Epistaxis

What is Epistaxis?

Epistaxis is defined as bleeding from the nostril, nasal cavity, or nasopharynx. Nosebleeds are due to the bursting of a blood vessel within the nose. This may be spontaneous or caused by trauma. Nosebleeds are rarely life threatening and usually stop on their own. Nosebleeds can be divided into 2 categories, based on the site of bleeding: anterior (in the front of the nose) or posterior (in the back of the nose).

Approximately 60% of the population will be affected by epistaxis at some point in time, with 6% requiring professional medical attention. The cause of nosebleeds are typically idiopathic (unknown), but they may also result from trauma, medication use, tumors, or nasal/sinus surgery.

Treatment of epistaxis may include the use of local pressure (ie pinching the nose - low over the fleshy portion, not high over the bony portion), decongestant nasal sprays, chemical or electric cautery (burning the vessel shut), hemostatic agents (topical therapies to stop bleeding), nasal packing, embolization (a procedure to place material within the vessel to block it off), and surgical arterial ligation (tying off the vessel). There is no single definitive treatment for the management of nosebleeds and many factors including severity of the bleeding, use of anticoagulants, and other medical conditions can play a role in which treatment is utilized.

Treatment

Direct pressure is usually effective for stopping epistaxis by applying pressure to the front of the nose. Nasal decongestants such as oxymetazoline or neosynephrine may also be used. Gently applying Vaseline or other ointment to the front of the nose with a Q-tip on a daily basis helps to moisturize the nose and prevent nose bleeds due to dryness. It is also very important to avoid any trauma to the nose after a nose bleed by picking healing scabs or blowing the nose too aggressively.

Chemical cauterization with silver nitrate is also used for control of epistaxis not controlled by local application of pressure. When these methods are not effective, anterior or posterior packing might be necessary. Packing can be absorbable or non-absorbable.

For complicated nose bleeds, another method of treatment is angiographic embolization of the internal maxillary artery. It has a success rate of 71% to 95%, but the procedure carries risk of stroke, ophthalmoplegia (limitation of eye movement), facial nerve palsy (not being able to move half the face), and hematomas (blood clots) at the catheterization site. Also revascularization (reopening of the blood vessel) after embolization is not uncommon.

Direct surgical ligation or clipping is an increasing popular alternative to embolization. The traditional approach for ligation of the anterior and posterior ethmoids artery is via an external facial incision, but other approaches have been described, including an approach through the corner of the eye. Endoscopic sphenopalatine artery (SPA) ligation (Figure 3) throught the nose, has been proposed as an ideal treatment for certain nosebleeds as it takes the major arterial supply to the nasal cavity at a point closest to the bleeding, and therefore minimizes the risk of persistent bleeding from other circulation and spares the patient from a transoral incision. A review found a 92% to 100% success rate with endoscopic SPA ligation. Failures of this technique are attributed to the failure to identify all branches of the SPA, or the significant dissection that may be required in a patient with suboptimal coagulation properties.

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