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Epistaxis (Nosebleed)

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Overview

Epistaxis (Nosebleed)

1. Clinical Overview

Summary

Epistaxis is the most common Otorhinolaryngological emergency, affecting 60% of the population at least once in their lifetime. While most cases are self-limiting anterior bleeds (Kiesselbach's Plexus), posterior bleeds (Woodruff's Plexus) can be life-threatening, particularly in the elderly and anticoagulated population. Management follows a strict escalation ladder from compression to chemical cautery, rigid packing, and ultimately surgical artery ligation.

Key Facts

  • Site: 90% Anterior (Little's Area), 10% Posterior (Sphenopalatine/Woodruff's).
  • Mortality: Rare (<0.1%), but carries significant morbidity in the elderly (aspiration, hypotension).
  • Admission: Nasal packing usually necessitates admission for airway monitoring.
  • Gold Standard: Endoscopic Sphenopalatine Artery Ligation (ESPAL) is superior to posterior packing for refractory bleeds.
  • Guideline Consensus: Use Silver Nitrate first line for visible vessels.

Clinical Pearls

The "Hippocratic Pinch" Error: Patients invariably pinch the nasal bones (the hard bridge). This does nothing. Instruct them to pinch the alae nasi (soft cartilage) against the septum to mechanically occlude Little's Area.

The Nasopulmonary Reflex: Insertion of posterior nasal packs can cause reflex bradycardia and hypoxia. Pulse oximetry is mandatory for packed patients.

"Don't Bilateral Burn": Never cauterize both sides of the septum in the same session. This devascularizes the cartilage, leading to septal perforation.

The "Sentinel Bleed": A minor bleed in a young male adolescent may be the first sign of a Juvenile Nasopharyngeal Angiofibroma (JNA). Do not ignore recurrence.

"The Drip Test": After anterior packing, look in the mouth. If blood is still dripping down the posterior pharynx, the pack has failed (Posterior Bleed).

"The 50/50 Rule": 50% of "posterior" bleeds are actually severe anterior bleeds that flow backwards. Always try anterior packing first.

"The Weather Warning": Anticipate a surge in admissions during cold snaps. Central heating dries the air, and thus the nose.

2. Epidemiology

Incidence

  • Lifetime Prevalence: 60%.
  • Medical Attention: Only 6-10% require medical intervention.
  • Hospitalization: Increases with age (>70 years).

Demographics

  • Age: Bimodal distribution.
    • Peaks at 2-10 years (Trauma/Picking).
    • Peaks at 50-80 years (Hypertension/Anticoagulation).
  • Gender: Males > Females (until menopause, suggesting a protective effect of estrogen).
  • Seasonality: Higher incidence in Winter (low humidity dries mucosa + upper respiratory tract infections).

Risk Factors

  1. Trauma: Digital (picking), facial fracture, nasogastric tube insertion.
  2. Environmental: Dry air, air conditioning, chemical irritants (cocaine).
  3. Medicinal:
    • Anticoagulants (Warfarin, DOACs).
    • Antiplatelets (Aspirin, Clopidogrel).
    • Topical Corticosteroids (poor technique spraying septum).
  4. Systemic Aetiologies:
    • Hypertension: Does not cause the break, but prevents the clot forming (high pressure hose).
    • Alcoholism: Hepatic coagulopathy (decreased Factors II, VII, IX, X) + Thrombocytopenia.
    • Renal Failure: Uremia causes platelet dysfunction.
    • Vitamin C Deficiency (Scurvy): Capillary fragility (rare but historical).
    • HHT: See Section 8.
  5. Anatomical: Septal deviation (disrupts laminar flow -> crusting at the deflection point).
3. Pathophysiology

Anatomy: The Vascular Supply

The nasal cavity is one of the most vascular organs in the body, acting as a radiator to warm inspired air. It receives a dual supply from both the Internal and External Carotid Arteries (ICA/ECA).

1. Internal Carotid System (via Ophthalmic Artery)

  • Anterior Ethmoidal Artery:
    • Exits the orbit through the anterior ethmoidal foramen.
    • Enters the anterior cranial fossa, then descends through the cribriform plate.
    • Supplies the Anterior Superior Septum.
  • Posterior Ethmoidal Artery:
    • Exits orbit via posterior foramen.
    • Descends to supply the Superior Turbinate and septum.
    • Clinical Relevance: These arteries are roughly at the level of the nipple line of the eyes. Bleeding from here is superior and often traumatic.

2. External Carotid System

  • Facial Artery -> Superior Labial Artery:
    • Gives off a septal branch that enters the nose anteriorly.
    • Clinical Relevance: Often the source of "Little's Area" bleeds near the nostril rim.
  • Maxillary Artery -> Sphenopalatine Artery (SPA):
    • The "Artery of Epistaxis".
    • Enters via the Sphenopalatine Foramen (posterior to middle turbinate).
    • Supplies the majority of the posterior septum and lateral wall.
  • Maxillary Artery -> Greater Palatine Artery:
    • Descends in the greater palatine canal, runs along the hard palate, and ascends through the Incisive Canal.
    • Supplies the anterior floor of the nose.

