgery through the posterior wall of the maxillary sinus.

— Ligation of the external carotid artery by dissection of the lateral external neck.

— A rterial em bolization.

Modern radiological techniques are now able to advance catheters into most peripheral

arteries. This is a highly efficient and increasingly used technique for controlling severe and prolonged epistaxis. After arteriography to identify the o ffen d in g vessel, the a p ­ propriate material (Gelfoam, plastic ball or very small plastic balloon) is then floated into position.

Unusual cases of ep istaxis

Trauma

Epistaxis after nasal and facial trauma can be life-threatening, as bleeding vessels may be torn and held open by displaced bone.

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E p is ta x is I Epistaxis after nasal and facial

continued. I trauma can be life-threatening,

I as bleeding vessels may be torn I and held open by displaced bone.

It is essential that treatment for epistaxis associated with trauma includes repositioning of all displaced and fractured nasal and facial bones.

Blood dyscrasias

It is essential that the primary cause is treated. This may in­

clude infusion with a coagula­

tion factor or platelet infusion.

Nasal packing needs to be done with great care and heavily lu­

bricated vaseline gauze must be used. The packing should be left in the nose until the pri­

mary blood dyscrasia is treated.

Great care should be taken with

cautery of the nasal mucosa, and its use is not usually rec­

ommended. Local coagulants such as oxidised cellulose, topi­

cal thrombin or microfibrillar collagen may be very useful.

These preparations do not need to be removed from the nose. ■

R eferences

1. Chapter 16:Rhinology. In: Scott Brown's Otolaryngology. 5th edn. Butterworth, 1987:272.

2. Cummings CW. Chapter 34. In:

Otolaryngology — Head and Neck Surgery Vol I. CVMosby, 1986: 614.

3. Bluestone CO. Chapter 27. In: Paediatric Otolaryngology Vol I. WB Saunders, 1983:

719.

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