Clinical Medicine and Therapeutics

REVIEW

Updates on the Management of Epistaxis

Chin-Lung Kuo, MD, PhD1,2*

1
Department of Otolaryngology, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
2
Institute of Brain Science, National Yang-Ming University school of Medicine, Taipei, Taiwan

netheless, cases of recurrent epistaxis should be checked by an otolaryngologist, and severe nosebleeds should be referred to the emergency department to avoid adverse consequences,

INTRODUCTION sphenopalatine artery and descending palatine artery. The sphenopalatine

ar- tery supplies the mucosa in most of the nasal septum and turbinates.
Epistaxis refers to hemorrhaging from the nose (i.e., nosebleed). This condi- The descending palatine artery has two or three branches, including the
tion is among the most common otolaryngologic emergency, affecting greater palatine artery, which takes a circuitous course passing inferiorly
rough- ly 60% of individuals [1], of whom 6-10% require medical attention through the greater palatine canal and foramen to supply the nasal septum
[2-6]. Most individuals experiencing epistaxis do not pursue medical help; and floor of the nose. The facial artery divides into various branches,
however, if not dealt with in an appropriate manner, cases of extreme including the angular artery, lateral nasal artery, and superior labial artery,
bleeding can lead to airway obstruction, aspiration, asphyxiation, which supplies the sep- tum and nasal alae [7]. The internal carotid artery
hypovolemic shock, or even death [7-9]. Recent advances in endoscopy supplies the region above the middle turbinate broadly via the anterior and
have facilitated nasal examina- tions; however, the effective management of posterior ethmoid arteries.
this condition depends on an awareness of the probable sources of epistaxis
and a comprehensive under- standing of the nasal structure. This paper
presents a review of the literature on epistaxis including recent advances in TYPES OF EPISTAXIS
its treatment. This article also pro- vides stepwise algorithms to guide
clinicians through the decision process un- derlying the management of Nosebleeds are categorized as primary or secondary. Primary nosebleeds
epistaxis. are idiopathic and spontaneous, whereas secondary events have definite
causes, such as trauma or the use of anticoagulants [20]. Despite the
complexity of the circulatory system in the nose, on the other hand,
EPIDEMIOLOGY nosebleeds can also be categorized simply as anterior or posterior,
depending upon the source of bleeding. Most cases of epistaxis (90% to
Epistaxis occurs in up to 60% of the general population [6]. The incidence of 95%) occur at an anastomosis re- ferred to as Kiesselbach’s plexus or Little’s
epistaxis presents a bimodal distribution, with most cases occurring in area in the inferior region of the an- terior septum [11,21-25]. This area is
individ- uals below the age of 10 and above the age of 70 [6,10-12]. The saturated with branches of the superior labial artery, anterior and posterior
average age of patients hospitalized for nosebleed is 70 years old [13]. ethmoid arteries, sphenopalatine artery, and greater palatine artery. These
Elderly individuals account for 40% of the cases requiring medical arteries are supplied by base branches of the internal and external carotid
intervention, due primarily to the fact that bleeding events among the arteries [26]. A relatively small number of cases of epistaxis (5 to 10% of the
elderly can have severe consequenc- es. Children tend to present with total) are associated with arteries beneath the posterior end of the inferior
uncomplicated nosebleeds in the anterior region, which seldom require turbinate, which forms Woodruff’s plexus [21,24,27].
surgical intervention [14]. Despite the low prev- alence of epistaxis among
children below the age of 2, all such cases should be carefully examined for
signs of trauma, the presence of an external object, or systemic illness [15]. ETIOLOGY
Males are slightly more likely than are females to ex- perience epistaxis
[12,16], due perhaps to the protective effects of estrogen [11,17-19]. Thus, Epistaxis is a multifactorial entity. The etiology of nosebleeds can be catego-
there is a predominance of males among hospitalized pa- tients below the rized according to the cause as local, systemic, environmental, or drug-
age of 49 and a more equal sex distribution above this point. related. The local origins of epistaxis include trauma, intranasal neoplasia,
inflamma- tory disease, and septal abnormality. A rich vascular network

