---

---

***LISTEN TO THE PODCAST HERE***

---

---

Anatomy

Anterior

• Kiesselbach’s Plexus (Little’s area)
  • Confluence of three main vessels
    • Septal branch of the anterior ethmoidal artery
    • Lateral nasal branch of the sphenopalatine artery
    • Septal branch of the superior labial branch of the facial artery

Posterior

• Woodruff’s Plexus
  • Posteriorlateral branches of the sphenopalatine artery
    • Posterior inferior turbinate

---

Epidemiology

• Up to 60% of population will experience a significant nosebleed each year
  • Only 10% need to seek attention
• Common ENT admission condition, but rarely needs surgical intervention
• Bimodal age distribution
  • Before 10 years or between 45-65 years
• Male predominance before the age of 49, then equalizes
  • Estrogen has been shown to protective for mucosa
• Anterior bleeds are significantly more common (>90%) and resolve with minor interventions
• Posterior bleeds can result in significant hemorrhage

---

Etiologies

• Nose picking
• Low environmental moisture
• Mucosal hyperemia of viral or allergic rhinitis
• Trauma
• Foreign body
• Anticoagulation
• Coagulopathies
  • Osler-Weber-Rendu, von Willebrand, hemophilias
• Connective tissue disease
  • Aneurysm development
• Neoplasm
  • Squamous cell, inverted papilloma
• Hypertension
  • Debated as a cause, but has shown to prolong bleeding
• Nasal medications
  • Steroids, oxymetazoline
• Heart failure

---

Patient Assessment

• Primary
  • Airway assessment
    • RR, O2
  • Cardiovascular stability
    • HR, BP
• Secondary
  • History
    • Medications
      • Anticoagulation, aspirin, nasal medications
    • PMH
      • Bleeding disorders, HTN, liver disease
      • Recent trauma
      • History of nosebleeds
        • How often, how long do they last, ever been admitted for one
• Diagnostic Studies
  • Coagulation studies should NOT be routinely ordered
    • Should be in patients on anticoagulation
  • In patients with prolonged bleeds:
    • CBC
    • Type and cross
• Examination
  • Have patient blow nose to remove clots and blood
  • Examine nasal cavity to see if you can see the bleeding site
    • Otoscope, nasal speculum
    • Don’t have patient tilt head back
      • Nasopharynx lies in anteroposterior plane and this will obscure the majority of the cavity from view

---

Interventions

• Initial (Woodpecker/Walrus technique)
  • Have patient blow nose to remove clots
  • In a small basin mix any or all of the following:
    • Oxymetazoline
    • Lidocaine with epinephrine
    • Tranexamic acid
    • If available, soak GelFoam/Surgicel in this fluid and place BEFORE the sponge sticks
  • Trim two oral sponge swabs to better fit in the nasal cavity and soak in the fluid
  • Make a nasal bridge clamp by taping two tongue depressors together on one end
  • Place swabs in nasal cavities and apply nasal clamp for 10-15 minutes
  • Ice pack can also be used

• Cautery
  • If the bleeding site can be visualized on direct examination
  • Apply topical anesthetic
  • Silver nitrate sticks
    • Start from periphery and roll to center of bleeding
    • No more than 10 seconds
    • A white eschar should form

• Nasal packing
  • Use if cautery fails
  • Ensure topical anesthesia
  • Soak in sterile water
  • Insert by sliding along the floor of the nasal cavity PARALLEL to floor
  • Insufflate the balloon with air

• Nasal Balloon Catheters
  • For posterior bleeds
  • Follow same steps for nasal packing
  • Insufflate posterior balloon FIRST and apply gently traction
  • Then insufflate the anterior balloon

• Foley Catheters
  • If you don’t have a prefabricated nasal balloons, a foley catheter can work
  • Insert the catheter until you can see it in the posterior oropharynx
  • Insufflate with 5-10cc of water
  • Apply traction to seat balloon in posterior choana
  • Add additional water to tamponade
  • Clamp catheter with umbilical clamp or c-clamp from NG tube

---

Disposition and Follow-up

• For simple nasal packing, patients should be evaluated by ENT within 24-48 hours
  • Discuss with consultant need for antibiotic prophylaxis
    • No good evidence supports routine use, but ENT often prefers
      • Amoxicillin-Clavulanate is most commonly used
      • Clindamycin or trimethoprim/sulfamethoxazole should be used if concern for nasal carrier of MRSA
• Posterior bleeds should be immediately assessed by ENT for potential surgical intervention
  • Endoscopic sphenopalatine artery ligation
  • Anterior ethmoid artery ligation
    • Open or endoscopic

---

1893 Cottage Physician

References

1. Kucik CJ, Clenney T. Management of epistaxis. Am Fam Physician. 2005; 71(2):305-11. [pubmed]
2. Villwock JA, Jones K. Recent Trends in Epistaxis Management in the United States JAMA Otolaryngol Head Neck Surg. 2013; 139(12):1279-84. [pubmed]
3. Kotecha B, Fowler S, Harkness P, Walmsley J, Brown P, Topham J. Management of epistaxis: a national survey. Ann R Coll Surg Engl. 1996; 78(5):444-6. [PDF]
4. Fishpool SJ, Tomkinson A. Patterns of hospital admission with epistaxis for 26,725 patients over an 18-year period in Wales, UK. Ann R Coll Surg Engl. 2012; 94(8):559-62. [PDF]
5. Min HJ, Kang H, Choi GJ, Kim KS. Association between Hypertension and Epistaxis: Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg. 2017; 157(6):921-927. [pubmed]
6. Shakeel M, Trinidade A, Iddamalgoda T, Supriya M, Ah-See KW. Routine clotting screen has no role in the management of epistaxis: reiterating the point. Eur Arch Otorhinolaryngol. 2010; 267(10):1641-4. [pubmed]
7. Lin G, Bleier B. Surgical Management of Severe Epistaxis. Otolaryngol Clin North Am. 2016; 49(3):627-37. [pubmed]