Epistaxis

Author: Quoc A Nguyen, MD; Chief Editor: Arlen D Meyers, MD, MBA

Contributor Information and Disclosures

Author
Quoc A Nguyen, MD Associate Clinical Professor, Director, Sinus and Allergy
Center, Department of Otolaryngology-Head and Neck Surgery, University of
California, Irvine, Medical Center
Quoc A Nguyen, MD is a member of the following medical societies: American
Academy of Facial Plastic and Reconstructive Surgery, Phi Beta
Kappa, American Academy of Otolaryngic Allergy,American Academy of
Otolaryngology-Head and Neck Surgery, The Triological Society, American
Rhinologic Society
Disclosure: Nothing to disclose.
Specialty Editor Board
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of
Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug
Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Ted L Tewfik, MD Professor of Otolaryngology-Head and Neck Surgery,
Professor of Pediatric Surgery, McGill University Faculty of Medicine; Senior
Staff, Montreal Children's Hospital, Montreal General Hospital, and Royal Victoria
Hospital
Ted L Tewfik, MD is a member of the following medical societies: American
Society of Pediatric Otolaryngology, Canadian Society of Otolaryngology-Head &
Neck Surgery

Disclosure: Nothing to disclose.

Chief Editor
Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and
Engineering, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical
societies: American Academy of Facial Plastic and Reconstructive
Surgery, American Academy of Otolaryngology-Head and Neck
Surgery,American Head and Neck Society
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant
or trustee for:
Medvoy;Testappropriate;Cerescan;Empirican;RxRevu<br/>Received none from
Allergy Solutions, Inc for board membership; Received honoraria from RxRevu

for chief medical editor; Received salary from Medvoy for founder and president;
Received consulting fee from Corvectra for senior medical advisor; Received
ownership interest from Cerescan for consulting; Received consulting fee from
Essiahealth for advisor; Received consulting fee from Carespan for advisor;
Received consulting fee from Covidien for consulting.
Additional Contributors
Hassan H Ramadan, MD, MSc Professor and Vice-Chair, Department of
Otolaryngology-Head and Neck Surgery, Professor, Department of Pediatrics,
West Virginia University School of Medicine
Hassan H Ramadan, MD, MSc is a member of the following medical
societies: American Academy of Otolaryngic Allergy, American Academy of
Otolaryngology-Head and Neck Surgery, American College of
Surgeons, American Rhinologic Society
Disclosure: Nothing to disclose.

Updated: Jun 24, 2015

Background
Epistaxis, or bleeding from the nose, is a common complaint. It is rarely life threatening
but may cause significant concern, especially among parents of small children. [1] Most
nosebleeds are benign, self-limiting, and spontaneous, but some can be recurrent.
Many uncommon causes are also noted.
Epistaxis can be divided into 2 categories, anterior bleeds and posterior bleeds, on the
basis of the site where the bleeding originates (see the image below).

Posterior epistaxis from the left

sphenopalatine artery.

The true prevalence of epistaxis is not known, because most episodes are self-limited
and thus are not reported. When medical attention is needed, it is usually because of
either the recurrent or severe nature of the problem. Treatment depends on the clinical
picture, the experience of the treating physician, and the availability of ancillary
services.[2, 3, 4, 5]
Also see Anterior Epistaxis Nasal Pack, Posterior Epistaxis Nasal Pack, andSurgery for
Pediatric Epistaxis.

Anatomy
The nose has a rich vascular supply, with substantial contributions from the internal
carotid artery (ICA) and the external carotid artery (ECA).
The ECA system supplies blood to the nose via the facial and internal maxillary arteries.
The superior labial artery is one of the terminal branches of the facial artery. This artery
subsequently contributes to the blood supply of the anterior nasal floor and anterior
septum through a septal branch.
The internal maxillary artery enters the pterygomaxillary fossa and divides into 6
branches: posterior superior alveolar, descending palatine, infraorbital, sphenopalatine,
pterygoid canal, and pharyngeal.
The descending palatine artery descends through the greater palatine canal and
supplies the lateral nasal wall. It then returns to the nose via a branch in the incisive
foramen to provide blood to the anterior septum. The sphenopalatine artery enters the
nose near the posterior attachment of the middle turbinate to supply the lateral nasal
wall. It also gives off a branch to provide blood supply to the septum.