ANATOMY renders the nose susceptible to epistaxis. This is exacerbated by the fact
that blood vessels with- in the nasal mucosa are outwardly situated, leaving
them exposed to damage. Most of the cases encountered by clinicians
The primary functions of the nose include warming and humidifying inhaled involve some sort of trauma or irritation to the mucosa and/or associated
air. This requires copious quantities of blood from external and internal blood vessels [28,29]. One com- mon example is injury resulting from the
carotid arteries (Figure 1). The external carotid artery serves as the major insertion of a finger (nose picking) [30]. Kiesselbach’s plexus is completely
contributor and provides arterial flow primarily via the maxillary artery and exposed just within the cavity of the nose. Nosebleeds due to blunt trauma
secondarily via the facial artery. The maxillary artery splits into several are typically from an anterior source.
branches, including the
Clinical Medicine and Therapeutics DOI: 10.24983/scitemed.cmt.2019.00106
2019;1(1):5
1 of
REVIE
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Figure 1. Arterial supply of the nasal cavity.

The introduction of a foreign object into the nose can cause profuse bleed- sociated with an underlying vasculopathy that includes atherosclerosis may
ing. In cases where the item has remained in that position for more than 24 be a risk factor for epistaxis [39]; however, there is little evidence to support
hours, bleeding may be accompanied by pus-filled nasal discharge [31]. this assertion [40]. Furthermore, elevated arterial blood pressure at the
Naso- tracheal intubation, nasogastric tube insertion, and the chronic use of onset of epistaxis may also be associated with stress and/or white coat
nasal cannula are some of the most common causes of epistaxis among syndrome [41]. Alcohol has been linked to an elevated risk of epistaxis [42].
hospital- ized patients. Fiberoptic guidance during nasotracheal intubation Alcohol consumption reduces platelet aggregation, which can prolong the
has been shown to reduce the incidence and severity of epistaxis, compared duration of bleeding. Hemodynamic changes may also be associated with
with con- ventional (unguided) insertion [32]. Recurrent epistaxis can be some cas- es of epistaxis. Epistaxis is the most common manifestation in
caused by sin- onasal tumors, including squamous cell carcinoma, adenoid patients with hereditary hemorrhagic telangiectasia (HHT, also called Osler-
cystic carcinoma, melanoma, inverted papilloma, or other rare tumors Weber-Rendu syndrome), occurring in 90% to 95% of patients [43]. HHT is
[25,33]. It is notable that nasopharyngeal cancers are far more common an autosomal dominant vascular disorder, which has been somewhat under
among southeast Asians than among Caucasians [34]. The possibility of reported [44]. Several patients with HHT have been found to be resistant to
nasopharyngeal cancer needs to be excluded in southeast Asians with treatment for epistaxis, including oral estrogen, topical estriol plus argon
nosebleeds, in particular if specific symp- toms and signs are concurrently plasma coagula- tion, oral tamoxifen, oral tranexamic acid, submucosal
observed, such as unilateral aural fullness and neck masses. When dealing bevacizumab, topical bevacizumab, and sclerotherapy [43,45-50].
with teenagers suffering from nosebleeds, it is imperative to consider Intravenous bevacizumab [51] and thalidomide [52,53] have been reported
juvenile nasopharyngeal angiofibroma, a benign but aggressive and as effective and safe in reduc- ing the incidence of epistaxis in HHT patients;
expansile tumor that can invade adjacent structures resulting in extensive however, further research is required to validate the benefits in terms of
bleeding [35]. Cases of neoplasia are rare; however, it is import- ant that quality of life. Many patients with other bleeding ailments suffer from
clinicians conduct a rigorous examination to conclusively exclude this recurrent episodes of epistaxis [45]. It is essential to consider a bleeding
