Epistaxis is simply nosebleeds. It is usually resolved with minimal treatment. However, sometimes it can cause a haemorrhage which needs urgent intervention.
The bleed can originate anteriorly or posteriorly:
- Anterior:
- Posterior:
This is most common (90%). There is a region in the anterior inferior quadrant of the nasal septum known as Little’s area. It contains the Kiesselbach plexus which is made of 5 arteries that all anastomose and supply oxygen to the nasal septum
These occur in the posterior nasal cavity due to branches of the sphenopalatine arteries. It is more common in elderly patients.
😷 Pathophysiology and presentation
Bleeding is usually unilateral. If it is bilateral it indicates a posterior bleed (which has higher risk of aspiration).
There can be primary and secondary causes of epistaxis:
Primary:
The majority of bleeds are primary bleeds. In these cases there is often no clear cause of the bleed.
Exacerbating factors can be nose picking and nose blowing foreign bodies.
Secondary:
This is when there is an identifiable factor, such as:
- Alcohol
- Antiplatelets
- Aspirin and NSAIDs
- Anticoagulants
- Cocaine
- Sinutsitis and colds
- Trauma
- Tumours
- Surgery
- Septal perforation
- Coagulopathy (immune thrombocytopenia or Waldenstrom’s macroglobulinaemia, Von Willebrand disease)
🔍 Investigations
First we should take a detailed history assessing for auny recent trama, co-morbidities, family history (of coagulopathy) and any drug history.
- An ABCDE assessment needs to be taken to in cases of life-threatening epistaxis.
- A nasal inspection may be undertaken using a nasal thudicum.
🧰 Management
[UPDATE THIS WITH NICE CKS GUIDANCE ON RECURRENT EPISTAXIS]
- Sit up and lean forward. Do not tilt the head backwards as this increases the risk of aspiration.
- Squeeze the nasal alae (cartilage) is the first-line management for most anterior bleeds. Compress for 10-15 minutes without interruption.
If 10-15 minutes of compression is not successful, we can try nasal cautery or nasal packing:
Cautery can be done in 2 ways:
- Electrical - basically diathermy.
- 🥇 Chemical - using silver nitrate sticks. They should be applied for 3-10 seconds.
It should be done after using a topical local anaesthetic such as co-phenylcaine.
After cauterisation, a topical antiseptic should be applied such as:
- Naseptin - chlorhexidine and neomycin.
We can use:
- Nasal tampons
- Inflatable packs
- Ribbon gauze impregnated with Vaseline.
If the bleed is from a posterior source or the source cannot be identified we can use ligation or radiological embolisation (blockage of the vessel deliberately [most commonly the sphenopaletine artery, but we should never embolism the anterior ethmoidal artery as this originates from the ICA]).