3. Little's Area (Kiesselbach's Plexus)

Located on the anteroinferior septum. It is the watershed confluence of 5 Arteries:

  1. Anterior Ethmoidal (ICA).
  2. Posterior Ethmoidal (ICA) - Note: Some texts exclude this, but it contributes superiorly.
  3. Sphenopalatine (ECA).
  4. Greater Palatine (ECA).
  5. Superior Labial (ECA).

Significance: Highly vascular, exposed to dry air (Venturi effect) and digital trauma. Source of 90% of bleeds.

4. Woodruff's Plexus

Located on the posterior lateral wall, just inferior to the posterior end of the Inferior Turbinate.

  • Sources: Sphenopalatine Artery branches + Pharyngeal branches.
  • Significance: A venous/arterial plexus responsible for Posterior Epistaxis. The bleeding here trickles backward into the throat.

Pathophysiology of Epistaxis: The 6-Step Mechanism

Step 1: Mucosal Injury/Desiccation

  • Low humidity or high airflow (Bernoulli principle/Septal deviation) dries the respiratory mucosa.
  • The protective mucus blanket is lost.

Step 2: Epithelial Disruption

  • The dry epithelium cracks (Micro-fissures) or is mechanically disrupted (Picking/Trauma).
  • This exposes the underlying vascular plexus (Tunica Adventitia).

Step 3: Vessel Rupture

  • Systemic pressure (Hypertension) or local shear force ruptures the vessel wall.
  • Arterial bleeds are pulsatile; Venous bleeds are oozing.

Step 4: Activation of Haemostasis

  • Vasoconstriction occurs (Reflex).
  • Platelets adhere to sub-endothelial collagen (Primary Plug).
  • Failure Point: Antiplatelets (Aspirin) prevent this plug formation.

Step 5: Coagulation Cascade

  • Fibrin mesh forms to stabilize the clot (Secondary Haemostasis).
  • Failure Point: Warfarin/DOACs prevent stable clot formation.

The Sinister Causes: Neoplasia

While rare, tumours must be excluded in recurrent unilateral bleeds.

  1. Juvenile Nasopharyngeal Angiofibroma (JNA):
    • Demographic: Adolescent males (Testosterone dependent).
    • Pathology: Highly vascular, benign but locally aggressive.
    • Sign: "Frog Face" deformity (late).
    • Radiology: Holman-Miller Sign (Anterior bowing of the posterior maxillary wall on CT).
    • Management: Embolization followed by surgical resection.
  2. Inverted Papilloma:
    • Presentation: Unilateral "Polyp" (fleshy mass).
    • Risk: 10% transformation to SCC.
    • Treatment: Medial Maxillectomy.
  3. Squamous Cell Carcinoma (SCC):
    • Risk Factor: Wood dust exposure (Adenocarcinoma), Nickel plating (SCC).
    • Signs: Loose teeth, facial numbness (V2 nerve palsy), cheek swelling.
  4. Esthesioneuroblastoma:
    • Origin: Olfactory neuroepithelium (Roof of nose).
    • Presentation: Anosmia + Epistaxis.

Granulomatous Variations

Epistaxis is often the first sign of systemic vasculitis.

  • Granulomatosis with Polyangiitis (GPA/Wegener's):
    • Triad: Upper Airway (Crusting/Saddle Nose) + Lungs (Nodules) + Kidney (Glomerulonephritis).
    • Marker: c-ANCA positive.
    • Treatment: Steroids + Cyclophosphamide/Rituximab.
  • Sarcoidosis:
    • Presentation: "Lupus Pernio" (Purple nose tip). Septal perforation.
    • Marker: Serum ACE elevated.
  • Tuberculosis (Lupus Vulgaris):
    • Rare ("Apple jelly" nodules).

Step 6: Outcome

  • Resolution: Fibrosis and mucosal regeneration.
  • Chronicity: If the crust is picked off (cycle of trauma), the vessel remains exposed (Granuloma formation).
4. Clinical Presentation

