Chapter 3

Epistaxis

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Raymond Sacks, F.C.S., F.R.A.C.S.,1,2 Peta-Lee Sacks, MBBS,3 and Rakesh Chandra, M.D.4
ABSTRACT

Epistaxis is a common problem that may range in severity from a minor nuisance to hemodynamically significant bleeding. Vascular anatomy allows for
predictable identification of suspicious bleeding sites. Historically, packing was the workhorse of management, but, currently, more directed interventions have
become available. These modalities may result in improvements in both cost-effectiveness and patient comfort.
(Am J Rhinol Allergy 27, S9 S10, 2013; doi: 10.2500/ajra.2013.27.3890)

he nasal mucosa is supplied by terminal branches of the external and internal carotid arteries. Various anastomoses exist between these two systems, the most important being Kiesselbachs plexus in the anterior nasal septum. In this location,
branches of the anterior ethmoid, nasopalatine, and superior labial
arteries anastomose. There is also a contribution from the terminus
of the posterior septal artery. This the most common site of epistaxis, and 90% of all epistaxis presentations occur in this area.1
These anastomoses are fundamental to an understanding of epistaxis and its management, underlying the significance of treating
the most distal site of bleeding.
Epistaxis is often characterized as either anterior or posterior. Historically, these distinctions have been arbitrary, respectively, based on
whether or not the practitioner is able to identify the site of bleeding
during anterior rhinoscopy. A more useful scheme stratifies the
source according to whether it originates anterior or posterior to the
maxillary sinus ostium. Anterior bleeding, which usually arises from
Kisselbachs plexus, generally allows for easier visualization and
access. In contrast, posterior epistaxis, which usually arises from
branches of the sphenopalatine artery, is more difficult to visualize. In
this scenario, hemorrhage is often swallowed, resulting in difficulties
assessing the amount of blood lost.

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ETIOLOGY

FURTHER EVALUATION

Three steps underlie the management of epistaxis:

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Epistaxis is often idiopathic but can be occasionally caused by

underlying pathology such as sinonasal tumor. As such, the following
differential should be considered (Table 1).

INITIAL ASSESSMENT

Initial assessment of epistaxis attempts to estimate the amount of

blood lost and the period over which the patient has been bleeding.
The patients vital signs should be assessed to exclude hypovolemic shock. It may be necessary to obtain i.v. access to check for any
From the 1Australian School of Advanced Medicine at Macquarie University, 2Sydney
Medical School at University of Sydney, Sydney, Australia, 3School of Medical Sciences, University of New South Wales, Sydney, Australia, and 4Department of OtolaryngologyHead and Neck Surgery, Northwestern University Feinberg School of
Medicine, Chicago, Illinois
R Chandra is a consultant/advisor for Intersect ENT, Gyrus/Olympus, and Sunovion
and received a research grant from Intersect ENT. P-L Sacks and R Sacks have no
conflicts of interest to declare pertaining to this article
Address correspondence and reprint request to Raymond Sacks, F.C.S., F.R.A.C.S.,
Sydney Adventist Hospital, The ENT Centre, Suite 12, 2529 Hunter Street, Hornsby,
NSW, Australia, 2077
E-mail address: rsacks@optusnet.com.au
Copyright 2013, OceanSide Publications, Inc., U.S.A.

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clotting abnormalities and to draw blood for type and screen. The
patient should be asked to apply constant pressure over the lower
cartilaginous part of the nose for 20 minutes and to avoid swallowing blood in order that blood loss can be estimated.

1. Establishing the site of bleeding

2. Stopping the bleeding
3. Treating the cause of bleeding2

The primary aims of the history are to assess the severity and
duration of the nosebleed and the circumstances in which it occurred.
The physician should also inquire about any other medical conditions, alcohol consumption, and any history of nosebleeds or bruising.
A family history of bleeding should also be considered. Examination
begins with anterior rhinoscopy. A significant amount of bleeding
may require suction, a headlamp, and a nasal speculum. Topical
vasoconstriction using 1% phenylephrine or 0.05% oxymetazoline
combined with a topical anesthetic may also be beneficial.3 If no
source of bleeding is revealed anteriorly, nasendoscopy should be
performed with particular attention to mucosal and submucosal lesions or masses within the middle meatus and nasopharynx. Laboratory investigations may be required according to the severity and
frequency of bleeding and may include a full blood count, coagulation studies, and hepatic and renal function tests. These tests may be
particularly relevant in patients taking warfarin and in those with
diseases that could result in coagulopathy. In the absence of a severe
bleed or a personal or family history suggestive of a bleeding disorder, laboratory evaluation for coagulopathy is typically not indicated.
Recurrent unilateral epistaxis that fails to respond to conservative
management should be investigated for neoplasm, particularly in
those who report symptoms of nasal obstruction, rhinorrhea, facial
pain, or an abnormal cranial nerve examination.4

MANAGEMENT
The approach to managing epistaxis tends to vary according to the
severity and location of the bleed as well as a variety of other factors.
As discussed previously, initial medical treatment aims to cease the
bleeding and is often used to improve visualization during the clinical
exam.

