Beruflich Dokumente
Kultur Dokumente
0025-7125/99 $8.00
.OO
EPISTAXIS
Luke K. S. Tan, MD, MMedSci, FRCS,
and Karen H. Calhoun, MD, FACS
Patients presenting with epistaxis are anxious and fear bleeding to death.
Although death from epistaxis is rare, it can occur, and significant morbidity is
relatively common.5,34 Although most pediatric epistaxis is treated on an outpatient basis, older patients (>60 years old) more often require hospital admission.25,44 Initial management of epistaxis is directed at stopping the bleeding,
and long-term treatment is directed at discovering and correcting the underlying
cause. This article updates current management options.
ANATOMIC CONSIDERATIONS IN EPISTAXIS
The blood supply to the nose arises from the internal maxillary and facial
arteries via the external carotid and the anterior and posterior ethmoid arteries
via the internal carotid artery. The anteroinferior septum (Littles area) is supplied by a confluence of both systems (Kisselbachs plexus). Littles area is a
common site of epistaxis because it is ideally placed to receive environmental
irritation (cold, dry air, cigarette smoke) and is easily accessible to digital trauma.
This area is easy to access and treat. Bleeding arising further within the nasal
cavity can be difficult to reach. Surgical ligation of the contributing arteries can
be challenging because of their deep location and complex anatomy.
PATHOPHYSIOLOGY
Much epistaxis ceases with pressure (digital or packing) over the bleeding
point. An intact coagulation system with accumulation of platelets and clot
formation is required. Abnormal platelet numbers or function or any abnormal-
43
44
ity in the coagulation cascade leads to failure of clot formation and persistent
bleeding.
CAUSE
Environmental Factors
Cold, dry air increases cases of epistaxis. In countries with seasonal climates,
hospital admissions for epistaxis increase during the winter months.24,44, h1 Patients were admitted at a rate of 0.829 patients per day for temperatures less
than 5C compared with 0.645 patients per day for temperatures between 5.1"C
and 10C.61Most had some form of dry air heating, without humidification, in
their homes.
Nasal ciliary activity decreases as temperature drops. Normal ciliary activity
(at 32C to 40C) occurs at about 15 Hz frequency, dropping to less than 5 Hz
below 20"C.lh Although extremely dry air is known to promote epistaxis, the
exact humidification as a preventive measure remains undefined. Temperatures
of above 52C have been associated with cellular damage.56
Local Factors
Trauma
Nose picking and accidental injury are the commonest traumatic causes of
epistaxis. Except with severe facial trauma, such as motor vehicle accidents, this
epistaxis is usually from an anterior nasal source and easily treated.lR
Nasal Septa1 Deviation
Nasal septal deviation is common, but its role in epistaxis is not certain. In
one study, 16% of patients with severe refractory epistaxis had marked septal
deviation.z3In another study of patients with recurrent epistaxis, 81% had septal
The epistaxis group also had a
deviation versus 31%)in the control
higher incidence of radiologically demonstrated septal deviation compared with
the control group (62% versus 37% [P<.02]). The bleeding tended to occur from
the side to which the septum was deviated. Exactly how a septal deviation
could cause bleeding is not clearly established. Because septal deviations do
cause nasal obstruction turbulent air flow, this may cause abnormal mucosal
drying, making the mucosa more susceptible to bleeding.
EPISTAXIS
45
Iatrogenic
Septal, turbinate, nasal, sinus, or orbital surgery can be followed by epistaxis. Blood-stained nasal discharge is common in the initial week or two after
surgery. Severe epistaxis can occur, especially after partial turbinate resection
(0.9% to 8.9%).14Management of such patients is aimed at controlling the bleeding and contacting the surgeon to provide appropriate follow-up.