Classification

History

Red Flags

Differential Diagnosis

  1. Digital Trauma (Nose Picking):
    • Clue: "Epistaxis Digitorum". Anterior crusting. Children.
  2. Juvenile Nasopharyngeal Angiofibroma (JNA):
    • Clue: Adolescent Male. Recurrent profuse unilateral bleeds. Nasal obstruction.
    • Action: Do not biopsy! (Torrential bleed). CT Angio.
  3. Granulomatosis with Polyangiitis (Wegener's):
    • Clue: Excessive crusting, saddle nose, renal failure, pulmonary nodules.
    • Labs: c-ANCA positive.
  4. Sinonasal Malignancy (SCC/Adenocarcinoma):
    • Clue: Unilateral obstruction, pain, occupational history (Wood dust).
    • Signs: Facial swelling, loose teeth.
  5. Pyogenic Granuloma:
    • Clue: Pregnant women (Hormonal). Lobular red mass on septum.
  6. Coagulopathy:
    • Clue: Bleeding gums, easy bruising, menorrhagia.
Anterior Epistaxis
Unilateral. Visible vessel/crust in Little's area. Bleeding flows out the nostril (unless lying down).
Posterior Epistaxis
Often bilateral flow (due to posterior pooling). Profuse bleeding into the pharynx (patient spitting out blood/clots). Failure of anterior packing. Cannot visualize bleeding point.
5. Clinical Examination

Preparation

  • PPE: Gloves, Apron, Eye Protection (Visor essential).
  • Position: Patient sitting upright, head neutral (sniffing position).
  • Equipment: Headlight, Thudicum speculum, Frazier suction, Bayonet forceps.

The ENT Toolkit

To find the bleed, you need the right tools.

  1. Thudicum Speculum: A spring-loaded metal clip. Hold it in your non-dominant hand. Squeeze to insert, release to open the nostril.
  2. Tilley's Forceps (Dressing Forceps): Angled ("Bayonet") shape keeps your hand out of your line of sight. Used to insert packs.
  3. Frazier Suction: A fine-bore metal sucker (Size 10-12Fr). Essential to clear clots. A "Yankauer" is useless here (too big).
  4. Jobson Horne Probe: A metal stick with a serrated end for holding cotton wool (to apply anaesthetic).

Technique: The Thudicum Grip

The Thudicum speculum is tricky to hold.

  1. The Grip:
    • Place the loop of the speculum over your Middle Finger.
    • Place your Index Finger and Ring Finger on the flat limbs.
    • Squeeze your fingers to close the blades (for insertion).
    • Relax your fingers (let the spring open) to dilate the nostril.
  2. Insertion:
    • Insert the blades vertically (parallel to the septum).
    • Do NOT touch the septum (Medial wall). It is excruciatingly painful.
    • Press the lateral blade against the nasal ala (painless).
    • Look past the hairs.
  3. The View:
    • Identify the septum (pink/smooth).
    • Identify the Inferior Turbinate (lateral/bumpy).
    • Look for Little's Area (anteroinferior septum) - look for a red dot or grey crust.

The Systematic Look

  1. External: Deformity? Swelling?
  2. Oropharynx: Look for blood trickling down the posterior pharyngeal wall (Active posterior bleed).
  3. Anterior Rhinoscopy:
    • Insert Thudicum (blades vertical).
    • Open gently.
    • Suction clots.
    • Inspect Little's Area (Septum).
    • Inspect Lateral Wall/Turbinates.
  4. Rigid Endoscopy (If available): To visualize sphenoethmoidal recess.

Procedure: Rigid Nasendoscopy (The "Three Pass" Technique)

If anterior rhinoscopy fails to find the bleed, use a 0-degree or 30-degree rigid endoscope.

  • Pass 1 (The Floor): Glide along the inferior meatus to the nasopharynx. Check for Woodruff's Plexus bleeds and Hasner's Valve (Lacrimal duct).
  • Pass 2 (The Middle Meatus): Retract slightly and inspect the middle meatus (Maxillary Ostium) and Sphenopaltine Foramen area.
  • Pass 3 (The Roof): Inspect the Sphenoethmoidal recess and Olfactory cleft (Ethmoidal arteries).
  • Note: Active bleeding often obscures the view. Suction is key.
6. Investigations

Bedside

  • Observations: BP, HR, O2 Sats.
  • ECG: If cardiac history or severe anaemia.

Labs

  • FBC: Baseline Haemoglobin (may not drop immediately) and Platelets.
  • Coagulation Screen (INR/APTT):
    • Usually normal unless on Warfarin or Liver disease.
    • Group and Save: Mandatory for profuse bleeding.

Imaging

  • Not Routine for simple epistaxis.
  • CT Angiogram (CTA):
    • Indication: Prior to embolization.
    • Finding: "Contrast Blush" (Extravasation) from the maxillary artery.
  • CT Paranasal Sinuses:
    • Indication: Unilateral obstruction or persistent bleed to rule out tumor.
    • Finding: Opacification, bony erosion (JNA/SCC).
  • MRI Head/Neck:
    • Indication: Assessing extent of Angiofibroma (JNA).
    • Finding: "Flow Voids" (High vascularity).

When to Refer to ENT?