The ICA contributes to nasal vascularity through the ophthalmic artery. This artery
enters the bony orbit via the superior orbital fissure and divides into several branches.
The posterior ethmoid artery exits the orbit through the posterior ethmoid foramen,
located 2-9 mm anterior to the optic canal. The larger anterior ethmoid artery leaves the
orbit through the anterior ethmoid foramen.
The anterior and posterior ethmoid arteries cross the ethmoid roof to enter the anterior
cranial fossa and then descend into the nasal cavity through the cribriform plate. Here,
they divide into lateral and septal branches to supply the lateral nasal wall and the
septum.
The Kiesselbach plexus, or Littles area, is an anastomotic network of vessels located
on the anterior cartilaginous septum. It receives blood supply from both the ICA and the
ECA.[6] Many of the arteries supplying the septum have anastomotic connections at this
site.

Pathophysiology
Bleeding typically occurs when the mucosa is eroded and vessels become exposed and
subsequently break.
More than 90% of bleeds occur anteriorly and arise from Littles area, where the
Kiesselbach plexus forms on the septum.[7, 8] The Kiesselbach plexus is where vessels
from both the ICA (anterior and posterior ethmoid arteries) and the ECA (sphenopalatine
and branches of the internal maxillary arteries) converge. These capillary or venous
bleeds provide a constant ooze, rather than the profuse pumping of blood observed
from an arterial origin. Anterior bleeding may also originate anterior to the inferior
turbinate.
Posterior bleeds arise further back in the nasal cavity, are usually more profuse, and are
often of arterial origin (eg, from branches of the sphenopalatine artery in the posterior
nasal cavity or nasopharynx). A posterior source presents a greater risk of airway
compromise, aspiration of blood, and greater difficulty controlling bleeding.

Etiology
Causes of epistaxis can be divided into local causes (eg, trauma, mucosal irritation,
septal abnormality, inflammatory diseases, tumors), systemic causes (eg, blood
dyscrasias, arteriosclerosis, hereditary hemorrhagic telangiectasia), and idiopathic
causes. Local trauma is the most common cause, followed by facial trauma, foreign
bodies, nasal or sinus infections, and prolonged inhalation of dry air. Children usually
present with epistaxis due to local irritation or recentupper respiratory infection (URI).
In a retrospective cohort study of 2405 patients with epistaxis (3666 total episodes),
Purkey et al used multivariate analysis to identify a series of risk factors for nosebleeds.
The likelihood of epistaxis was found to increase in patients with allergic rhinitis, chronic
sinusitis, hypertension, hematologic malignancy, coagulopathy, or, as mentioned,
hereditary hemorrhagic telangiectasia. The investigators also found increased
nosebleeds in association with older age and colder weather.[9]

Trauma
Self-induced trauma from repeated nasal picking can cause anterior septal mucosal
ulceration and bleeding. This scenario is frequently observed in young children. Nasal
foreign bodies that cause local trauma (eg, nasogastric and nasotracheal tubes) can be
responsible for rare cases of epistaxis.
Acute facial and nasal trauma commonly leads to epistaxis. If the bleeding is from minor
mucosal laceration, it is usually limited. However, extensive facial traumacan result in
severe bleeding requiring nasal packing. In these patients, delayed epistaxis may signal
the presence of a traumatic aneurysm.
Patients undergoing nasal surgery should be warned of the potential for epistaxis. As
with nasal trauma, bleeding can range from minor (due to mucosal laceration) to severe
(due to transection of a major vessel).

Dry weather
Low humidity may lead to mucosal irritation. Epistaxis is more prevalent in dry climates
and during cold weather due to the dehumidification of the nasal mucosa by home
heating systems.

Drugs
Topical nasal drugs such as antihistamines and corticosteroids may cause mucosal
irritation. Especially when applied directly to the nasal septum instead of the lateral
walls, they may cause mild epistaxis. Medications such as nonsteroidal antiinflammatory drugs (NSAIDs) are also frequently involved.

Septal abnormality
Septal deviations (deviated nasal septum) and spurs may disrupt the normal nasal
airflow, leading to dryness and epistaxis. The bleeding sites are usually located anterior
to the spurs in most patients. The edges of septal perforations frequently harbor
crusting and are common sources of epistaxis.

Inflammation
Bacterial, viral, and allergic rhinosinusitis causes mucosal inflammation and may lead to
epistaxis. Bleeding in these cases is usually minor and frequently manifests as bloodstreaked nasal discharge.
Granulomatosis diseases such as sarcoidosis, Wegener granulomatosis, tuberculosis,
syphilis, and rhinoscleroma often lead to crusting and friable mucosa and may be a
cause of recurrent epistaxis.
Young infants with gastroesophageal reflux into the nose may have epistaxis secondary
to inflammation.

Tumors

Benign and malignant tumors can manifest as epistaxis. Affected patients may also
present with signs and symptoms of nasal obstruction and rhinosinusitis, often
unilateral.
Intranasal rhabdomyosarcoma, although rare, often begins in the nasal, orbital, or sinus
area in children. Juvenile nasal angiofibroma in adolescent males may cause severe
nasal bleeding as the initial symptom.

