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Epistaxis Diagnosis and Treatment Update A Review PDF
Epistaxis Diagnosis and Treatment Update A Review PDF
Epistaxis Diagnosis and Treatment Update A Review PDF
German A. Soto-Galindo and José Luis Treviño González* Accepted: 27 June 2017
Published: 28 June 2017
Department of Otolaryngology and Head and Neck Surgery, University of Nuevo Leon,
Medicine School and University Hospital, USA ISSN: 2379-948X
Copyright
© 2017 González et al.
Abstract
Epistaxis is a nose hemorrhage of a very variable severity. This entity is the most frequent chief OPEN ACCESS
complaint in the emergency room involving the Otolaryngology Department. It is categorized into
anterior and posterior epistaxis depending on the affected area. Anterior bleedings are easier Keywords
to treat and luckily they account to the 80% of cases. The correct identification of the bleeding site • Epistaxis
and its etiology is vitally important for a successful treatment. Visualization of the bleeding site is • Endoscopic surgery
usually achieved by rhinoscopy, but in some cases nasal endoscopy is needed. The first measure • Artery ligation
that needs to be taken is local pressure. If the bleeding persists, the correct identification of the • Cauterization
site and chemical cauterization with silver nitrate should be performed. Electrical cauterization
is indicated if the previous treatment fails. Surgical intervention is recommended if bleedings
are refractory to conservative treatment. There is a variety of surgical approaches with specific
indications and different success rates described in the manuscript.
Cite this article: Soto-Galindo GA, Treviño González JL (2017) Epistaxis Diagnosis and Treatment Update: A Review. Ann Otolaryngol Rhinol 4(4): 1176.
González et al. (2017)
Email:
Central
the middle and inferior meatus. The second one gives a branch epistaxis is still in debate. There is plenty of evidence that supports
that irrigates the superior turbinate and then runs through the the association of high blood pressure in Epistaxis [11,12]. Some
nasal septum until it anastomoses with the terminal branch of the authors, as Moriyuki, have found that systolic blood pressure is
major palatine artery [5–7]. significantly higher in patients with Epistaxis [13]. However, in
one study, the author measured the blood pressure of patients
Internal Carotid compound during the bleeding event and it showed no difference to the one
Ethmoidal Arteries. The ophthalmic artery, branch of the measured on routine situations [14].
internal carotid, gives rise to the anterior and posterior ethmoidal Cardiovascular factors are associated with the risk of epistaxis
arteries. The first one rises from the anterior ethmoidal foramen events due to the volume overload and increased pressure in
and irrigates the frontal and anterior ethmoidal sinuses. Then it venous vessels, triggering rupture of the thin arteries in the
gives rise to branches which irrigate the superior portion of the Kiesselbach area. This factors include congenital heart failure,
septum and the lateral nasal wall. The second one is implicated mitral stenosis, coarctation of the aorta, and superior vena cava
in the irrigation of the posterior region of the lamina cribosa [7]. obstruction.
Kiesselbach Area Coagulation dysfunctions are usually developed by
This area is also called Little´s area and it is irrigated by medication such as non-steroidal anti-inflammatory drugs,
branches of the sphenopalatine artery, grater palatine artery and clopidogrel and warfarin. Lymphoproliferative diseases, chronic
facial artery. This area is composed of potentially vulnerable thin alcohol intake, renal and liver dysfunction are also related to
large vessels. It’s a site of great relevance, being the most affected platelet/coagulation dysfunction [15].
portion in anterior Epistaxis [8]. One third of patients with recurrent epistaxis have and
SIGNS AND SYMPTOMS underlying hemostatic disorder, such as coagulation factor
deficiencies, Von Willebrand disease, and several rare inherited
The clinical appearance of a patient with an epistaxis event platelet function disorders. [16]]
will depend on the etiology of the underlying pathology. However,
patients may be emotionally altered due to the evident blood loss TREATMENT
they are observing. This anxiety may cause an increase in blood [Anterior epistaxis are simpler and easier to treat. Since the
pressure and tachycardia. 80% of nasal bleedings are anterior, the most part of this events
are solved with conservative treatment.
DIAGNOSIS
Medical therapy
Clinical diagnosis is commonly evident and presents no
challenge for physicians to identify. Usually, a headlight and a Usually, non-severe epistaxes are stopped by applying local
rhinoscope may be enough to identify the bleeding area. However, pressure in the affected area. However, if this approach does
the etiological diagnosis may be complicated in some cases due not solve the hemorrhage, the first line of treatment is chemical
to the wide variety of pathological entities that predisposes cauterization with silver nitrate. As stated by the Guidelines of
epistaxis events. the French Society of Otolaryngology, this initial treatment is less
aggressive for the mucosa. In case of failure, electric cauterization
The etiological diagnoses in nose bleedings are classified into
should be performed [17].
two major factors: local and systemic. However, in more than half
of the events the specific etiology is not found [9]. There is controversy when it comes to decide whether to
use chemical/electrical cauterization or nasal packing with
Local Factors vasoconstrictor agents. Some authors claim that when a single
These factors commonly produce nose bleeding by altering site of anterior bleeding is identified, a phenylephrine or
the normal physiology of the nasal mucosa and its vessels. Facial oxymetazoline solution are effective examples of vasoconstrictor
trauma including nose picking is most relevant during infancy. drugs, and re inspection must be done after at least five minutes
Foreign bodies and insertion of medical materials such as of direct pressure to the nasal septum with cotton pledges soaked
nasogastric tube or nasotraqueal intubation are also a cause of in vasoconstrictor agents, previously placed in the anterior
epistaxis. Infectious and inflammatory entities such as sinusitis, portion of the septum [18].
rhinitis and allergies; and topical decongestants and drugs like On the other hand, a newer study work showed evidence
cocaine are also local factors contributing to nose bleeding events that suggest the effectiveness of electro cauterization. It showed
[9]. better results over the nasal packing, which presented more
Systemic Factors bleeding recurrences. It stated that electrocautery must be the
first-choice treatment in all sites of bleeding, and nasal packing
These causes are associated with epistaxis, and the most should be inadvisable for posterior bleedings due to the pain [19].
common systemic factors include pathologies that increase
the blood pressure, cardiovascular disease, factors that alter If nasal packing is decided, topical antibiotic should be placed
the coagulation processes, and inherited or acquired blood in the pack. It should not be left more than five days to prevent
dyscrasias [10]. infections, and the most serious complication: toxic shock. Also,
oral antibiotics should be prescribed for as long as the packs
The theory that states that hypertension is the cause of remain in the nose [20].
Central
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