7. Management Algorithm
                 ACTIVE EPISTAXIS
                        ↓
         DANGER? (Airway/Shock) → Resuscitate (ABC)
                        ↓
                  First Aid (20 mins)
            (Trotter's Method + Ice)
                        ↓
                 Still Bleeding?
           ┌────────────┴────────────┐
          NO                        YES
     Discharge Advice                ↓
                             Prepare Nose
                       (Co-Phenylcaine + Suction)
                                     ↓
                             Visualize Vessel?
                       ┌─────────────┴─────────────┐
                      YES                          NO
                 Chemical Cautery          Anterior Packing
                 (Silver Nitrate)          (Rapid Rhino)
                        ↓                          ↓
                  Bleeding Stops?            Bleeding Stops?
                 ┌──────┴──────┐           ┌───────┴───────┐
                YES           NO          YES              NO
             Discharge       Pack        Admit           Posterior
               +            Again          +             Packing
            Naseptin                     Obs            (Foley/Surgical)

Step 1: First Aid (Trotter's Method)

  1. Sit Forward: Prevents aspiration/swallowing.
  2. Mouth Open: Rest breathing.
  3. Pinch Soft Part: Compress the alae nasi against the septum for 20 minutes.
  4. Ice: Apply to forehead/bridge (Reflex vasoconstriction).

Step 2: Preparation

  1. Clear the Nose: Ask patient to blow gently once to clear clots, or suction.
  2. Anaesthetize/Vasoconstrict:
    • Co-Phenylcaine (Lidocaine 5% + Phenylephrine 0.5%).
    • Soak cotton wool pledgets and insert for 5-10 mins.
    • Reduces pain and shrinks turbinates for view.

Pharmacology of the Nose (Topical Preparation)

A dry, anaesthetic field is essential for assessment.

AgentCompositionEffectNotes
Co-PhenylcaineLidocaine 5% + Phenylephrine 0.5%Anaesthesia + VasoconstrictionGold Standard spray. Bitter taste.
Cocaine PasteCocaine 10%Intense VasoconstrictionHistorical. Controlled drug (CD). Cardiac risk.
Adrenaline1:1000 (Topical)Potent VasoconstrictionSoak gauze. Do NOT inject 1:1000.
Oxymetazoline0.05% SprayVasoconstrictionOTC Decongestant. No anaesthesia.
TXATranexamic AcidAntifibrinolyticSoak gauze (500mg). Reduces re-bleed?

Pediatric Epistaxis Protocol

Pediatric Epistaxis Protocol

Children present a unique challenge due to anxiety and anatomy.

  • Etiology: 90% Digital Trauma (Picking) + Staph Aureus colonization (Crusting).
  • First Line: Naseptin Cream bd for 2 weeks. (Treats the Staph, softens the crust, reduces itch, stops picking).
  • Second Line: Silver Nitrate.
    • Caveat: Only if the child can sit still. If not, do NOT struggle (risk of burns to face/eye).
    • Option: EUA (Examination Under Anaesthetic) + Cautery.
  • Red Flags:
    • Male adolescent (JNA).
    • Bleeding gums/Easy bruising (Leukemia/ITP).

Step 3: Chemical Cautery

  • Indication: Visible anterior bleeding point.
  • Agent: Silver Nitrate (AgNO3) stick.
  • The Chemistry:
    • Reaction: AgNO3 + H2O → AgOH + HNO3 (Nitric Acid).
    • Mechanism: It is an ACID BURN. It causes coagulative necrosis of the mucosa.
    • Safety: If it drips on skin, it burns. Neutralize with Saline immediately (forms AgCl precipitate).
  • Technique:
    1. Rim the vessel (cauterize surrounding mucosa to cut supply).
    2. Target the vessel stump (hold for 3-5s until grey/white).
  • Aftercare: Naseptin cream (Chlorhexidine/Neomycin) qds for 2 weeks. (Moisturizes + Anti-staph). Check Peanut Allergy.

In-Patient Admission Protocol (For Packed Patients)

Admission is mandatory for posterior packs (Risk of hypoxia).

  1. Bed Rest: Toilet privileges only. 30-degree head up (Reduces venous pressure).
  2. Oxygen: Humidified O2 if saturation <94%. (Mouth breathing dries the throat).
  3. Fluids: IV Maintenance (Patient cannot drink easily with pack).
  4. Analgesia: Packs are painful. Regular Paracetamol + Codeine (watch for respiratory depression).
  5. Monitoring: 4-hourly Obs. Watch for Arrhythmia.

Step 4: Anterior Packing

If cautery fails, is not possible (diffuse ooze), or the patient is anticoagulated.

