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Epistaxis
is nose bleeding, which occurs from the anterior or posterior portion
of the nasal septum. Diagnosis is by direct visualization. Treatment
varies by site of bleeding but includes cautery and various types
of packing.
Most nasal bleeding is anterior, originating from a plexus of vessels in the anteroinferior septum (Kiesselbach's area). Less common but more serious are posterior nose- bleeds, which tend to occur in patients with preexisting atherosclerotic vessels or bleeding disorders who have undergone nasal or sinus surgery. In Rendu-Osler-Weber syndrome, multiple severe nosebleeds may result from arteriovenous aneurysms in the mucous membrane. Severe epistaxis is often caused by coagulopathy from liver disease.
Most epistaxes occur secondary to local trauma (including nose blowing and picking) and drying of the nasal mucous membrane. Less common causes include local infections, such as vestibulitis, rhinitis, and sinusitis; systemic infections, such as AIDS; foreign bodies (particularly in children); arteriosclerosis; hypertension (when poorly controlled); a benign or malignant tumor in a paranasal sinus or in the nasopharynx; and septal perforations. Epistaxis of any cause is common in patients with bleeding tendencies (eg, thrombocytopenia, liver disease, coagulopathies, anticoagulant use).
Symptoms,
Signs, and Diagnosis
Bleeding ranges from a trickle to a strong flow. Although major epistaxis quickly involves both nares, most patients can localize the initial flow to one side, which focuses the clinical examination.
Anterior bleeding sites are usually apparent on direct examination with a nasal speculum and a bright light. If no site is apparent and bleeding is severe or recurrent, fiberoptic endoscopy may be necessary.
Routine laboratory testing is not required. Patients with symptoms or signs of bleeding from other sites (eg, melena, petechiae) and those with severe or recurrent epistaxis undergo CBC, PT, and PTT. CT may be performed if a foreign body, a tumor, a fracture, or sinusitis is suspected.
Treatment
Presumptive treatment for actively bleeding patients is that for anterior bleeding. The need for blood replacement is determined by the Hb level, symptoms of anemia, and vital signs.
Anterior epistaxis:
Bleeding can usually be controlled by pinching the nasal alae together for 10 min. If this maneuver fails, a cotton pledget impregnated with a vasoconstrictor (eg, phenylephrine 0.25%) and a topical anesthetic (eg, lidocaine 2%) is inserted and the nose pinched for another 10 min. The bleeding point may then be cauterized with electrocautery or silver nitrate on an applicator stick. Cauterizing 4 quadrants immediately adjacent to the bleeding vessel is most effective. Care must be taken to avoid burning the mucous membrane too deeply. Alternatively, a nasal tampon of expandable foam may be inserted. Coating the tampon with a topical ointment, such as bacitracin or mupirocin , may help. If these methods are ineffective, various commercial nasal balloons can be used to tamponade bleeding sites. Alternatively, an anterior nasal pack consisting of ½-in petrolatum gauze may be inserted; up to 72 in may be required. This procedure is painful, and analgesics usually are needed.
Posterior epistaxis:
Posterior bleeding may be difficult to control. Commercial nasal balloons are quick and convenient; a gauze posterior pack is effective but more difficult to position. Both are very uncomfortable; IV sedation and analgesia may be needed, and hospitalization is required.
The posterior gauze pack consists of 4-in gauze squares folded, rolled, tied into a tight bundle with 2 strands of heavy silk suture, and coated with antibiotic ointment. The ends of 1 suture are tied to a catheter that has been introduced through the nasal cavity on the side of the bleeding and brought out through the mouth. As the catheter is withdrawn from the nose, the postnasal pack is pulled into place above the soft palate in the nasopharynx. The 2nd suture hangs down the back of the throat and is trimmed below the level of the soft palate so that it can be used to remove the pack. This oral suture prevents aspiration into the larynx if the pack falls from the nasopharynx into the airway. The nasal cavity anterior to this pack is firmly packed with 1⁄2-in petrolatum gauze, and the 1st suture is tied over a roll of gauze at the anterior nares to secure the postnasal pack. The packing remains in place for 4 to 5 days. An antibiotic (eg, amoxicillin/clavulanate 875 mg po bid for 7 to 10 days) is given to prevent sinusitis and otitis media. Postnasal packing lowers the arterial Po2, and supplementary O2 is given while the packing is in place.
Rarely, the internal maxillary artery and its branches must be ligated to control the bleeding. The arteries may be ligated with clips using microscopic guidance and a surgical approach through the maxillary sinus. Alternatively, embolization by angiography may be used.
Bleeding disorders:
In Rendu-Osler-Weber syndrome, a split-thickness skin graft (septal dermatoplasty) reduces the number of nosebleeds and allows the anemia to be corrected. Laser (Nd:YAG) photocoagulation, another coagulation technique, is performed in the operating room. Selective embolization is very effective, particularly in patients who cannot tolerate general anesthesia or for whom surgical intervention has not been successful. New endoscopic sinus devices have made transnasal surgery more effective.
In patients with liver disease, blood may be swallowed in large amounts and should be eliminated promptly with enemas and cathartics to prevent hepatic encephalopathy. The GI tract should be sterilized with nonabsorbable antibiotics (eg, neomycin 1 g po qid) to prevent the breakdown of blood and the absorption of ammonia.
Last full review/revision November 2005
Content last modified November 2005
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