Blood dyscrasias
Congenital coagulopathies should be suspected in individuals with a positive family
history, easy bruising, or prolonged bleeding from minor trauma or surgery. Examples of
congenital bleeding disorders include hemophilia and von Willebrand disease. [6]
Acquired coagulopathies can be primary (due to the diseases) or secondary (due to
their treatments). Among the more common acquired coagulopathies are
thrombocytopenia and liver disease with its consequential reduction in coagulation
factors. Even in the absence of liver disease, alcoholism has also been associated with
coagulopathy and epistaxis. Oral anticoagulants predispose to epistaxis.

Vascular abnormalities
Arteriosclerotic vascular disease is considered a reason for the higher prevalence of
epistaxis in elderly individuals.
Hereditary hemorrhagic telangiectasia (HHT; also known as Osler-Weber-Rendu
syndrome) is an autosomal dominant disease associated with recurrent bleeding from
vascular anomalies. The condition can affect vessels ranging from capillaries to arteries,
leading to the formation of telangiectasias and arteriovenous malformations. Pathologic
examination of these lesions reveals a lack of elastic or muscular tissue in the vessel
wall. As a result, bleeding can occur easily from minor trauma and tends not to stop
spontaneously.
Various organ systems such as the respiratory, gastrointestinal, and genitourinary
systems may be involved. The epistaxis in these individuals is variable in severity but is
almost universally recurrent.
Other vascular abnormalities that predispose to epistaxis include vascular neoplasms,
aneurysms, and endometriosis.

Migraine
Children with migraine headaches have a higher incidence of recurrent epistaxis than
children without the disease.[10] The Kiesselbach plexus, which is part of the
trigeminovascular system, has been implicated in the pathogenesis of migraine. [11]

Hypertension
The relationship between hypertension and epistaxis is often misunderstood. Patients
with epistaxis commonly present with an elevated blood pressure. Epistaxis is more

common in hypertensive patients, perhaps owing to vascular fragility from long-standing

disease.
Hypertension, however, is rarely a direct cause of epistaxis. More commonly, epistaxis
and the associated anxiety cause an acute elevation of blood pressure. Therapy,
therefore, should be focused on controlling hemorrhage and reducing anxiety as
primary means of blood pressure reduction.
A study by Sarhan and Algamal, which included 40 patients with epistaxis and 40
controls, reported that the number of attacks of epistaxis was higher in patients with a
history of hypertension, but the investigators were unable to determine whether a
definite link existed between nosebleeds and high blood pressure. They did find,
however, that control of epistaxis was more difficult in hypertensive patients; patients
whose systolic blood pressure was higher at presentation tended to need management
with packing, balloon devices, or cauterization.[12]
Excessive coughing causing nasal venous hypertension may be observed in pertussis
or cystic fibrosis.

Idiopathic causes
The cause of epistaxis is not always readily identifiable. Approximately 10% of patients
with epistaxis have no identifiable causes even after a thorough evaluation. [13]

Epidemiology
The frequency of epistaxis is difficult to determine because most episodes resolve with
self-treatment and, therefore, are not reported. [14] However, when multiple sources are
reviewed, the lifelong incidence of epistaxis in the general population is about 60%, with
fewer than 10% seeking medical attention.[6, 15, 14]
The age distribution is bimodal, with peaks in young children (2-10 y) and older
individuals (50-80 y). Epistaxis is unusual in infants in the absence of a coagulopathy or
nasal pathology (eg, choanal atresia, neoplasm). Local trauma(eg, nose picking) does
not occur until later in the toddler years. Older children and adolescents also have a
less frequent incidence. Consider cocaine abuse in adolescent patients.
Prevalence of epistaxis tends to be higher in males (58%) than in females (42%).

Prognosis
For most of the general population, epistaxis is merely a nuisance. However, the
problem can occasionally be life-threatening, especially in elderly patients and in those
patients with underlying medical problems. Fortunately, mortality is rare and is usually
due to complications from hypovolemia, with severe hemorrhage or underlying disease
states.
Overall, the prognosis is good but variable; with proper treatment, it is excellent. When
adequate supportive care is provided and underlying medical problems are controlled,

most patients are unlikely to experience any rebleeding. Others may have minor
recurrences that resolve spontaneously or with minimal self-treatment. A small
percentage of patients may require repacking or more aggressive treatments.
Patients with epistaxis that occurs from dry membranes or minor trauma do well, with no
long-term effects. Patients with HHT tend to have multiple recurrences regardless of the
treatment modality. Patients with bleeding from a hematologic problem or cancer have a
variable prognosis. Patients who have undergone nasal packing are subject to
increased morbidity. Posterior packing can potentially cause airway compromise and
respiratory depression. Packing in any location may lead to infection.

