Approach to Epistaxis

Abstract

Epistaxis, commonly referred to as nosebleeds, is a frequent clinical presentation with etiologies spanning from localized trauma to systemic conditions and medication effects. Despite its high prevalence, management approaches vary significantly depending on the cause and severity. To provide a comprehensive review of current management strategies for epistaxis, focusing on initial interventions, evaluation techniques, and preventive measures. A structured review of the literature was conducted to identify effective strategies for the initial management, evaluation, and prevention of epistaxis. Emphasis was placed on practical applications for clinicians in both emergency and outpatient settings. Initial Management: Direct pressure and topical vasoconstrictors remain the first-line interventions. Persistent cases may require nasal packing or cautery. Evaluation: Identification of underlying causes such as hypertension, coagulopathies, and structural nasal abnormalities is crucial, particularly in recurrent or severe cases. Laboratory tests and imaging may aid in diagnosis and management planning. Prevention: Patient education on nasal hygiene, avoidance of nasal trauma, and maintenance of a humidified environment are critical in reducing recurrence. Integrating effective initial management with thorough evaluation and preventive strategies significantly improves patient outcomes.

1. Case Scenario

Ms. J, a 39-year-old woman, presents to the emergency department with a recurrent and concerning issue of spontaneous nosebleeds, necessitating immediate medical attention. She reports experiencing three episodes in the past month, each characterized by bleeding from the anterior nasal passages. These episodes are often triggered by minor trauma, such as an accidental bump or gentle nose picking.

Each episode typically lasts between 10 and 15 min, with bleeding stopping only after applying pressure to the nostrils. Despite a history of seasonal allergies, Ms. J denies any recent upper respiratory infections, significant nasal trauma, or the use of anticoagulant medications that might exacerbate her condition. Upon examination, her vital signs are stable, alleviating concerns of acute complications from excessive bleeding.

Visual inspection of the nasal mucosa reveals erythematous patches and a small area of crusting, indicating underlying inflammation. Although there is no active bleeding during the examination, the frequency and persistence of Ms. J’s epistaxis underscore the need for a comprehensive evaluation to determine the underlying cause and develop a tailored management plan to alleviate her symptoms and prevent future episodes.

Question: What is the next best step in management for a 39-year-old patient presenting with recurrent episodes of anterior epistaxis?

(A)

Prescribe intranasal corticosteroids.

(B)

Perform nasal endoscopy.

(C)

Apply silver nitrate cautery to the bleeding site.

(D)

Order a complete blood count (CBC) and coagulation studies.

(E)

Teach proper nasal packing technique for self-administration.

Answer:

C. In the management of recurrent anterior epistaxis, especially when episodes are brief and easily controlled, silver nitrate cautery is often the initial approach. This procedure involves applying silver nitrate directly to the bleeding site to induce tissue coagulation and achieve hemostasis. It is a quick and effective method that can be performed in an outpatient setting.

2. Initial Approach

2.1. Overview of Epistaxis

Epistaxis, or nosebleeds, is a common condition with a wide range of underlying causes. Recent data highlight its significance in emergency settings, with a 30-day all-cause mortality rate of 3.4% among those affected [1]. Notably, hereditary hemorrhagic telangiectasia (HHT) is highly associated with epistaxis, with over 96% of individuals with HHT experiencing this condition [2]. Recurrent epistaxis admissions (REAs) occur in approximately 14% of cases, influenced by various early and late risk factors [3]. Despite trials with medications such as bevacizumab, estriol, and tranexamic acid showing limited success in reducing the frequency of epistaxis, ongoing research continues to explore effective management strategies [4,5]. Furthermore, advancements in diagnostic technology, including computer-aided systems utilizing dynamic uncertain causality graph (DUCG), have demonstrated high diagnostic accuracy for epistaxis, although further research is needed to refine our understanding and management of this condition [5].

Epistaxis affects around 60% of the general population, making it a prevalent issue in otolaryngology. However, only a small fraction—about 6%—of those experiencing epistaxis seek medical attention [6]. Severe cases necessitating emergency department visits occur in about 0.5% of cases, with only 0.2% requiring hospitalization. Interestingly, there is a bimodal age distribution, with epistaxis being more common in individuals younger than 10 years and those between 70 and 79 years of age [6]. Pregnancy is another condition associated with epistaxis. Hormonal changes, particularly increased estrogen and progesterone, lead to vascular engorgement of the nasal mucosa, making it more prone to bleeding. These changes typically resolve postpartum.