ANTERIOR EPISTAXIS
Should topical vasoconstriction be unsuccessful and an accessible
site of bleeding can be identified, cauterization should be implemented.5 This should be performed with caution to avoid damage to

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S9

zation,9 and surgical arterial ligation.3 Severe cases typically require

one of the two latter methods.1011 Embolization is performed by a
neurointerventional radiologist. This method is 85% effective but
carries risks of cerebrovascular accident if particles are released into
the internal carotid system iatrogenically or via collateral circulation.
Patients may also have postprocedural jaw discomfort and claudication. Presently, transnasal endoscopic sphenopalatine artery ligation
or cautery is the primary surgical alternative in these intractable
cases. The artery is controlled where it enters into the posterior nasal
cavity via the sphenopalatine foramen. This region is situated behind
the crista ethmoidalis, a landmark formed by the orbital process of the
palatine bone. Overall success is also in the range of 85%, and major
complications are rare. Minor complications include nasal crusting
and nasal/palatal paresthesias. There is significant debate as to which
of these methods, angiography with embolization or endoscopic
sphenopalatine artery ligation, is preferred. However, current perspectives indicate that early treatment with either of these modalities
is more successful and cost-effective than prolonged inpatient posterior packing, which is markedly uncomfortable and also carries risks
including staphylococcal infection, toxic shock syndrome, and bradydysrhythmia. Often, the algorithm for management of severe intractable posterior epistaxis will depend on the resources available at a
particular institution.

Table 1 Etiology of epistaxis

Local causes
Idiopathic
Trauma

Digit trauma
Foreign body
Nasal oxygen and CPAP
Nasal fracture
Postoperative
Anatomical
Septal deviation
Spurs
Inflammatory/infectious Viral/bacterial rhinosinusitis
Allergic rhinosinusitis
Granulomatous disease
Environmental irritants
Neoplastic
Hemangioma of septum or turbinates
Hemangiopericytoma
Nasal papilloma
Pyogenic granuloma
Angiofibroma
Carcinoma
Drugs
Topical intranasal corticosteroids
Cocaine abuse
Systemic causes
Inherited
Hemophilia
Von Willebrands disease
Hereditary hemorrhagic
telangiectasia
Platelet abnormalities
Thrombocytopenia
Platelet dysfunction
Malignancy
Leukemias
Drugs
Chemotherapy
Chronic alcoholism
Anticoagulants, e.g. Warfarin
Anti-platelet, e.g. aspirin

healthy surrounding mucosa. Cautery can be performed chemically

or electrically depending on the severity of the bleed. Silver nitrate
sticks, which release oxygen free radicals to coagulate tissue, are
useful in minor bleeding; however, it will likely be washed away by
severe bleeding before becoming effective. Electric cauterization can
be applied to anesthetized mucosa and is more useful in severe
bleeding. Laser cauterization has a limited role in acute epistaxis but
may be used in patients with hereditary hemorrhagic telangiectasia.3,6
It is important to note that cauterization by any means should be
applied only to one side of the septum to avoid perforation over a
period of 46 weeks.4
Failure of cauterization may indicate the need for nasal packing.5
There are various types of absorbable and nonabsorbable options.
Patients with nasal packing should commence topical antibiotics to
avoid toxic shock syndrome.3 Other complications of nasal packing
include septal hematomas, abscesses, and sinusitis. In the rare case
that anterior packing should fail, ethmoidal vessels may be ligated
through a Lynch incision. This approach reduces the risk of stroke
and blindness associated with embolization of anterior and posterior
ethmoid arteries.7

The vast majority of epistaxis arises anteriorly, from Kiesselbachs

plexus in the anterior nasal septum.
Posterior epistaxis can be difficult to visualize but most often arises
from branches of the sphenopalatine artery.
Although it may seem trivial to state, it is important to highlight
that finding the exact site of the bleeding is critical for safe and
efficient management.
Maintain suspicion for underlying neoplastic conditions.
Current trends favor early intervention for posterior epistaxis, with
either embolization or sphenopalatine artery ligation, rather than
prolonged packing.

REFERENCES
1.
2.

3.
4.
5.
6.

7.

8.

9.

POSTERIOR EPISTAXIS

10.

Posterior bleeding most commonly arises from branches of the

sphenopalatine artery,8 which is the medial (distal) termination of the
internal maxillary. The main modes of treatment in these patients
include endoscopic electric cauterization, posterior packing, emboli-

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CLINICAL PEARLS

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CPAP continuous positive airway pressure.

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Gifford TO, and Orlandi RR. Epistaxis. Otolaryngol Clin North Am
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Schlosser RJ. Clinical practice. Epistaxis. N Engl J Med 360:784789,
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Harvey RJ, Kanagalingam J, and Lund VJ. The impact of septodermoplasty and potassium-titanyl-phosphate (KTP) laser therapy in the
treatment of hereditary hemorrhagic telangiectasia-related epistaxis.
Am J Rhinol 22:182187, 2008.
Srinivasan V, Sherman IW, and OSullivan G. Surgical management
of intractable epistaxis: Audit of results. J Laryngol Otol 114:697700,
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Schwartzbauer HR, Shete M, and Tami TA. Endoscopic anatomy of
the sphenopalatine and posterior nasal arteries: Implications for the
endoscopic management of epistaxis. Am J Rhinol 17:6366, 2003.
Gurney TA, Dowd CF, and Murr AH. Embolization for the treatment
of idiopathic posterior epistaxis. Am J Rhinol 18:335339, 2004.
Christensen NP, Smith DS, Barnwell SL, and Wax MK. Arterial
embolization in the management of posterior epistaxis. Otolaryngol
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Snyderman CH, Goldman SA, Carrau RL, et al. Endoscopic sphenopalatine artery ligation is an effective method of treatment for posterior epistaxis. Am J Rhinol 13:137140, 1999.
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