Patient Education
For patient education resources, see the Breaks, Fractures, and Dislocations Center, as
well as Broken Nose.
The following precautions should be imparted to the patient:

Use nasal saline spray.

Avoid hard nose blowing or sneezing.
Sneeze with the mouth open.
Do not use nasal digital manipulation.
Avoid hot and spicy foods.
Avoid taking hot showers.
Avoid aspirin and other NSAIDs.
The following simple instructions for self-treatment for minor epistaxis should be
provided:
Apply firm digital pressure for 5-10 minutes.
Use an ice pack.
Practice deep, relaxed breathing.
Use a topical vasoconstrictor.

Epistaxis Clinical Presentation

Author: Quoc A Nguyen, MD; Chief Editor: Arlen D Meyers, MD, MBA

History
Controlling significant bleeding or hemodynamic instability should always take
precedence over obtaining a lengthy history.
Ask specific questions about the severity, frequency, duration, and laterality of the
nosebleed. Determine whether the bleed occurs after exercise or during sleep or is
associated with a migraine. Determine whether hematemesis or melena has occurred
because posterior bleeding in particular may present in this fashion.

Inquire about precipitating and aggravating factors and methods used to stop the
bleeding. Most nosebleeds are reported as spontaneous events and are frequently
related to nose picking or other trauma; therefore, investigate the various possibilities.
Foreign bodies inserted in the nose may also present with epistaxis, but bleeding may
be less and accompanied by foul or purulent discharge if the object has been retained
for some time. A unilateral nasal discharge suggests the presence of a foreign body.
Children easily can insert small batteries from electronic devices (eg, calculators,
watches, handheld video games) into their nostrils. Not only can local irritation and
bleeding result, but these can leak and cause a chemical alkali burn that may result in
local tissue necrosis. Severe complications (eg, nasal stenosis) can result from
batteries. Removal is a priority; removing the batteries within 4 hours of insertion is best.
In addition to obtaining a head and neck history with an emphasis on nasal symptoms,
elicit a general medical history concerning relevant medical conditions, current
medications, and smoking and drinking habits.
Inquire about previous epistaxis, hypertension, hepatic or other systemic disease, easy
bruising, or prolonged bleeding after minor surgical procedures. A history of frequent
recurrent nosebleeds, easy bruising, or other bleeding episodes should make the
clinician suspicious of a systemic cause and prompt a hematologic workup. Obtain any
family history of bleeding disorders or leukemia.
Children with severe epistaxis are more likely to have required nasal cauterization, an
underlying coagulopathy, a positive family history of bleeding, and anemia. Although
unusual, children with bleeding disorders (eg, von Willebrand disease) can occasionally
have normal coagulation profiles. More than 1 sample may be required to notice the
abnormality due to biologic variability throughout the day.
Use of medicationsespecially aspirin, NSAIDs, warfarin, heparin, ticlopidine, and
dipyridamoleshould be documented, as these not only predispose to epistaxis but
make treatment more difficult. Particularly in children, include investigation of suspicion
of accidental ingestion (eg, accidental ingestion of rat poison in toddlers).

Physical Examination
Before evaluating a patient with epistaxis, have sufficient illumination, adequate suction,
all the necessary topical medications, and cauterization and packing materials ready.
Remove all packings, even though bleeding may not be active. The importance of
obtaining adequate anesthesia and vasoconstriction if time permits cannot be
overemphasized. A comfortable patient tends to be more cooperative, allowing for better
examination and more effective treatment.
Perform a thorough and methodical examination of the nasal cavity. Blowing the nose
decreases the effects of local fibrinolysis and removes clots, permitting a better
examination. Application of a vasoconstrictor (eg, 0.05% oxymetazoline) before the
examination may reduce hemorrhage and help to pinpoint the precise bleeding site. A

topical anesthetic (eg, 4% aqueous lidocaine) reduces pain associated with the
examination and nasal packing. Clots are then suctioned out to permit a thorough
examination.
Gently insert a nasal speculum (see the image below) and spread the naris vertically.
Begin the examination with inspection, looking specifically for any obvious bleeding site
on the septum that may be amenable to direct pressure or cautery. This permits
visualization of most anterior bleeding sources. Anterior bleeds from the nasal septum
are most common type, and the site can frequently be identified if bleeding is active.

Nasal speculum.