possibility. diathesis when treating patients with recur- rent spontaneous epistaxis
Systemic causes of epistaxis include hypertension, cirrhosis, alcoholism, [11,54].
aberrations in clotting ability, inherited bleeding diatheses, and vascular/ Environmental factors also play an important role in the onset of
cardiovascular diseases [20,36,37]. Despite the fact that hypertension is not epistax- is. There is a general increase in epistaxis in the winter months, due
a direct cause of epistaxis, it has been linked to cases of severe or refractory to lower temperatures and drier air [11,16,36,55]. Dry air tends to irritate
epistaxis [15,36,38]. Some researchers have surmised that hypertension the mucosa, leaving it susceptible to bleeding under even slight aggravation.
as- Irritation from
nasal infection or allergic rhinitis can also make the nasal mucosa friable, fol- also crucial that clinicians inquire about hematemesis and the occurrence of
lowing the inflammation of nasal turbinates [13,42,56-61]. Epistaxis has black, tarry stools [45]. Patients
been associated with the topical use of nasal steroids; however, the
incidence of epi- staxis among patients taking these drugs is only slightly
above the incidence of those taking a placebo, and the symptoms are
usually minor and self-limiting [62-66]. Manfredini et al. linked the incidence
of epistaxis to cardiac rhythms. They found that the time of epistaxis
occurrence presents a biphasic circadian pattern, with a primary peak in the
morning, a smaller secondary peak in the evening, and a nocturnal nadir
[67]. The authors commented that this biphasic pattern closely resembles
the circadian rhythm of blood pressure, suggesting that blood pressure may
be associated with epistaxis.
A number of drugs such as warfarin, dipyridamole, rivaroxaban, and
nonsteroidal anti-inflammatory drugs (NSAIDs) can affect blood coagulation
[1,29,40,68]. NSAIDs, including aspirin and ibuprofen, are the most common
drugs that may interfere with coagulation [45]; however, researchers have
yet to establish a definitive causal association between the use of NSAIDs
and ep- istaxis [69-71]. It has been estimated that 24% to 33% of patients
admitted for nosebleeds are taking anticoagulants or antiplatelet
medications [2]. Vitamin K antagonists, such as phenprocoumon, have also
been shown to contribute to recurrent epistaxis [68,72]. It has been
reported that specific serotonin re- uptake inhibitors and antibiotics can
induce epistaxis; however, most of those bleeding episodes are mild and
easily reversed [1]. Overall, it is important that clinicians refer to the
medication history of patients with epistaxis and consid- er alternative
causes.
Patients undergoing treatment with anticoagulants face an elevated risk
of nosebleeds; however, there are as yet no clear guidelines regarding the
means by which epistaxis patients should be treated in cases of an elevated
international normalized ratio (INR) of 5 or more [11]. There is also a
degree of controversy regarding whether patients with thromboembolic
risks present- ing with a minor nosebleed or bleeding from an inaccessible
site should be treated using local measures or surgical interventions. Further
high-quality re- search will be required to resolve this issue [73,74]. At
present, clinicians base their selection of treatment methods on the site
and extent of bleeding, histo- ry of bleeding, the perceived likelihood of
progression to more severe bleed- ing, comorbidities including hypertension
and renal insufficiency, INR level, and the likelihood that INR has been
supratherapeutic over the previous few measurements [75]. Treatment
options include ceasing warfarin treatment, ceasing warfarin with vitamin K,
or initiating aggressive anticoagulation rever- sal for patients presenting with
pronounced bleeding [73]. As long as hemo- stasis can be achieved, patients
with mild nasal bleeding can safely continue with their warfarin regimen,
albeit with suitable adjustments [28].

