Epistaxis: Evaluation, Prevention strategies and Management

Definition and overview

Epistaxis, is the medical term for a loss of blood from the tissue that lines the inside of the nose. While it is a common complaint, it is rarely life threatening. However, it can cause significant concern. 

Types epistaxis and their features

Anterior epistaxis: Bleeding from a source anterior to the plane of the piriform aperture. This includes bleeding from the anterior septum and rare bleeds from the vestibular skin and mucocutaneous junction.

1. Site: Mostly from Little’s area or anterior part of lateral wall
2. Age: Mostly occurs in children or young adults 
   
3. Cause: Mostly trauma
   
4. Features: Anterior bleeds are almost always unilateral, unless the nasal septum is perforated.
   
5. Usually mild, can be easily controlled by local pressure or anterior pack
   

Anterior bleeds usually occur in Kiesselbach plexus on the anterior nasal septum and account for 90% of all nose bleeds. They may also occur on the anterior inferior turbinate.

• Posterior epistaxis: Bleeding from a vessel situated posterior to the piriform aperture. This allows further subdivision into lateral wall, septal and nasal floor bleeding.

1. Site: Mostly from posterosuperior part of nasal cavity; often difficult to localise the bleeding point
2. Age: Mostly After 40 years of age 
   
3. Cause: Spontaneous; often due to hypertension or arteriosclerosis
   
4. Features: Because posterior bleeds occur behind the septum, the blood will often exit both nares and large clots can accumulate in the nasopharynx.
   
5. may be asymptomatic or may present with other symptoms (hematemesis, hemoptysis).
6. Bleeding is severe, requires hospitalization; postnasal packing often required

Posterior bleeds: 5–10% of cases (Woodruff plexus); usually branches of sphenopalatine arteries or in the nasopharynx, often from branches of the carotid arteries.

What is the Woodruffs Plexus? 

Woodruffs Plexus is the Most common site for posterior epistaxis

1. Location: Found in the lateral nasal wall inferior to the posterior end of inferior turbinate.
2. Contributing vessels: Anastomosis between sphenopalatine artery and posterior pharyngeal artery.
   
3. Features: It is a venous plexus 

What is the Causes Of Epistaxis?

Cause of epistaxis divide into primary (Idiopathic) & Secondary causes:

1. Primary: Between 70% and 80% of all cases of epistaxis are idiopathic, spontaneous bleeds without any proven precipitant or causal factor. This is called as primary epistaxis.
2. Secondary: Those cases where the cause of epistaxis is defined like trauma, surgery or anticoagulant overdose.
   

• Coagulopathy secondary to liver disease/kidney disease/ leukemia or myelosuppression
• Trauma or Post surgery like inferior turbinectomy, endoscopic sinus surgery
  
• Warfarin intake (anticoagulant treatment)
  
• Tumors–Juvenile nasopharyngeal angiofibroma hemangiopericytoma. Any young male with profuse and recurrent epistaxis should be investigated for angiofibroma.
  
• Hereditary hemorrhagic telangiectasia (HHT) or Osler-Weber-Rendu disease

Hemophilia which is not a cause of secondary epistaxis but is implicated in the etiology of primary epistaxis though its role is doubted there also.

Epistaxis in children

Epistaxis is rare in children < 2 years. Peak prevalence is in 3–8 years of age.

Epistaxis is more common in children with upper respiratory allergies. “There is a seasonal variation with a higher prevalence in the winter months perhaps due to the greater frequency of upper respiratory tract infections.”

Epistaxis in children are More likely anterior, idiopathic (primarily), and recurrent.  

The Most common cause of Epistaxis in Children 

1. M/C cause of Epistaxis in children is Idiopathic 
2. 2nd M/C cause: Digital trauma/Nose pricking in little’s area which is due to crusting which occurs because of URTI
   
3. Most common cause of unilateral epistaxis in children is Foreign body. In any child with unilateral epistaxis, foreign body should be ruled out.
   
4. Recurrent epistaxis in a 10-year-old boy with unilateral nasal mass is diagnostic of juvenile nasopharyngeal fibroma. Consider neoplasm if recurrent unilateral epistaxis, especially if not responding to treatment.

NB: The M/C cause of epitaxis in adults: Hypertension. When recurrent bleeds occur in adults, secondary epistaxis is most likely. Except for NSAIDs/aspirin use which can cause recurrent epistaxis

What is the Most common site for epistaxis in children and young adults? 