If an anterior source cannot be visualized, if the hemorrhage is from both nares, or if

constant dripping of blood is seen in the posterior pharynx, the bleeding may be from a
posterior site. After placement of an anterior pack, and, if bleeding is noted in the
pharynx with the anterior pack in place, strongly consider a posterior bleed.
Massive epistaxis may be confused with hemoptysis or hematemesis. Blood dripping
from the posterior nasopharynx confirms a nasal source. Approximately 90% of
nosebleeds can be visualized in the anterior portion of the nasal cavity.
Fiberoptic endoscopy may be performed with a flexible or (preferably) rigid endoscope
to inspect the entire nasal cavity, including the nasopharynx. The rigid endoscope is
preferred because of its superior optics and its ability to allow endoscopic suction and
cauterization.
Examine the skin for evidence of bruises or petechiae that may indicate an underlying
hematologic abnormality.
Assess vital signs. Although high blood pressure rarely, if ever, causes epistaxis on its
own, it may impede clotting. Check blood pressure, and complete a workup if high blood
pressure is present. Persistent tachycardia must be recognized as an early indicator of
significant blood loss requiring intravenous (IV) fluid replacement and, potentially,
transfusion.

Complications
Complications of epistaxis may include the following:

Sinusitis
Septal hematoma/perforation
External nasal deformity
Mucosal pressure necrosis
Vasovagal episode
Balloon migration
Aspiration

Epistaxis Differential Diagnoses

Author: Quoc A Nguyen, MD; Chief Editor: Arlen D Meyers, MD, MBA

Diagnostic Considerations
Recurrent epistaxis in children could be caused by a foreign body, especially if the
nosebleeds are accompanied by symptoms of unilateral nasal congestion and purulent
rhinorrhea. Delayed epistaxis in a trauma patient may signal the presence of a traumatic
aneurysm.
Other conditions to be considered include the following:

Chemical irritants
Hepatic failure
Leukemia
Thrombocytopenia
Heparin toxicity
Ticlopidine toxicity
Dipyridamole toxicity
Trauma
Tumor

Differential Diagnoses

Allergic Rhinitis

Barotrauma

Cocaine Toxicity

Coumarin Plant Poisoning

Disseminated Intravascular Coagulation in Emergency Medicine

Emergent Treatment of Endometriosis

Nasal Foreign Bodies

Nonsteroidal Anti-inflammatory Agent Toxicity

Pediatric Osler-Weber-Rendu Syndrome

Rodenticide Toxicity

Salicylate Toxicity

Sinusitis Imaging

Type A Hemophilia

Type B Hemophilia

von Willebrand Disease

Warfarin and Superwarfarin Toxicity

Epistaxis Workup

Author: Quoc A Nguyen, MD; Chief Editor: Arlen D Meyers, MD, MBA

Approach Considerations
For the most part, laboratory studies are not needed or helpful for first-time nosebleeds
or infrequent recurrences with a good history of nose picking or trauma to the nose.
However, they are recommended if major bleeding is present or if a coagulopathy is
suspected.

Laboratory Tests
Laboratory tests to evaluate the patients condition and underlying medical problems
may be ordered depending on the clinical picture at the time of presentation. If the
bleeding is minor and not recurrent, then a laboratory evaluation may not be needed.
If a history of persistent heavy bleeding is present, obtain a hematocrit count and type
and cross-match. If a history of recurrent epistaxis, a platelet disorder, or neoplasia is
present, obtain a complete blood count (CBC) with differential. The bleeding time is an
excellent screening test if suspicion of a bleeding disorder is present. Obtain the

international normalized ratio (INR)/prothrombin time (PT) if the patient is taking

warfarin or if liver disease is suspected. Obtain the activated partial thromboplastin time
(aPTT) as necessary.

Other Studies
Direct visualization with a good directed light source, a nasal speculum, and nasal
suction should be sufficient in most patients. However, computed tomography (CT)
scanning, magnetic resonance imaging (MRI) or both may be indicated to evaluate the
surgical anatomy and to determine the presence and extent of rhinosinusitis, foreign
bodies, and neoplasms. Nasopharyngoscopy may also be performed if a tumor is the
suspected cause of bleeding.
Sinus films are rarely indicated for a nosebleed. Angiography is rarely indicated.

Epistaxis Treatment & Management

Author: Quoc A Nguyen, MD; Chief Editor: Arlen D Meyers, MD, MBA

Approach Considerations
When medical attention is needed for epistaxis, it is usually because of the problem is
either recurrent or severe. Treatment depends on the clinical picture, the experience of
the treating physician, and the availability of ancillary services.
In most patients with epistaxis, the bleeding responds to cauterization, nasal packing, or
both. For those who have recurrent or severe bleeding for which medical therapy has
failed, various surgical options are available. After surgery or embolization, patients
should be closely observed for any complications or signs of rebleeding.
Medical approaches to the treatment of epistaxis may include the following:

Adequate pain control in patients with nasal packing, especially in those with
posterior packing (However, the need of adequate pain control has to be balanced
with the concern over hypoventilation in the patient with posterior pack.)