While most epistaxis cases are spontaneous, some are triggered by trauma. Common risk factors include facial injury, mucosal irritation from physical or chemical sources, allergic or infectious rhinitis, nasal tumors, and environmental factors like temperature and humidity. Systemic conditions such as hypertension, coagulation disorders, diabetes, heart failure, anemia, liver disorders, and the use of certain medications, including anticoagulants and intranasal drugs, can also contribute to epistaxis. Typically, epistaxis originates from the anterior part of the nose at Kiesselbach’s plexus, where several vessels converge, including the anterior ethmoidal artery, the sphenopalatine artery, the greater palatine artery, and the superior labial artery. However, bleeding can also originate from Woodruff’s plexus in the posterior nasal cavity, supplied by branches of the sphenopalatine and posterior ethmoidal arteries, which may not be visible during an anterior nasal examination [7]. The etiology of epistaxis is detailed in

Table 1. Etiology of epistaxis. Adapted from [7,8].

Causes	Examples
Local Causes
	Nasal infections (e.g., sinusitis, rhinitis)
	Digital manipulation
	Deviated septum
	Trauma (e.g., blunt trauma, nasal fractures)
	Chronic nasal cannula use
	Tumors (e.g., nasal polyps, malignancies)
	Foreign bodies (especially in children)
Systemic Causes
	Alcoholism
	Hypertension
	Vascular malformations
	Coagulopathies (e.g., Von Willebrand disease, hemophilia)
	Malignant hematological diseases (e.g., acute leukemia, myelodysplastic syndrome)
	Benign hematological diseases (e.g., immune thrombocytopenia, anemia)
Environmental Factors
	Allergies
	Environmental dryness (more common in winter months)
Medications
	NSAIDs (e.g., ibuprofen, naproxen, aspirin)
	Anticoagulants (e.g., warfarin)
	Platelet aggregation inhibitors (e.g., clopidogrel)
	Topical nasal steroid sprays
	Supplement/alternative medications (e.g., Vitamin E, ginkgo, ginseng)
	Illicit drugs (e.g., cocaine)

.

2.2. Primary Assessment

A thorough medical history is essential in evaluating epistaxis. It is important to inquire about the frequency, duration, and severity of the nosebleeds, including their recurrence and intensity, to determine the seriousness of the condition and guide appropriate treatment [9]. Additionally, questions should be asked about potential triggers, such as trauma or manipulation of the nasal area, to help identify underlying causes [9]. Assessing for associated symptoms like nasal congestion or allergies can reveal concurrent conditions that may be contributing to the nosebleeds. Moreover, gathering information on any prior treatments or interventions, including medications, illegal substance usage, procedures, or home remedies, provides insight into the patient’s previous management strategies and their effectiveness [9]. Furthermore, laboratory investigations, including a complete blood count (CBC) with platelet count and coagulation studies, should be performed to rule out systemic disorders such as thrombocytopenia or coagulation abnormalities. These tests are particularly important in patients with recurrent epistaxis or a history suggestive of systemic disease.

2.3. Physical Examination

During the physical examination for epistaxis, it is crucial to conduct a detailed assessment of the nasal cavity. Utilizing tools such as a nasal speculum, headlamp, and suction catheter can aid in locating the bleeding site. In cases where visual identification is challenging, particularly with posterior nosebleeds, nasal endoscopy can greatly enhance the ability to pinpoint the source of bleeding [8]. The examination should also include an evaluation for swelling and palpation of nasal structures. Likewise, it is essential to check for signs of septal hematoma, foreign bodies, and active bleeding during the examination [8].

Monitoring vital signs, particularly blood pressure, is critical in patients presenting with epistaxis. Elevated blood pressure is often observed during nosebleeds and may indicate underlying arterial hypertension [10]. Factors such as advanced age, peripheral vascular disease, cardiovascular conditions, and a history of previous nosebleeds have been associated with epistaxis. Therefore, regular monitoring of vital signs, especially blood pressure, is vital for the timely identification and management of any potential underlying conditions in patients with epistaxis [10].

Examining the nasal mucosa for signs of bleeding, inflammation, or abnormalities is a key component of the assessment. Adequate lighting and ensuring the patient is comfortably seated are important for a thorough evaluation. Anterior rhinoscopy allows for visual inspection of the nasal cavity, and if further examination is required, a flexible fiberoptic nasopharyngoscope can be used. Identifying signs such as active bleeding, inflammation, or lesions helps in determining the source of the nosebleed. It is also important to consider the possibility of a nasal foreign body, particularly in children [8].

In cases where underlying structural issues or nasal masses are suspected, nasal endoscopy and imaging studies play critical roles. Nasal endoscopy provides direct visualization of the nasal cavity, assisting in identifying bleeding sites and assessing for any present masses [11]. Imaging techniques, such as computed tomography (CT) or magnetic resonance imaging (MRI), offer detailed views of the nasal cavity and surrounding sinuses, helping detect structural abnormalities or masses, or vascular lesions, which may be causing the nosebleeds. These assessments are crucial for accurately diagnosing and addressing the underlying causes of epistaxis, especially when they are not immediately apparent during routine examination [11].