MANAGEMENT OF EPISTAXIS

Evaluation of Epistaxis
Figure 2 presents a flow diagram detailing the evaluation and management
of patients with epistaxis. Before examining patients with epistaxis,
practitioners must ensure that the patient has a patent airway and
cardiovascular stabili- ty. In cases of extensive bleeding and/or low blood
pressure, it is important to transport the patients to the emergency
department as soon as possible to avoid subsequent consequences.
Clinicians in the emergency department should collect data related to blood
type and cross-matching for possible blood transfusions [76,77].
After confirming hemodynamic stability, clinicians should collect a
focused history to identify the factors that could contribute to epistaxis.
Clinicians should obtain an account of the acute episodes and previous
incidents (if any), including the extent, seriousness, frequency, and laterality
of nosebleeds, as well as the methods used to control them. In cases of
severe hemorrhaging or refractory epistaxis, it is important to consider
conditions that predispose the patient to bleeding or other related injuries,
including coagulation disorders, medications, and alcohol consumption. It is
undergoing treatment with anticoagulants should be evaluated to identify
potential hemostatic disorders. Routine clotting screening is not required
for patients who do not present with relevant risk factors [78,79].
The initial evaluation is meant to eliminate factors that could
predispose the patient to epistaxis and identify the source of bleeding.
Epistaxis can be classified as anterior or posterior according to the source
of bleeding, and it is crucial to differentiate between the two. Anterior
nosebleeds are the most common and are usually self-limited. Posterior
epistaxis generally involves more profuse bleeding and cannot always be
managed in a primary care set- ting [11]. Slight bleeding is generally
indicative of an anterior source; howev- er, a large volume of blood does
not necessarily indicate a posterior source. Bleeding from both the
nostrils is a clear indication of a posterior source. Bi- lateral epistaxis can
occur in patients with a septal defect or bilateral nasal lesions.

Initial Management of Epistaxis

Initial management includes the application of pressure to areas of
bleeding using cotton or gauze saturated in a topical decongestant
[80,81]. In cases where a clinician is unable to determine the source of
the bleeding, nasal packing should be applied in both nasal cavities using
vasoconstrictor-soaked pledgets to hasten hemostasis. Vasoconstrictors,
such as oxymetazoline, phenylephrine, or lidocaine, can reduce topical
bleeding through vasoconstric- tion without the risk of elevating systemic
blood pressure [80,82]. If this proves insufficient to halt bleeding, then
the source is most likely posterior, and pos- terior packing may be
required. Tilting the head forward helps to prevent the pooling of blood
in the posterior pharynx and thereby may prevent nausea and airway
obstruction.
The severity of epistaxis can range from light nosebleeds to
potentially fatal bleeding. Minor events are easily managed in a clinical
environment; however, major events often require hospital admission and
even surgical in- tervention. In the event that the patient does not
respond to initial treatment, efforts must be made to find the cause of
the bleeding [6,68,83]. Children must be examined closely for a foreign
body or nasal mass to ensure that epistaxis is benign [84]. Bleeding
disorders should also be clinically excluded for patients with recurrent
epistaxis.