Oral and topical antibiotics to prevent rhinosinusitis and possibly toxic shock
syndrome

Avoidance of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs)

Medications to control underlying medical problems (eg, hypertension, vitamin K

deficiency) in consultation with other specialists
Also see Anterior Epistaxis Nasal Pack, Posterior Epistaxis Nasal Pack, andSurgery for
Pediatric Epistaxis.

Manual Hemostasis

Initial treatment begins with direct pressure. The nostrils are squeezed together for 5-30
minutes straight, without frequent peeking to see if the bleeding is controlled. Usually, 510 minutes is sufficient.
Patients should keep their heads elevated but not hyperextended because
hyperextension may cause bleeding into the pharynx and possible aspiration. This
maneuver works more than 90% of the time.
If direct pressure is not sufficient, gauze moistened with epinephrine at a ratio of
1:10,000 or phenylephrine (Neo-Synephrine) may be placed in the affected nostril to
help vasoconstrict and achieve hemostasis.

Humidification and Moisturization

If bleeding is caused by excessive dryness in the home (eg, from radiator heating),
patients may benefit from humidifying the air with a cool mist vaporizer in the bedroom
or, as a simpler alternative, placing a metal basin of water on top of a radiator to
humidify the ambient air.
Nasal saline sprays are useful. Oxymetazoline may also be used, with fewer cardiac
adverse effects. To minimize the risk of rhinitis medicamentosa and tachyphylaxis, these
agents should be used for no more than 3-5 days at a time.
The physician may consider local application of bacitracin or petrolatum ointment
directly to the Kiesselbach area with a cotton applicator to prevent further drying
(studies recommend 2 wk).

Cauterization
Bleeding from the Kiesselbach plexus (Littles area) is frequently treated with silver
nitrate cauterization.[13] Manage the vessels leading to the site before managing the
actual bleeding site. Avoid random and aggressive cauterization and cautery on
opposing surfaces of the septum.
Electrocauterization with an insulated suction cautery unit can also be used. This
method is usually reserved for more severe bleeding and for bleeding in more
posteriorly located sites, and it often requires local anesthesia. The effectiveness of both
cauterization methods can be enhanced by using rigid endoscopy, especially in the
case of more posteriorly located bleeding sites (see the image below). [16]

Resolved posterior epistaxis after

endoscopic cauterization of the left sphenopalatine artery.

After the bleeding has been controlled, instruct the patient to use nasal saline spray and
antibiotic ointment and to avoid strenuous activities for 7-10 days. NSAIDs are to be
avoided if at all possible. Digital manipulation of the nose is to be avoided. A topical
vasoconstrictor may be used if minor bleeding recurs with the dislodging of the eschar.

Nasal Packing
Nasal packing can be used to treat epistaxis that is not responsive to cauterization. Two
types of packing, anterior and posterior, can be placed. In both cases, adequate
anesthesia and vasoconstriction are necessary.
A study by Kundi and Raza suggested that in patients with epistaxis, removal of nasal
packs after 12 hours leads to a lower incidence of headache and excessive lacrimation
than does removal of packs after 24 hours, with no significant difference in bleeding
recurrence. The study involved 60 patients with epistaxis, evenly divided between the
12-hour and 24-hour groups.[17]

Anterior
For anterior packing, various packing materials are available. Petroleum jelly gauze (0.5
in 72 in) filled with an antibiotic ointment is traditionally used (see the image below).
Layer it tightly and far enough posteriorly to provide adequate pressure. Blind packing
with loose gauze is to be avoided.

Vaseline gauze packing.

Merocel sponges can be placed relatively easily and quickly but may not provide
adequate pressure (see the image below). They should be coated with an antibiotic
ointment and can be hydrated with a topical vasoconstrictor.

Expandable (Merocel) packing (dry).

All packings should be removed in 3-4 days. Absorbable materials (eg, Gelfoam,
Surgicel, Avitene) may be used in patients with coagulopathy to prevent trauma upon
packing removal. Administer prophylactic antibiotics to all patients with packing, and
instruct them to avoid physical strain for 1 week.
Also see Anterior Epistaxis Nasal Pack.

Posterior
Epistaxis that cannot be controlled by anterior packing can be managed with posterior
packing. Classically, rolled gauzes are used, but medium tonsil sponges can be
substituted.
Recently, inflatable balloon devices (eg, 12 or 14 French Foley catheters) or specially
designed catheters manufactured by companies such as Storz and Xomed (eg, Storz
Epistaxis Catheter, Xomed Treace Nasal Post Pac) have become popular because they

are easier to place. Avoiding overinflation of the balloon is important because it can
cause pain and displacement of the soft palate inferiorly, interfering with swallowing.
A 2010 study by Garcia Callejo et al determined that gauze packing, despite being
slower and more uncomfortable, has a higher success rate, produces fewer local
injuries, and costs less than inflatable balloon packing. [18]
Regardless of the type of posterior pack used, an anterior pack should also be placed.
Admit all patients with posterior packing to the intensive care unit (ICU) for close
monitoring of oxygenation, fluid status, and pain control. An antibiotic should also be
given to prevent rhinosinusitis and possible toxic shock syndrome.
Also see Posterior Epistaxis Nasal Pack.