Inflammation (Infection and Allergy)
Epistaxis can result from nasal lining inflammation, with acute respiratory
infections, chronic sinusitis, or allergic rhinosinusitis. In children and the mentally disabled, intranasal foreign bodies cause unilateral foul-smelling discharge
that can be accompanied by epistaxis. Children with both nasal allergy symptoms and positive skin tests have more frequent epistaxis (20.2%) than those
with symptoms alone (9.9%),positive skin test alone (3.4%),or neither symptoms
nor positive skin test (2.1%). This study suggests that allergic rhinitis predisposes
to epistaxis, either by mucosal irritation or possibly by the atopic state contributing to a hemostasis
Tumors
Many airborne irritants and toxic chemicals (sulfuric acid, ammonia, gasoline, chromates, gl~taraldehyde)~~
irritate or harm the nasal mucosa, resulting in
epistaxis. Cigarette smoke, primary or secondary, is another common irritant.
Systemic Factors
Hypertension
46
Renal Disease
Heavy alcohol consumption increases the risk of epistaxis. The same platelet
reactivity inhibition that provides a protective effect for the coronary arteries
may also increase bleeding time, making epistaxis more difficult to
50
Bleeding risk, however, was not linearly related to alcohol consumption, with
those consuming 1 to 10 alcoholic drinks per week most affected and those
drinking more than 10 drinks per week less affected. Rebound of platelet activity
may explain this finding, but the mechanics have yet to be elucidated. The use
of NSAIDs did not confer an additional risk of increased bleeding
Coagulation and Vascular Abnormalities
EPISTAXIS
47
sine diphosphate and collagen-induced platelet aggregation, enhancing disaggregation and prolonging bleeding time.4zEpistaxis has also occurred in a patient
using hyperosmolar sodium chloride (2%) eye drops.2yThe patient developed
dry nasal mucosa, presumably from osmosis, when the eye drops arrived in the
nasal cavity via the nasolacrimal duct. The problem resolved when sodium
chloride ointment was substituted for the drops. Use of steroid nasal sprays can
also be complicated by epistaxis, which is usually mild and stops after cessation
of use of sprayz4
MANAGEMENT
There are three levels of epistaxis management: (1) first-aid measures, (2)
acute management, and (3) interventions.
First-Aid Measures
In one series of patients taking systemic anticoagulants, 25% had experienced epistaxis in the previous year. Less than half of the patients could think
of a single first-aid measure to stop nosebleeds. Clearly, additional education in
this at-risk population could reduce both morbidity and patient anxiety.
First-aid measures include the following:
1. Digital compression. Although so simple as to seem reflexic, fewer than
50% of emergency department personnel could describe the correct site
to apply digital pressure in a nosebleed (Fig. l).3R
A swimmers clip has
also been used for epistaxis.62
2. Cotton or tissue plug in the nose. Patients often arrive in the office with
a piece of tissue pushed into the nostril that has been bleeding.
3. Bending forward at the waist. This position allows gravity to keep blood
flowing out the nostrils, rather than posteriorly down the throat.
4. Spitting out any blood that trickles down the back of the throat. The
patient is prevented from swallowing large amounts of blood.
Figure 1. Digital compression over the nasal alar and anterior septa1 area is effective
against most anterior bleeds.
48
Thumb and index finger nasal compression pressure is used as the first
measure by the physician while other treatments are being instituted. Local
finger compression should be employed for at least 5 minutes to allow formation
of a hemostatic plug over the bleeding vessel.
Cauterization
Most epistaxis originates in the anterior nasal cavity, often in Littles area.
Effective local vasoconstrictive measures include pseudoephrine (Afrin), phenylephrine (Neo-Synephrine), or epinephrine (1:10,000) applied to the area on
cotton pledget.
The area of bleeding can be cauterized. Silver nitrate is the most convenient
cauterization agent, available in ready-made sticks. Local anesthesia with 4%
lidocaine solution (applied by cotton pledget for 5 minutes) can reduce the
stinging of cautery. Accurate identification of the bleeding points and a good
light for intranasal examination are the keys to successful cauterization. The
temptation to cauterize a large area of the septum to cover all bleeding points
should be resisted. The authors routinely use a cotton-tipped applicator to
EPISTAXIS
49
mop up residual silver nitrate after application, to prevent local damage to the
underlying perichondrium. Postcautery, antibiotic cream or ointment is applied
to the cauterized area twice a day for 5 days to prevent crusting and infection.