Treating Anterior Epistaxis

Compression is the primary treatment mode for minor anterior epistaxis.
This involves having the patient bend forward at the waist while sitting
up to avoid swallowing blood. The clinician then applies pressure by
grasping the alae distally and pinching them tightly against the septum
without releasing the pressure for 5 to 10 minutes. If the initial treatment
fails to stop the bleeding, a plug of cotton wool or a pledget can be
inserted into the nasal cavity. Blood clots accumulated in the pharynx
should be gently removed by suction, and a cold compress can be
applied to the bridge of the nose before referring the patient to a
specialist.
Patients lacking hemodynamic stability should be immediately
referred to the emergency room for stabilization. Stadler et al. reported
that an emer- gency consultation for epistaxis may be an unfavourable
predictor of mortality [85]. Patients who are expected to maintain
hemodynamic stability should be referred to an otolaryngologist for a
more comprehensive medical evaluation and management [11]. The
adoption of nasal endoscopes in the field of oto- rhinolaryngology has
shifted the paradigm by which epistaxis is treated and has greatly
improved outcomes. Endoscopes make it far easier to identify the point
of bleeding with a high degree of accuracy [86]. It has been reported
that without endoscopic assistance, clinicians fail to identify the point of
bleeding in up to 50% of cases involving severe epistaxis [86].
Topical vasoconstrictors, such as oxymetazoline, phenylephrine, and
lidocaine, have proven highly effective in the treatment of epistaxis [80,82].
Otolaryngologists spray a vasoconstrictor into the bleeding nostril and then
insert a vasoconstric- tor-soaked pledget into both nasal cavities and
compress them tightly for 5 to 10 minutes before slowly removing the
pledgets [80]. During nasal packing, it is im- portant that the clinician inspect
the oropharynx for signs of continuing bleeding.
Figure 2. Flow diagram for the management of epistaxis.
 In cases where direct pressure using vasoconstrictor-soaked pledgets is meant to assist in clearing blood clots from the nasal cavity.
unsuccessful, chemical cautery can be attempted. This involves the applica-
tion of a silver nitrate stick directly to the bleeding point for 10 to 20
seconds. Topical silver nitrate interacts chemically with the lining of the
nasal mucosal, causing it to become inflamed. This leads to the excretion of
fibrinous exu- date, which coagulates on the surface to form a
pseudomembrane that stops the bleeding [87]. Electrocauterization is also
effective in dealing with per- sistent epistaxis of the anterior septum. A
metallic hoop warmed by an electric circuit is placed around the bleeding
artery, thereby enabling the application of heat to the affected area via
radiation (i.e., without coming into direct con- tact). It is notable that the
overuse of cauterization or the application of these techniques to both
sides of the nasal septum can lead to septal perforation or other mucosal
trauma, which may worsen the bleeding.
A failure to identify the bleeding point or stop the bleeding via
cauteriza- tion is an indication that pressure should be applied directly at
the site of epi- staxis using special packing materials lubricated with
antibiotic ointment. Sev- eral packing materials have been developed
specifically for the treatment of epistaxis to overcome the difficulties
involved in inserting conventional ribbon gauze (e.g., Vaseline or bismuth-
iodoform paraffin paste impregnated packs). Two common pre-prepared
packs on the market include non-absorbable Merocel (Medtronic Inc.,
Minneapolis, MN, USA) and absorbable Nasopore (Polyganics, Groningen,
the Netherlands). In randomized, controlled trials, these materials were
shown to stop the bleeding in approximately 60 to 90% of refractory cases
[88-91].
Merocel is a sponge of hydroxylated polyvinyl acetate, which has been
compressed through dehydration. Rehydration through the injection of nor-
mal saline causes it to increase in size within the nasal cavity, thereby com-
pressing the bleeding point [92]. It also allows localized clotting factors to
reach the concentration levels required for coagulation [87]. The downside
of non-absorbable packing is the need to remove it, which can cause the pa-
tient considerable pain and discomfort. Nasopore is dissolvable, bioresorb-
able foam, which expands through the absorption of water to support the
surrounding tissue and apply pressure to bleeding vessels in the nasal cavity.
Nasopore can be suctioned from the nasal cavity after it begins to dissolve,
usually within a few days of insertion [92]. Note that nasal packing material
should always be inserted backwards along the roof of the mouth, instead
of upwards. Incorrect insertion of these materials can exacerbate mucosal
damage and worsen the bleeding. In the event that nasal bleeding continues
after initial packing, additional packing on the opposite side of the nasal
cavity is required.