Management of packing failure

Packing failure can be caused by inadequate placement resulting either from lack of
patient cooperation (especially in the pediatric age group) or from anatomic factors (eg,
deviated septum). In cases of packing failure, a careful endoscopic examination with the
patient under general anesthesia may be considered. Bleeding sites can be cauterized
under endoscopic guidance, a deviated septum can be straightened, spurs can be
removed, and meticulous packing can be placed. [19]
If these steps fail to control the bleeding, arterial ligation (see below) may be performed
at the same time.

Arterial Ligation
The choice of the specific vessel or vessels to be ligated depends on the location of the
epistaxis. In general, the closer the ligation is to the bleeding site, the more effective the
procedure tends to be.

External carotid artery

Ligation of the external carotid artery (ECA) can be performed with the patient under
local or general anesthesia. A horizontal skin incision is made between the hyoid bone
and the superior border of the thyroid cartilage. Subplatysmal skin flaps are then raised,
and the sternocleidomastoid muscle is retracted posteriorly.
Next, the carotid sheath is opened and its contents exposed. The ECA is identified by
following the internal carotid artery (ICA) for a few centimeters and dissecting the ECA
beyond its first few branches. After the ECA has been positively identified, it is usually
ligated just distal to the superior thyroid artery. Continued bleeding after ligation may be
from anastomoses with the opposite carotid system or the ipsilateral ICA.

Internal maxillary artery

Internal maxillary artery ligation has a higher success rate than ECA ligation because of
the more distal site of intervention.

Traditionally, the internal maxillary artery is accessed transantrally via a Caldwell-Luc

approach. With the help of an operating microscope, the posterior sinus wall is removed
in a piecemeal fashion, and the posterior periosteum is carefully opened. The internal
maxillary artery and 3 of its terminal branches (ie, sphenopalatine, descending palatine,
pharyngeal) are elevated with nerve hooks, then clipped. The posterior sinus wall is
then packed with Gelfoam, and the gingivobuccal incision is closed.
More recently, transoral and transnasal endoscopic approaches have been described.
The transoral approach is useful in patients with midface trauma, hypoplastic antra, or
maxillary tumors.
In the transoral approach, the buccinator space is first entered through a gingivobuccal
incision. The buccal fat pad is removed, and the attachment of the temporalis to the
coronoid process is identified. This process facilitates the identification of the internal
maxillary artery. The vessel is then doubly clipped and divided. This procedure has a
higher failure rate than the transantral approach because the site of ligation is more
proximal.
The transnasal endoscopic method requires skills with endoscopic instruments. A large
middle meatal antrostomy is made to expose the posterior sinus wall. The middle
turbinate can be partially resected to ensure adequate exposure. The remaining steps
are similar to those of the traditional transantral approach.
Endoscopic technique can also be used to ligate the sphenopalatine artery at its exit
from the sphenopalatine foramen.[20, 21] An incision is made just posterior to the posterior
attachment of the middle turbinate. The mucosal flap is then carefully elevated to reveal
the sphenopalatine artery, which is then clipped and ligated.

Ethmoid artery
If bleeding occurs high in the nasal vault, consider ligation of the anterior ethmoid artery,
the posterior ethmoid artery, or both. These arteries are approached through an external
ethmoidectomy incision.
The anterior ethmoid artery is usually found approximately 22 mm (range, 16-29 mm)
from the anterior lacrimal crest. If clipping the artery does not stop the bleeding, then the
posterior ethmoid artery may be ligated. This artery is found approximately 12 mm
posterior to its anterior counterpart. It should be clipped, not cauterized, because it is
only 4-7 mm anterior to the optic nerve.

Embolization
Bleeding from the ECA system may be controlled with embolization, either as a primary
modality in poor surgical candidates or as a second-line treatment in those for whom
surgery has failed. Patients considered candidates for embolization should be
transferred to hospitals with interventional radiology capability.[19]
Preembolization angiography is performed to check for the presence of any unsafe
communications between the ICA and ECA systems. Selective embolization of the

internal maxillary artery[22] and sometimes the facial artery may be performed.
Postprocedure angiography can be used to evaluate the degree of occlusion. The most
common reason for failure is continued bleeding from the ethmoid arteries.