A. Rapid Rhino (Pneumatic Tamponade) - The Gold Standard

  • Mechanism: The Carboxymethylcellulose (CMC) surface becomes a hydrocolloid gel when wet. It promotes platelet aggregation and clotting, while the balloon provides pressure.
  • Sizes:
    • 5.5cm: Anterior bleeds (Little's Area).
    • 7.5cm: Deep anterior/mid-cavity bleeds.
  • Technique (Step-by-Step):
    1. Soak: Submerge the mesh in sterile water (NOT Saline - Saline reduces the gel effect) for 30 seconds.
    2. Insert: Slide along the floor of the nose (parallel to the palate). Do not aim upwards (cribriform plate risk).
    3. Inflate: Use a 20ml syringe with AIR. Inflate the pilot cuff until it feels "tense" (like a grape).
    4. Tape: Secure the pilot cuff to the cheek.
  • Advantage: Less pain on insertion/removal than sponges.

B. Merocel (Polyvinyl Alcohol Sponge)

  • Mechanism: Compressed foam that expands 3x when hydrated.
  • Technique:
    1. Coat with antibiotic ointment (Lubrication).
    2. Insert along floor.
    3. Expand by injecting 10ml Saline into the sponge.
  • Disadvantage: Painful removal. Tissue adherence.

C. BIPP (Bismuth Iodoform Paraffin Paste) Packing

  • Mechanism: Traditional ribbon gauze.
  • Indication: Post-op packing or refractory bleeds.
  • Duration: Can be left in for 5-7 days (Antiseptic).

Step 5: Posterior Rescue

Indication: Bleeding continues down the posterior pharnyx despite anterior packs.

  1. Double Balloon Catheter (e.g., Brighton/Epistat):
    • Has an anterior (30ml) and posterior (10ml) balloon.
    • Inflate posterior first -> Pull back -> Inflate anterior.
  2. Foley Catheter Technique:
    • Preparation: Check balloon integrity. Lubricate.
    • Insertion: Pass 12-14Fr Foley catheter along the floor until tip is seen in oropharynx.
    • Inflation: Inflate balloon with 5-10ml Water.
    • Retraction: Pull gently until it lodges against the posterior choana.
    • Anterior Pack: Pack the nose anteriorly (gauze/Rapid Rhino) in front of the Foley to preventing it slipping.
    • Clamp: Use an umbilical clamp (padded with gauze) at the nostril to hold tension. Protect the Columella (Risk of necrosis).

Step 6: Surgical Intervention

When conservative measures fail, surgical ligation is indicated.

A. Endoscopic Sphenopalatine Artery Ligation (ESPAL)

  • Success Rate: >95%.
  • Procedure:
    1. Endoscopic approach to lateral nasal wall.
    2. Identify the Crista Ethmoidalis (Anatomical landmark).
    3. The SPA exits the foramen just posterior to this.
    4. Clip/Diathermy the artery branches.
  • Advantage: Avoids admission and prolonged packing.

Historical Management: The Bellocq Pack

Before Foley catheters, posterior packing was done with the "Bellocq" technique. A gauze roll was tied to a string. The string was passed through the nose, caught in the throat, and pulled out the mouth to tie the pack in place. It was traumatic and is now obsolete.

  • Modern Equivalent: The 12Fr Foley Catheter.

B. Anterior Ethmoidal Artery Ligation

  • Indication: Superior bleeds (Trauma) refractory to packing.
  • Approach: Lynch incision (External - Medial canthus).

Troubleshooting: When it goes wrong

  1. "It's bleeding through the cautery!"
    • Issue: The flow is washing away the Silver Nitrate before it acts.
    • Fix: Apply a pledget soaked in Adrenaline (1:1000) with firm pressure for 5 minutes. Then try again.
  2. "The Rapid Rhino won't fit!"
    • Issue: Septal deviation or narrow nose.
    • Fix: Use a 5.5cm (Anterior) pack instead of 7.5cm. Or use a rigid Merocel (slimmer profile before expansion).
  3. "The Pilot Cuff is hard but the balloon is soft"
    • Issue: You are inflating the pilot cuff, but the channel to the main balloon is kinked.
    • Fix: Insert fully before inflating. Massage the balloon.
  4. "The patient is vasovagal"
    • Issue: Pain/Anxiety causes hypotension.
    • Fix: Lie flat. Legs up. Remove pack? (Only if cardiac arrest imminent).

Balloon Safety

  • Pressure Necrosis: The nasal mucosa is sandwiched between the balloon and the cartilage. High pressure > capillary perfusion pressure causes necrosis within hours.
  • Pilot Cuff Check: The pilot cuff should be tense but compressible (like the tip of your nose), not rock hard.
  • Duration: Most packs are removed after 24-48 hours. Any longer requires prophylactic antibiotics.

Discharge Checklist

For patients managed with Cautery or Nasedptin (No Pack):

  1. Naseptin Supply: Given tube? (Check peanut allergy).
  2. written Advice: No blowing, heavy lifting, or hot drinks for 48 hours.
  3. Cardiovascular: BP checked? GP letter for hypertension review?
  4. Anticoagulation: INR checked?
  5. Safety Net: "If it bleeds for >20 mins despite pinching, return."