Both sides of the septum should not be cauterized at the same time because of
the risk of septal perforation. Repeated cauterization in the same area can also
lead to septal perforations.
Other Measures
50
by inexperienced physician^.^^ Both nasal tampons and gauze packing are efficacious and well t~lerated.~
After anterior packing, the oropharynx is inspected. If blood is still visible
trickling from the nasopharynx, either the anterior pack is suboptimally placed,
or there is a posterior nasal bleeding source. The nasal cavity measures about
7 cm from columella to nasopharynx, so the most common error in anterior
nasal packing is failure to pack adequately the posterior aspects of the anterior
nasal cavity.
Adequate lighting and long forceps (bayonet or Tilley's nasal packing forceps) are necessary for placement of an effective anterior gauze pack. Gauze
coated with BIPP (bismuth iodoform paraffin paste) can be left in the nasal
cavity for up to a week with low risk of infection. Vaseline gauze packing is
usually removed by 72 hours. Antibiotic prophylaxis is usually administered.
Elderly or frail patients with anterior nasal packing and most patients with
posterior nasal packing should be hospitalized for oxygen supplementation,
intravenous hydration, bed rest, and mild sedation. Because bilateral nasal
packing obstructs the nose and prevents nasal breathing, it often causes hypooxygenation. Anterior-posterior nasal packing with sedation is accompanied by
decreased arterial oxygen tension and altered pulmonary mechani~s.~
Oxygen is
usually administered via face mask with anterior and posterior packing (unless
the carbon dioxide is elevated). Sedation is carefully titrated, keeping in mind
the patient's cardiopulmonary status.
Other materials used for nasal packing include Kaltostat, Ativene, and
porcine fat (salt pork). A randomized trial comparing Kaltostat and bismuth
tribromophenate (Xeroform) showed similar efficacy and patient a c c e p t a n ~ e . ~ ~
Ativene successfully controlled 77% of idiopathic anterior epistaxis and can be
useful in hereditary telangiectasia epistaxis60Salt pork has been used for nasal
packing in patients with thrombocytopenia, commonly secondary to renal failure
or medications. Homogenates of salt pork contain an aqueous factor that serves
as a platelet substitute, inducing platelet aggregation and enhancing adenosine
diphosphate and collagen-induced aggregation. The pork fat is less irritating to
the mucosa on removal than gauze
This material is not used in patients
who avoid pork for religious reasons.
Posterior Nasal Packing
EPISTAXIS
51
anteriorly, usually around the columella. Care is taken to pad and protect
the columella from excessive pressure that could cause ischemic necrosis. This
unpleasant procedure can be performed under mild sedation, but use of general
anesthesia when possible is a kindness to the patient. Posterior packs are usually
left in place for 48 to 72 hours because earlier removal is associated with an
increased risk of rebleeding.
An alternative to posterior packing with gauze is balloon catheters inserted
in the nasopharynx via the nostrils and inflated with sterile water. The balloons
are secured anteriorly using a clamp (e.g., umbilical cord clamp). Either Foley
catheters or balloons designed specifically for the nasopharynx can be used. The
balloons have a tendency to deflate with time, and volume can drop by 30% or
more in 72
The authors usually deflate the balloons at 48 hours and
remove both anterior and posterior packings at 72 hours.
Complications of Nasal Packing
Nasal packing can be complicated by death.5 Aspiration of blood, cardiopulmonary failure secondary to hypoxia, and toxic shock syndrome have led to
mortality in patients with epistaxis. Complications in nasal packing include
Surgery
Endoscopic Cauterization. Endoscopes have revolutionized sinonasal surgery over the past two decades. In the management of epistaxis, use of the
52
endoscope can permit identification of posterior bleeding sites, which can then
be directly cauterized, avoiding packing.12,51 It is especially useful in patients
who continue to bleed through well-placed nasal packs.
For these patients, the packings are usually removed when the patient is
under general anesthesia. The nasal cavity is cleansed and endoscopically examined. Common bleeding sites include the region of distribution of the sphenopalatine artery, posterior end of inferior turbinate, posterior-inferior septum, and
anterior sphenoid face. The suction electrocautery is useful. In the rare cases in
which no bleeding sites are located, Merocel packs are placed for 48 hours.