Little’s Area (the anteroinferior part of the nasal septum). This area is called as little’s area as it was identified by James Little in 1879. It is also called as locus valsalvae and is the confluence of internal and external carotid artery. This vascular area is the most common site of nose bleed in children and young adults. It gets dried due to the effect of inspiratory current and easily traumatised due to frequent picking (fingering) of nose.

The Arteries contributing in Little’s Area

1. Sphenopalatine artery (also called as artery of epistaxis)
2. Anterior ethmoidal artery
3. Septal branch of greater palatine artery
   
4. Septal branch of superior labial artery (branch of Facial artery). These arteries form the Kiesselbach’s plexus.

Evaluation and Prevention

Evaluation of patients with epistaxis 

Most patients with epistaxis do not require any laboratory testing. However, additional studies may be indicated in patients with a history of bleeding problems, oral anticoagulant use, possible hepatic disease, or bleeding that is difficult to control. 

1. A CBC to check hemoglobin and look for thrombocytopenia or leukemia.
2. A prothrombin time and partial thromboplastin time to look for overanticoagulation or hepatic dysfunction

Prevention strategies for recurrent or Idiopathic Epistaxis 

1. Humidification at night
2. Cut fingernails and minimize picking. 
   
3. For topical-nasal medication users, direct spray laterally away from septum. Use opposite hand to spray (i.e., right hand to spray in left nostril). 
   
4. Petroleum jelly to prevent anterior mucosal drying 
   
5. Control hypertension (HTN) (controversial association with increased risk for recurrent epistaxis).
   
6. Patient is seated, head forward, to avoid blood going down the posterior pharynx.

Management

Initial stabilization: In a patient who presents with hypotension and tachycardia, an intravenous line should be started, blood samples should be drawn, and fluid resuscitation should be initiated immediately. An adequate airway should be ensured in all patients.

General Measures

1. The patient should be seated in a protective gown with a basin to collect blood. 
2. While waiting for treatment, the patient applies direct pressure by pinching the lower part of the nose (nasal ala) for 5 to 20 minutes without a break. This stops bleeding in most patients.
3.  Cleanse nasal cavity of blood clots by blowing nose.
4. An ice pack placed over the dorsum of the nose may help with hemostasis.
   
5. If the bleeding has stopped, the patient should be observed for 15 to 30 minutes. No additional treatment is necessary.

The absence of an anterior bleed and continued epistaxis point to a more serious posterior bleed.

If General measures fail, Treatment options Include: 

First Line: If general measures fail, affected naris may be sprayed with topical vasoconstrictor, such as: 

• Phenylephrine: 0.5–1%
• Oxymetazoline: 0.05% 
  
• Epinephrine: 1:1,000 

Second Line 

1) Chemical (silver nitrate) or electrical cautery 

• If an actively bleeding anterior septal site is visualized, this may be treated with gentle silver nitrate cautery for ~10 seconds for definitive treatment. 75% silver nitrate is preferred. Apply in a spiral fashion, starting around the bleeding vessel, moving inward.
• Limit cautery (silver nitrate) to one side of septum, or wait 4 to 6 weeks in between treatments to reduce risk of perforation. 

2) Nasal packing: ribbon gauze, nasal tampons, nasal balloon catheter 

• Posterior bleed – In the emergent setting, this may be attempted utilizing a Foley catheter or a specific posterior packing balloon.
• With both methods, the tubing is introduced through the nose similar to the passage of a nasogastric tube. 
  
• Once it reaches the posterior oral pharynx, the balloon is inflated and the tubing is pulled back outward to tamponade the posterior bleeding source. 
• If using a Foley catheter (10 to 14F catheter), the balloon can be inflated with 10 mL of saline.

Posterior nasal packing can cause cardiovascular complications like pulmonary hypertension and corpulmonale since it leads to sleep apnea.

3) Other Options: 

1. FloSeal: A biodegradable hemostatic sealant (a thrombin-type gel) in one  is more effective and better tolerated than packing. 
2. Local application of tranexamic acid may reduce bleeding time as compared to anterior packing.

4) For intractable/refractory: Consider surgical ligation, endoscopic ligation/cautery, endovascular embolization.

Concurrent anticoagulation 

• If bleeding stops with packing, may continue same dose of warfarin if INR therapeutic; decrease dose if supratherapeutic INR.
• If bleeding persists despite packing, stop anticoagulation and administer vitamin K 10 mg IV ×1, recheck INR in 30 minutes, if still >1.5, give PCC.
  

Novel anticoagulation may be associated with lower rates of epistaxis than warfarin. When epistaxis occurs, it may be harder to control.