C. Embolization

  • Indication: Surgical failure or unfit for GA.
  • Risk: 1-2% Stroke risk (ICA migration). Facial nerve palsy.

Special Situation: Hereditary Haemorrhagic Telangiectasia (HHT)

Osler-Weber-Rendu Syndrome is an autosomal dominant vasculopathy causing mucocutaneous telangiectasias.

  • Diagnosis (Curacao Criteria): (Diagnosis requires 3/4)
    1. Spontaneous Recurrent Epistaxis.
    2. Multiple Telangiectasias (Lips, Oral cavity, Fingers).
    3. Visceral AVMs (Lung, Liver, Brain).
    4. Family History (First degree relative).
  • Management Principles:
    • AVOID CAUTERY: Silver nitrate creates ulcers which heal with more telangiectasia, worsening the problem.
    • Lubrication: Oil/Vaseline to prevent crusting.
    • Packing: Use dissolvable packs only. Removal of rigid packs tears the friable mucosa.
  • Advanced Therapy:
    • KTP Laser: Photoangiolysis of vessels.
    • Bevacizumab (Avastin): Submucosal injection (Anti-VEGF).
    • Sclerotherapy: Polidocanol injection.
    • Septodermoplasty (Saunders Operation):
      • Removing the fragile nasal mucosa from the anterior septum.
      • Replacing it with a Split Skin Graft (SSG) from the thigh.
      • Rationale: Skin is tougher than mucosa and does not have telangiectasias.
    • Young's Procedure:
      • Calculated surgical closure of the nostrils (suturing skin to skin).
      • Mechanism: Stops all airflow. No airflow = No drying/crusting = No bleeding.
      • Reversal: Can be reversed after 1-2 years if telangiectasia regress.
    • Tranexamic Acid: Oral preventative dose (1g tds).

Anticoagulation Decisions: To Stop or Not?

Balancing thrombotic risk vs hemorrhagic risk.

  • Warfarin:
    • Single Bleed (Controlled) + INR Therapeutic: Continue Warfarin.
    • Recurrent Bleed + INR Therapeutic: Consider withholding 1-2 doses (with medical liaison).
    • INR > 5: Stop Warfarin. Give Vitamin K.
  • Mechanical Heart Valves:
    • NEVER STOP without Cardiology input.
    • Bridge with LMWH if INR subtherapeutic.
  • DOACs:
    • Short half-life (12 hours). Simply withholding one dose is often enough to secure hemostasis.

Managing the Anticoagulated Patient

  • Warfarin:
    • Check INR.
    • If INR > 5.0 and bleeding: Give Vitamin K (1-3mg IV) and Prothrombin Complex Concentrate (Beriplex/Octaplex).
    • If INR therapeutic: Tamponade usually sufficient. Reversal takes time.
  • DOACs (Apixaban/Rivaroxaban):
    • No routine monitoring.
    • Reversal: Andexanet Alfa (if available/approved).
    • Dialysis (Dabigatran).
  • Antiplatelets (Aspirin/Clopidogrel):
    • Platelet Transfusion: Generally NOT guided. (PATCH Trial: Platelet transfusion in spontaneous intracerebral haemorrhage associated with antiplatelet therapy increased death/disability).
    • Hold medication for 5-7 days if safe (Cardiac risk?).
8. Complications

Immediate

  • Hypovolaemic Shock: Cardiac arrest.
  • Aspiration: Pneumonia.
  • Vasovagal: Fainting during packing.

Procedure-Related

  • Septal Perforation: From bilateral cautery or picking.
  • Nasopulpmonary Reflex: Hypoxia/Bradycardia from packing.
  • Nasal Synechiae: Adhesions between septum and turbinate.

Septal Perforation: A Preventable Disaster

  • Pathophysiology: The septal cartilage receives blood supply from the overlying mucoperichondrium. Bilateral cautery burns the mucosa on both sides, stripping the supply. The cartilage dies (avascular necrosis) and falls out.
  • Symptoms:
    • Whistling: Classical sign on breathing.
    • Crusting: Turbulent flow causes drying.
    • Bleeding: From the crust edges.
  • Management:
    • Conservative: Saline douching and Vaseline.
    • Prosthetic: Septal Button (Silastic plug).
    • Surgical: Mucosal rotation flaps (Difficult, high failure rate).

Toxic Shock Syndrome (TSS)

Rare but fatal complication of nasal packing (Staph aureus proliferation).

  • Pathophysiology: Stasis allowing exotoxin production.
  • Diagnostic Criteria:
    1. Fever: >38.9°C.
    2. Hypotension: Sys BP <90.
    3. Rash: Diffuse macular erythroderma (Sunburn-like).
    4. Desquamation: Peeling of palms/soles 1-2 weeks later.
    5. Multisystem: Vomiting, Renal, Hepatic failure.
  • Treatment: Remove pack immediately. IV Fluids. Clindamycin + Penicillin.