The authors have been using endoscopic examination in the outpatient
setting with selected patients. Using good topical anesthesia and mild sedation
and a suction/electrocautery unit, some more posteriorly placed bleeding points
can be identified and cauterized with minimal patient discomfort. Many of these
patients would traditionally have required nasal packing and hospitalization, so
avoidance of this is popular with both patients and managed care companies.
Arterial Ligation. Arterial ligation decreases arterial blood flow to the
bleeding area. Commonly ligated supplying branches include the internal maxillary artery (terminating as the sphenopalatine artery) and the anterior ethmoidal
artery. Ligation of the external carotid artery is also possible, although uncommonly needed.
Posterior epistaxis is usually supplied by the terminal branches of the
internal maxillary artery. The third part of the internal maxillary artery courses
behind the maxillary antrum to the sphenopalatine foramen at the superomedial
sinus. As the internal maxillary artery exits the sphenopalative foramen, it
divides into medial (to the sphenoid/septum) and lateral (lateral nasal wall)
divisions. The transantral (via the maxillary antrum) approach allows ligation
just before the terminal branching. Traditionally the transantral approach involved the removal of anterior wall of the maxillary sinus (Caldwell Luc) for
surgical access.hThe microscope is used for dissection behind the posterior wall
of the antrum. The endoscope has provided an alternative approach with less
morbidity, although it is technically more difficult (Fig. 2).68
Ethmoidal arterial ligation is performed when bleeding arises in the superior nose (above the middle turbinate). Ethmoidal artery ligation uses a curved
incision around the medial canthus. The globe is retracted away from the lamina
papyracea, and the anterior ethmoidal artery is encountered about 24 mm from
the anterior lacrimal crest. The vessels are clipped and ligated under direct
vision. Patients with intractable epistaxis without an identifiable bleeding point
may benefit from ligation of both the anterior ethmoidal artery and the internal
maxillary artery.
Embolization. An alternative to surgical ligation is embolization of external
carotid artery branches.", 26, 58 This procedure is particularly useful in patients at
high risk for a general anesthetic or with unfavorable anatomy (small maxillary
antra).47Embolization is successful in up to 96% of cases, although vascular
anatomic variations limit application in some cases. One benefit of embolization
over arterial ligation is that more selective blockade of smaller branches is possible.
Complications of embolization include up to 6% of neurologic sequelae. The
risk of particulate material embolization to the internal carotid systems has been
minimized by the current use of microcoils.13
Blood Transfusion
With the risk of disease transmission through blood products increasing,
epistaxis is treated to minimize the need for transfusion. Nasal packing has been
EPISTAXIS
53
Figure 2. A, Endoscopic view of the posterior wall of a left maxillary sinus that has been
opened showing the internal maxillary artery ligated by clips. B,Schematic diagram of A.
54
tients requiring more than 3 units of blood should be considered for surgical
intervention. The cost a n d risk of surgical intervention m u s t be weighed against
the risks of transfusion a n d compromised cardiovascular status if rebleeding occurs.
Dealing with a patient w i t h active severe epistaxis can be bloody. The
authors recommend universal precautions for all health care personnel involved
in the care of these patients, including face mask with shields, gowns, hair
coverage, a n d double-gloving.
SUMMARY
Epistaxis is a common clinical problem. The widespread availability of
endoscopic equipment is shifting management philosophy toward targeting the
bleeding point. This shift may have a significant impact on decreasing length of
stay a n d blood transfusion rates. Advances i n interventional radiology have also
reduced the risk of embolization. Patient education, especially teaching first-aid
measures to patients a t high risk for nosebleeds, also encourages more effective
use of health care resources.
ACKNOWLEDGMENTS
The authors thank Carol Chan for her assistance with the illustrations.