3. Beyond the Initial Approach

3.1. Management of Epistaxis

3.1.1. Direct Pressure and Topical Vasoconstrictors

The primary treatment for anterior nosebleeds involves applying direct pressure to the nose for approximately 10 min. Patients should be instructed to pinch the soft, cartilaginous part of the nose rather than the bony areas to effectively control the bleeding. If direct pressure alone is insufficient, vasoconstrictors such as oxymetazoline or thrombogenic foams and gels may be utilized [8]. Prior to administering these treatments, it is essential to clear the nasal passages of any clots using suction. This step is critical for two reasons: clots can prevent the medication from reaching the bleeding vessel, and if nasal packing becomes necessary, the clots may be displaced posteriorly, increasing the risk of aspiration [8]. Should topical treatments fail to control the bleeding, a more detailed examination is warranted to identify the bleeding vessel, which can then be cauterized using silver nitrate [8].

3.1.2. Thrombocytopenia-Specific Treatment

In cases of epistaxis caused by thrombocytopenia, platelet transfusion should be prioritized to stabilize the patient and optimize clotting before proceeding with invasive measures such as nasal packing or cautery.

3.1.3. Nasal Packing

Historically, posterior nasal packing involved the use of ribbon gauze coated with bismuth iodoform paraffin paste (BIPP) or petrolatum, inserted in layers using specialized forceps [12]. Today, Foley catheters are commonly employed for posterior nasal packing due to their ease of use and availability. Before insertion, it is important to inflate and deflate the balloon of the catheter to ensure there are no leaks and to lubricate the tip to facilitate smooth passage through the nose. The patient should be seated upright with their head slightly tilted back, and assistance may be required to prevent sudden movements. After administering appropriate intravenous pain relief and topical numbing spray, the catheter should be gently inserted along the nasal floor on the side where the bleeding is suspected [12]. To inflate the balloon properly, begin with 5–7 mL of sterile water, applying gentle traction to ensure the balloon rests against the posterior choana. If bleeding persists and the patient can tolerate it, an additional 5–7 mL may be added [12]. However, it is crucial not to exceed a total volume of 15 mL, as overinflation can increase the risk of pressure necrosis in the soft palate, leading to significant discomfort for the patient. Additionally, inflating the balloon too far anteriorly in the nasal cavity can cause considerable discomfort, while positioning it too low in the pharynx may result in airway obstruction [12]. For patients with bleeding disorders, reabsorbable nasal packing materials, such as gelatin-based or oxidized cellulose dressings, may be preferred as they avoid the need for removal and minimize the risk of rebleeding [13]. These materials are particularly advantageous in scenarios where traditional packing removal may exacerbate mucosal trauma or bleeding (Figure 1).

Other modern options for nasal packing include Rapid Rhino, a balloon tampon coated with carboxymethylcellulose that promotes clotting and provides effective hemostasis. These are pre-lubricated and require saline or distilled water activation before insertion [14]. Similarly, Merocel packing, made of polyvinyl alcohol sponges, expands upon contact with blood to tamponade bleeding and is a widely used, effective option [15]. Two-balloon catheter systems, such as the posterior and anterior Rapid Rhino variants, can address both anterior and posterior epistaxis with high efficacy, particularly in patients failing other conservative measures [14]. In severe or refractory cases, surgical interventions like endoscopic sphenopalatine artery (SPA) ligation may be required. This minimally invasive procedure offers a high success rate while minimizing morbidity compared to traditional open methods [16]. Interventional radiology, specifically arterial embolization, is another valuable option for managing intractable posterior epistaxis, requiring collaboration with radiologists to target the sphenopalatine or internal maxillary artery [16].

3.2. Emerging Techniques and Specialist Considerations

For specialists managing complex or refractory cases of epistaxis, several advanced techniques and considerations are available:

○

Endoscopic Sphenopalatine Artery (SPA) Ligation: This minimally invasive surgical approach involves ligating the sphenopalatine artery to control severe or recurrent posterior epistaxis. It is highly effective and associated with lower morbidity compared to traditional open procedures [17].

○

Interventional Radiology: Embolization of the sphenopalatine or internal maxillary artery is a valuable option for patients unresponsive to surgical and packing interventions. This approach requires collaboration with an interventional radiologist and is typically reserved for life-threatening cases or when bleeding cannot be localized [18].

○

Computer-Aided Diagnostic Tools: Emerging research has demonstrated the utility of dynamic uncertain causality graph (DUCG) systems for diagnosing the underlying causes of epistaxis. These tools use patient data to predict potential etiologies and guide targeted management, representing a promising area for future specialist practice [5].