Late

  • Anemia: Iron deficiency.
  • Recurrence: 60% re-bleed rate with packing alone.
9. Prognosis & Outcomes
  • Simple Anterior: Excellent. Cautery curative in 80%.
  • Posterior/Refractory: Mortality increases with age and comorbidities (COPD/Cardiac).
  • ESPAL: High success, low recurrence compared to re-packing.
10. Evidence & Guidelines
  • NoPac Trial (2016): RCT showed no difference between Silver Nitrate and Electrocautery for anterior bleeds. Support use of AgNo3 as first line (cheaper/easier).
  • Topical TXA: Cochrane review (2021) suggests topical Tranexamic Acid may reduce bleeding time compared to standard care, but evidence quality is low.
  • Antibiotics for Packing: Systematic reviews show NO significant benefit in preventing Toxic Shock Syndrome, yet practice remains common. (Guideline: Consider if pack in >48 hours or immunocompromised).

Recent Trials

  • Rapid Rhino Pain Scores: Soyka et al. (2011) showed significantly lower visual analogue pain scores for Rapid Rhino insertion/removal compared to traditional Merocel packs.
  • Tranexamic Acid Debate: While the Cochrane review was equivocal, many centres now use "soaked" packs as standard. The theoretical risk of thrombosis is negligible with topical application.
  • Antibiotic Prophylaxis: A meta-analysis (2018) found no reduction in infection rates with prophylactic antibiotics for nasal packs <48 hours. However, for posterior packs (>48h), most guidelines still recommend cover for TSS.
11. Patient Explanation

How to stop a nosebleed at home

How to stop a nosebleed at home

  1. Don't Tilt Back: Blood tastes awful and makes you vomit. Lean forward.
  2. Pinch the Soft Bit: Pinching the hard bone at the top does nothing. You need to squeeze the soft nostrils shut for 20 minutes.
  3. Ice: Put a bag of peas on your forehead.

Aftercare

  • Do not blow your nose for 1 week.
  • Sneeze with your mouth open.
  • Use the antiseptic cream (Naseptin) gently.
  • Avoid heavy lifting.

Discharge: Life after the Bleed

  • Flying: Avoid for 2 weeks. Cabin air is very dry (10% humidity) and pressure changes can provoke re-bleeding.
  • Exercise: No heavy lifting or straining (Valsalva raises venous pressure) for 1 week.
  • Alcohol: Avoid for 48 hours. It is a vasodilator.
  • Hot Showers: Avoid steam. It dilates vessels. Keep showers cool/tepid.

Prevention: The "Nasal Hygiene" Regimen

For recurrent bleeds, treating the dry nose prevents cracking.

  1. Vaseline/Bactroban: Apply a pea-sized amount to the nostrils twice daily.
  2. Saline Douching: Rinse the nose (Neti pot/NeilMed) to clear crusts.
  3. Humidification: Use a room humidifier in winter.
  4. Stop Picking: Keep fingernails short.

How to apply the cream properly

Many patients shove the nozzle up their nose and squirt. This is wrong.

  1. Pea Sized Amount: Squeeze a blob of Naseptin/Bactroban onto your little finger.
  2. Rub it in: Put your finger just inside the nostril and rub it onto the nasal septum (the middle bit).
  3. Sniff: Sniff gently to massage it further back.
  4. Taste: You might taste it in the back of your throat. This is normal.
  5. Clean Hands: Wash hands before and after to prevent introducing infection (Staph).

Common Myths

  • Myth: "Tilt your head back."
    • Fact: This causes blood to run down the throat/airway.
  • Myth: "Ice doesn't work."
    • Fact: It works by reflex vasoconstriction, but pressure is more important.
  • Myth: "Aspirin causes nosebleeds."
    • Fact: It makes them bleed longer, but rarely causes the vessel to burst (that's usually dryness or trauma).

More Old Wives' Tales

  • Myth: "Put a cold key down your back."
    • Fact: This causes a momentary shock vasovagal response, but does not stop a blown artery.
  • Myth: "Stuff tissue up there."
    • Fact: Tissue is rough and shreds the clot when you pull it out. Use a medical pack or nothing.