References
1. Adler D, Ritz E: Perforation of the nasal septum in patients with renal failure. Laryngo-
EPISTAXIS
55
56
43. Murray AB, Milner RA: Allergic rhinitis and recurrent epistaxis in children. Ann
Allergy Asthma Immunol 74:30-33, 1995
44. Okafor BC: Epistaxis: A clinical study of 540 cases. Ear Nose Throat J 63:153-159, 1984
45. Ong CC, Pate1 KS: A study comparing rates of deflation of nasal balloons used in
epistaxis. Acta Otorhinolaryngol Belg 50:33-35, 1996
46. OReilly BJ, Simpson DC, Dharmeratnam R Recurrent epistaxis and nasal septa1
deviation in young adults. Clin Otolaryngol 21:12-14, 1996
47. Pearson BW, Mackenzie RG, Goodman WS: The anatomical basis of transantral ligation
of the maxillary artery in severe epistaxis. Laryngoscope 79:969-984, 1969
48. Pringle MB, Beasley P, Brightwell AP: The use of Merocel nasal packs in the treatment
of epistaxis. J Laryngol Otol 110:543-546, 1996
49. Rebeiz EE, Byran DJ, Ehrlichmann RJ, et al: Surgical management of life-threatening
epistaxis in Osler-Weber-Rendu disease. Ann Plast Surg 35:208-213, 1995
50. Renuad S, Lorgeril M de: Wine, alcohol, platelets, and the French paradox for coronary
heart disease. Lancet 339:1523-1526, 1992
51. Rudert H, Maune S Endonasal coagulation of the sphenopalatine artery in severe
posterior epistaxis. Laryngorhinootologie 76:77-82, 1997
52. Schiatkin B, Strauss M, Houck J R Epistaxis: Medical versus surgical therapy: A
comparison of efficacy, complications, and economic considerations. Laryngoscope
971392-1396, 1987
53. Shaw CB, Wax MK, Wetmore SJ: Epistaxis: A comparion of treatment. Otolaryngol
Head Neck Surg 109:60-65, 1993
54. Simpson HK, Baird J, Allison M, et al: Long-term use of low molecular weight heparin
tinzaparin in haemodialysis. Haemostasis 26:90-97, 1996
55. Stangerup SE, Dommerby H, Lau T Hot-water irrigation as a treatment of posterior
epistaxis. Rhinology 34:18-20, 1996
56. Stangerup SE, Thomsen U K Histological changes in the nasal mucosa after hot-water
irrigation: An animal study. Rhinology 34:14-17, 1996
57. Stine KC, Becton DL: DDAVP therapy controls bleeding in Ehlers-Danlos syndrome. J
Pediatr Haematol Oncol 19:156-158, 1997
58. Strong EB, Bell DA, Johnson LP, et al: Intractable epistaxis: Transantral ligation vs
embolization: Efficacy review and cost analysis. Otolaryngol Head Neck Surg 113:674
678, 1995
59. Sugarman PM, Alderson DJ: Training model for nasal packing. J Accid Emerg Med
12:276-278, 1995
60. Taylor MT Avitene-its value in the control of epistaxis. J Otolaryngol9:466471, 1980
61. Tomkinson A, Bremmer-Smith A, Craven C, et al: Hospital epistaxis admission rate
and ambient temperature. Clin Otolaryngol 20:239-240, 1995
62. Turner P: The swimmers nose clip in epistaxis. J Accid Emerg Med 13:134, 1996
63. Vickery CL, Kuhn FA: Using the KTP/532 laser to control epistaxis in patients with
hereditary hemorrhagic telangiectasia. South Med J 89:78-80, 1996
64. Viduich RA, Blanda MP, Gerson LW: Posterior epistaxis: Clinical features and acute
complications. Ann Emerg Med 25:592-596, 1995
65. Wantke F, Focke M, Hemmer W, et al: Formaldehyde and phenol exposure during an
anatomy dissection course: A possible source of -1gE-mediated sen&tization. Allergy
51:837-841, 1996
66. Watson MG, Shenoi PM: Drug induced epistaxis? J R SOCMed 83:162-164, 1990
67. Weiss NS: Relation of high blood pressure to headache, epistaxis, and selected other
symptoms. N Engl J Med 287631-633, 1972
68. Winstead W Sphenopalatine artery ligation: An alternative to internal maxillary artery
ligation for intractable posterior epistaxis. Laryngoscope 106(5 pt 1):667-669, 1996