○

Role of Novel Hemostatic Agents: Agents such as Ankaferd Blood Stopper and fibrin-based topical powders have shown promise in achieving hemostasis in refractory cases. While further studies are needed to establish their efficacy, these agents offer potential as adjunctive treatments [19,20].

○

Multidisciplinary Care: Complex cases often require collaboration with hematologists, oncologists, and interventional radiologists. For example, in patients with hematological malignancies, a multidisciplinary approach is essential to address both the epistaxis and its underlying etiology.

4. Further Evaluation

Following the initial management of epistaxis, it is essential to regularly monitor patients for any ongoing bleeding or signs of instability. Before proceeding with further evaluation, it is crucial to ensure that the bleeding is adequately controlled. Topical agents such as Ankaferd Blood Stopper, Traumastem powder, and tranexamic acid have shown effectiveness in achieving rapid and efficient hemostasis, thereby minimizing the risk of complications [19,20].

Once the initial bleeding is controlled, a thorough evaluation to determine the underlying causes of epistaxis is necessary. Common triggers include hypertension, trauma, and blood clotting disorders. Cases that do not respond to initial treatment may require more extensive investigation, particularly in older patients with multiple comorbidities or those on anticoagulant therapy. Severe posterior bleeding often necessitates hospitalization, and lab tests are especially important for patients on blood thinners [21]. Identifying risk factors such as anticoagulant use and hypertension can guide the implementation of preventive measures. Otolaryngologists should be prepared to manage severe or recurrent cases with a range of treatments, including radiological or surgical interventions [6,21].

5. Preventive Measures

To prevent nasal trauma, advise patients to handle their noses with care, avoiding forceful blowing, picking, or rubbing. Caution should also be given against engaging in activities that may result in nasal injury. Encourage the use of a humidifier at home, particularly in dry weather, to maintain nasal moisture and reduce the likelihood of nosebleeds [22]. Additionally, recommend the regular use of saline nasal sprays to keep the nasal passages hydrated and prevent dryness, which can lead to epistaxis. It is also important to counsel patients to avoid irritants such as tobacco smoke, strong odors, and chemicals, as these can irritate the nasal passages and increase the risk of nosebleeds (

Table 2. Preventive measures for epistaxis. Adapted from [17].

Preventive Measures for Epistaxis
Avoiding Nasal Trauma	- Gently blow your nose. - Avoid picking or rubbing the inside of your nose. - Exercise caution during activities that might cause nasal injuries.
Humidification	- Use a humidifier at home, particularly in dry weather. - Maintain moisture in the nasal passages to reduce the risk of nosebleeds.
Nasal Hygiene	- Regularly apply saline nasal sprays to keep nasal passages moist. - Prevent dryness that can lead to nosebleeds.
Avoiding Irritants	- Avoid exposure to tobacco smoke, strong odors, and chemicals. - These substances can irritate the nasal passages and increase the risk of epistaxis.

) [22].

6. Disposition and Follow-Up

It is not unusual for patients to experience recurring episodes of epistaxis even after receiving treatment, leading some to return to the emergency room and many requiring additional interventions. Recurrent admissions for epistaxis are classified into early (within 30 days) and late (31 days to 3 years) following the initial admission, with distinct risk factors associated with each timeframe [3,23]. Offering clear verbal and written instructions to patients experiencing epistaxis is vital to prevent future bleeds and minimize returns to emergency care. Research shows that providing such guidance markedly decreases re-attendance rates and enhances patient outcomes. Educating patients about preventive measures and how to manage potential future bleeds is crucial for improving their overall care and reducing the chances of recurring episodes [24].

7. Addressing Knowledge Gaps in Epistaxis Management

Effective management of epistaxis extends beyond clinical interventions to include the education and training of medical teams. Studies have highlighted significant gaps in healthcare providers’ knowledge regarding first-aid management of epistaxis, which can contribute to re-recurrent bleeding due to improper techniques. For instance, Sowerby et al. conducted a needs assessment that revealed deficiencies in basic epistaxis first-aid knowledge among healthcare providers, emphasizing the need for structured educational programs to improve outcomes and patient safety [25]. Similarly, Boldes et al. reported findings from a multi-center knowledge assessment, showing that medical workers often lack awareness of evidence-based first-aid practices for epistaxis, underscoring the importance of targeted education initiatives [26].

By addressing these knowledge gaps through formal training sessions and protocol dissemination, healthcare teams can ensure the adoption of proper techniques such as appropriate patient positioning, correct nasal compression, and the avoidance of common errors. Incorporating education as part of routine epistaxis management strategies could play a critical role in reducing recurrence rates, improving patient outcomes, and optimizing care pathways in both emergency and outpatient settings.