Treating Posterior Epistaxis

Cases of posterior epistaxis are far less common and are generally referred
to otolaryngologists for further management [26]. Difficulties in imaging and
accessing the source of bleeding can greatly hinder treatment efforts.
Several packing strategies have been devised for posterior epistaxis. In some
cases, packing is meant only to stem the bleeding until a surgical solution
can be im- plemented. The conventional approach involves the insertion of
rolled gauze through the choana, which is then held in place in the
oropharynx using silk stitches [45,93]. A number of companies have
developed “posterior packs”, most of which involve the inflation of balloon
catheters in the nasopharyngeal space to halt epistaxis. One alternative to
posterior nasal tamponade is the insertion of a 10 to 14 French Foley
catheter into the nasal passageway until it is visible in the oropharynx. The
balloon is then filled with 10 to 15 mL of sterile water, whereupon the
Foley catheter is retracted anteriorly until it is lodged against the posterior
choana within the nasopharynx [11,45]. The catheter can be secured using
a clamp before inserting an anterior pack.
Hot water irrigation is another approach to controlling posterior
epistaxis [94-98]. A modified epistaxis-balloon-catheter is introduced into
the bleeding nasal cavity to obstruct the choana. Continuous irrigation using
500 mL of hot water (50 ⁰C) is then applied for 3 minutes. This treatment is
meant to de- crease local blood flow by inducing mucosal edema. It is also
 After packing, it is important to examine the oropharynx to compression, the patient should
determine whether posterior nasal bleeding has ceased. If the nasal
packing proves ef- fective, then it should be kept in place for 24 to 72
hours to enable time for healing prior to removal [7,25,45,99].
Maintaining nasal packing for longer than 72 hours increases the risk of
complications, such as necrosis, toxic shock syndrome (fever,
hypotension, desquamation, and mucosal hyperemia), sinus or
nasolacrimal infections, and dislodgment [11].

Managing Conservative Treatment Failures

In cases where bleeding continues after packing, the patient should be
im- mediately transferred to the emergency department for further
management via arterial embolization or surgical intervention. For more
than 30 years, em- bolization has proven to be a highly effective
alternative to surgical ligation in the treatment of posterior epistaxis with
success rates of approximately 90% [93]. The reported rate of severe
complications, including stroke or blindness, ranges from 2 to 4%
[93,100]. Before conducting an arteriogram, it is import- ant to perform
an otolaryngologic examination for the localization and/or lat- eralization
of bleeding points. In the event that embolization fails to stop the
bleeding, then surgical intervention is required.
When surgical intervention is deemed the only remaining option, the
ar- teries to be targeted must first be identified based on physical
examinations, endoscopic results, and the medical history of the patient.
The conventional approach to the surgical ligation of ethmoidal vessels
involves Lynch incisions [101]. Bipolar electrocoagulation is applied to clip
or coagulate vessels after raising the periosteum off of the lacrimal crest
and posteriorly into the orbit. Advances in endoscopy have also led to
the development of endoscopic liga- tion techniques [102-104]. It is very
likely that endoscopic artery ligation is a better treatment option for
posterior epistaxis, due to its effectiveness and the fact that it is far less
costly than is endovascular embolization [12]. Note that there may be an
overlay between the right and left arterial systems, which can result in
continuous nosebleeds despite unilateral arterial ligation.

COMPLICATIONS

Cauterization brings with it the risk of septal perforation, whereas

packing can induce compression necrosis. The distress felt by patients
undergoing these procedures can be alleviated using oral painkillers. Any
packing method can result in a walled-off cavity in the sinuses, which
greatly increases the risk of infection, toxic shock syndrome, or sinusitis
[61]. Otolaryngologists therefore recommend the administration of
prophylactic antibiotics with staphylococcal coverage, including
amoxicillin-clavulanate or a second-generation cephalo- sporin [91,104-
110].
There is, however, still some debate regarding the prescribing of
prophy- lactic antibiotics for patients with nasal packing to prevent
secondary bacterial sinonasal infection or toxic shock syndrome [11,111].
In practice, prophylactic antibiotics should be administered only to those
facing a higher risk of infec- tion, such as those who are
immunosuppressed, have diabetes, or are of ad- vanced age [11].
The dislodgement of posterior packing due to erroneous positioning
can intensify vagal tone, resulting in bradycardia, hypotension,
hypoventilation, or aspiration. It is therefore recommended that patients
who undergo posterior packing be hospitalized and kept under
observation [8,112]. Hospitalization may also be required for patients
who have serious comorbidities, related symptoms, and/or intractable
anterior nasal bleeding.

DISCHARGE INSTRUCTIONS

All patients who experience recurring epistaxis should be given

rudimenta- ry training in first-aid to deal with recurrences. They must
first learn to apply pressure accurately in the cartilaginous region of the
nose (rather than the na- sal bridge) for at least 5 to 10 minutes. During
 be sitting up and bent forward at the waist to minimize the risk of
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