Palliative Therapy for Hereditary Hemorrhagic Telangiectasia

Management of hereditary hemorrhagic telangiectasia (HHT) is palliative because the
underlying defect is not curable. Options include coagulation with potassium-titanylphosphate (KTP) or neodymium:yttrium-aluminum-garnet (Nd:YAG) lasers,
septodermoplasty, embolization, and estrogen therapy.[23]

Complications of Treatment
Potential treatment complications include the following :

Cauterization - Synechia, septal perforation

Anterior packing - Synechia, rhinosinusitis, toxic shock syndrome, eustachian
tube dysfunction, scarring of the nasal ala and columella
Posterior packing - Synechia, rhinosinusitis, toxic shock syndrome, eustachian
tube dysfunction, dysphagia, scarring of nasal ala and columella, hypoventilation,
sudden death
Transantral internal maxillary artery ligation - Anesthetic risks, rhinosinusitis,
oroantral fistula, infraorbital numbness, dental injury
Transoral internal maxillary artery ligation - Anesthetic risks, cheek numbness,
trismus, tongue paresthesia
Anterior or posterior ethmoid artery ligation - Anesthetic risks, rhinosinusitis,
lacrimal duct injury, telecanthus, blindness
Embolization - Facial pain, trismus, facial paralysis, skin necrosis, blindness,
stroke, groin hematoma

Dietary Measures
Few dietary measures are indicated. Patients should avoid hot and spicy foods and
drink plenty of fluids.

Activity Restriction
Patients should avoid strenuous activities, hot showers, and digital trauma. They should
use nasal saline spray liberally and should employ digital pressure and ice packs as
needed for minor recurrences.

Prevention of Epistaxis
To the extent possible, patients should avoid the following:

Strenuous activities - Protection from direct trauma from some sports activities is
afforded by the use of helmets or face pieces.

Hot and dry environments The effects of such environments can be mitigated
by using humidifiers, better thermostatic control, saline spray, and antibiotic ointment
on the Kiesselbach area.
Hot and spicy foods
Digital trauma In children, nose picking is difficult to deter and should probably
be considered inevitable. Keeping the childs nails well trimmed may be helpful.
Nose blowing and excessive sneezing - Instruct patients to sneeze gently with
the mouth open.
Inappropriate or careless use of drugs - Consider drug education relating to use
or accidental ingestion of aspirin, warfarin (eg, rat poison in toddlers), or drug abuse in
adolescents.

Consultations
A hematologist may have to be consulted. Consultation with an interventional radiologist
may also be appropriate.

Long-Term Monitoring
Use supportive measures to prevent recurrence (eg, nasal saline spray, Bactroban
nasal ointment). Arrange for follow-up care to remove packing in 3-4 days.

Epistaxis Medication

Author: Quoc A Nguyen, MD; Chief Editor: Arlen D Meyers, MD, MBA

Medication Summary

Most patients with epistaxis who seek medical attention are likely to be treated
with cauterization, anterior packing, or both. Those with severe or recalcitrant
bleeding may need posterior packing, arterial ligation, or embolization.
Pharmacotherapy plays only a supportive role in treating the patient with
epistaxis.

Topical vasoconstrictors
Class Summary

Topical vasoconstrictors act on alpha-adrenergic receptors in the nasal mucosa,

causing vessels to constrict.

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Oxymetazoline 0.05% (Afrin)

Oxymetazoline is applied directly to mucous membranes, where it stimulates

alpha-adrenergic receptors and causes vasoconstriction. Decongestion occurs
without drastic changes in blood pressure, vascular redistribution, or cardiac
stimulation.
Oxymetazoline can be used in combination with lidocaine 4% to provide effective
nasal anesthesia and vasoconstriction.

Anesthetics
Class Summary

When anesthetics are used concomitantly with vasoconstrictors, their anesthetic

effect is prolonged and the pain threshold increased.

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Lidocaine 4% (Xylocaine)

Lidocaine decreases permeability to sodium ions in neuronal membranes. This

results in the inhibition of depolarization, blocking the transmission of nerve
impulses.
Lidocaine can be used in combination with oxymetazoline 0.05% to provide
effective nasal anesthesia and vasoconstriction.

Antibiotic ointments
Class Summary

Antibiotic ointments help prevent local infection and provide local moisturization.

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Mupirocin ointment 2% (Bactroban nasal)

Mupirocin ointment inhibits bacterial growth by inhibiting RNA and protein

synthesis. It is a compounded medication.

Cauterizing agents
Class Summary

Cauterizing agents coagulate cellular proteins, which can in turn reduce bleeding.

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Silver nitrate

Silver nitrate coagulates cellular protein and removes granulation tissue. It also
has antibacterial effects.