HHT Resources

For patients with hereditary disease:

  • Cure HHT: Global advocacy group.
  • Medical Alert: Patients with pulmonary AVMs need antibiotic prophylaxis for dentistry (Endocarditis risk?) - Check guidelines.
  • Genetic Counselling: Recommended before starting a family.
12. References

Primary Papers

  1. Schlosser RJ. Clinical practice. Epistaxis. N Engl J Med. 2009. [PMID: 19228621]
  2. Shakeel M, et al. The NoPac Trial: Silver nitrate cautery in epistaxis. Clin Otolaryngol. 2016. [PMID: 26332356] (No difference vs Diathermy).
  3. McLarnon CM, et al. Endoscopic sphenopalatine artery ligation. Rhinology. 2012. [PMID: 22616070]
  4. Joseph J, et al. Tranexamic acid for patients with nasal haemorrhage (epistaxis). Cochrane Database Syst Rev. 2018. [PMID: 30596479]
  5. Kotecha B, et al. Management of Epistaxis: A National Survey. Ann R Coll Surg Engl. 1996. [PMID: 8943638]
  6. Gifford TO, et al. The effect of local anesthesia and vasoconstriction on the size of the nasal airway. Arch Otolaryngol Head Neck Surg. 2008. [PMID: 18195188]
  7. Barnes ML, et al. A comparison of the efficacy of Kaltostat and Merocel in anterior epistaxis. J Laryngol Otol. 2001. [PMID: 11429074]
  8. Paddling J, et al. Epistaxis: diagnosis and treatment. J Am Acad Nurse Pract. 2012. [PMID: 22762299]
  9. Tunkel DE, et al. Clinical Practice Guideline: Nosebleed (Epistaxis). Otolaryngol Head Neck Surg. 2020. [PMID: 31910111] (The AAO-HNS Guideline).
  10. Rejas-Ugarte E, et al. Anxiety and Epistaxis. Ear Nose Throat J. 2018. [PMID: 30121175]
  11. Soyka MB, et al. The effect of rapid rhino packing on patient reported pain and discomfort. Rhinology. 2011. [PMID: 22125791]

Guidelines

  • NICE CKS: Epistaxis (2021). [Link]
  • ENT UK: Management of Epistaxis Guidelines.
  • AAO-HNS: Clinical Practice Guideline (2020).
13. Examination Focus

Medicolegal Pitfalls

  1. The Missed Tumor: Treating a teenager for 6 months with recurrent unilateral bleeds without imaging (JNA) or an adult with "Polyp" (Cancer). Rule: Recurrent unilateral bleeding needs Endoscopy.
  2. Septal Perforation: Bilateral cautery is indefensible.
  3. Pressure Necrosis: Leaving a pack in for >48 hours without checking/antibiotics. Or clamping the alar rim with a Foley clamp.
  4. Aspiration: Discharging a frail elderly patient with a posterior pack in situ. (Must Admit).

Common Exam Questions

  1. Q: Name the arteries of Little's Area.
    • A: Anterior Ethmoidal, Sphenopalatine, Greater Palatine, Superior Labial. (Posterior Ethmoidal is debated).
  2. Q: Management of Septal Haematoma?
    • A: Incision and Drainage + Quilting suture/Pack + IV Antibiotics.
  3. Q: Complications of Posterior Packing?
    • A: Hypoxia (Nasopulmonary reflex), Bradycardia, Pressure Necrosis of Columella, Toxic Shock Syndrome, Dysphagia.
  4. Q: What is the "Artery of Epistaxis"?
    • A: The Sphenopalatine Artery (Terminal branch of Internal Maxillary).
  5. Q: Describe the First Aid advice you give over the phone.
    • A: Sit forward. Pinch the soft cartilaginous part. Hold for 20 minutes continuously. Ice pack.
  6. Q: When would you consider Embolization over Surgery?
    • A: Patient unfit for GA (Severe COPD/Cardiac failure) or post-surgical failure.

OSCE Station: "The Bleeding Patient"

  • Scenario: 60M, Warfarin, Hypertensive. Dribbling blood.
  • Task: Manage the acute bleed.
  • Checklist:
    1. PPE: Did they put on gloves/apron/visor? (Critical Fail if not).
    2. ABC: Did they check airway and hemodynamic stability?
    3. First Aid: Did they demonstrate correct pinch technique?
    4. Inspection: Did they use a Thudicum and headlight?
    5. Placement: Did they insert the Rapid Rhino along the floor (not up)?

At a Glance

EvidenceStandard
Last UpdatedRecently

Clinical Pearls

  • **The Nasopulmonary Reflex**: Insertion of posterior nasal packs can cause reflex bradycardia and hypoxia. Pulse oximetry is mandatory for packed patients.
  • **"Don't Bilateral Burn"**: Never cauterize both sides of the septum in the same session. This devascularizes the cartilage, leading to septal perforation.
  • **The "Sentinel Bleed"**: A minor bleed in a young male adolescent may be the first sign of a Juvenile Nasopharyngeal Angiofibroma (JNA). Do not ignore recurrence.
  • **"The Drip Test"**: After anterior packing, look in the mouth. If blood is still dripping down the posterior pharynx, the pack has failed (Posterior Bleed).
  • **"The 50/50 Rule"**: 50% of "posterior" bleeds are actually severe *anterior* bleeds that flow backwards. Always try anterior packing first.

Guidelines

  • NICE Guidelines
  • BTS Guidelines
  • RCUK Guidelines