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Epistaxis
Head and neck
Epistaxis
Cause
Peter D Ross
Local Idiopathic Infection Inflammatory
Leo G McClymont
Trauma Neoplasm Iatrogenic
The function of the nose is to humidify, filter and warm inhaled air for delivery to the lungs. It has a rich blood supply to provide the warmth and moisture required to enable this. Epistaxis (from Greek meaning ‘a dripping’) is blood flow from the nasal cavity, nasal sinuses or postnasal space. This bleeding varies in presentation from recurrent epistaxis to life-threatening haemorrhage.
Congenital Structural Systemic Iatrogenic
Blood supply of the nose
Haematological
• The blood supply comes from the internal and external carotid arteries. • The internal carotid artery gives two branches: anterior and posterior ethmoidal arteries. These branches originate from the ophthalmic artery within the orbit, entering the nose through the medial orbital wall. They supply the very upper extremes of the septum and lateral nasal wall. • Three branches come from the external carotid artery. The sphenopalatine is the largest and most significant. It arises from the maxillary artery, in the pterygomaxillary fossa, exiting through the sphenopalatine foramen, posterior to the origin of the middle turbinate. It supplies the lateral wall, as well as sending a posterior branch to supply most of the septum. • Bleeding can occur anywhere in the nose, but the anterior septum is the most common source. Here the nasal arteries form a plexus, known as ‘Little’s area’ (‘Kiesselbach plexus’). First aid is initially directed at this site.
Vascular Congenital
Miscellaneous
Sinusitis, nasal vestibulitis Rhinitis, allergies, environmental irritants Nose picking, nasal fracture, cocaine abuse Nasal and sinus tumours Surgery, nasal corticosteroid sprays, nasal oxygen Vascular abnormalities Perforation and deviation of septa Anticoagulants/antiplatelet agents Haemophilia, liver disease, thrombocytopenia Hypertension, atherosclerosis Hereditary haemorrhagic telangiectasia (Osler–Rendu– Weber) Constipation, prostatic hypertrophy, chronic cough
Table 1
Little’s area, but may also originate anterior to the inferior turbinate. Posterior hemorrhage originates from behind this area.
Investigations Further investigation may not be necessary if the bleeding has been minor and did not recur. Assessment of circulation, coagulation and systemic health are indicated in more significant cases.
Aetiology
Laboratory tests include: • full blood count • fluid balance and renal function • coagulation studies • blood typing in case transfusion is required.
Up to 85% of cases are idiopathic; the remaining causes split into local or systemic causes, and contributing factors (Table 1). Systemic factors are more frequently responsible in later life, with local factors more commonly responsible in younger patients. Neoplasia is a rare cause (Table 2).
Classification
Warning signs and symptoms that suggest neoplasia
Epistaxis is classified according to the site of the primary bleeding: anterior or posterior. Anterior bleeding is usually (90%) from
• Unilateral nasal blockage • Facial pain • Headaches • Facial swelling/deformity • Patient originating from South-east Asia (nasopharyngeal carcinoma) • Loose teeth
Peter D Ross MRCS(Glas) is a Specialist Registrar in Otolaryngology on the East of Scotland Rotation, UK. Leo G McClymont FRCS(Ed) is a Consultant Otolaryngologist and Head and Neck Surgeon at Raigmore Hospital, Inverness, UK.
SURGERY 24:9
Examples
Table 2
296
© 2006 Elsevier Ltd. All rights reserved.
Head and neck
Imaging: CT, MRI and angiography of internal and external c arotid circulation is required. It is reserved for treatment-resistant cases: • to help identify a bleeding point • if a malignant cause is suspected • to assess the surgical anatomy.
• Localize bleeding point using anterior rhinoscopy, and direct treatment to it. A variety of methods are used, including dia thermy or fibrin glue. Referral to an ear, nose and throat specialist may be required if this fails. • Packing should be reserved for cases that do not have access to a modern Ear, Nose and Throat Department. Anterior packing involves placing a tampon that applies local pressure within the nose, or stabilizes clot. Merocel is the most commonly used tampon. These should be placed along the floor of the nose to prevent injury to the cribiform plate (if angled vertically).
Management Management varies according to the severity of the bleeding and on local facilities. Modern equipment, particularly the nasal endoscope, has transformed the treatment of epistaxis. These instruments allow directed treatment to the bleeding point or to the supplying vessel. Indications for nasal packing are limited, particularly because the trauma inflicted on the nasal mucosa makes identification of the bleeding point difficult with the endoscope. However, many patients are seen without this equipment and expertise.
Serious nasal haemorrhage Patients can die from epistaxis. Early treatment focuses on stabilizing the patient, correcting losses and reducing nasal blood loss. Definitive treatment can follow thereafter. Treatment • Resuscitation using large-bore intravenous access and fluids. Blood may be required. • Constant monitoring of pulse and blood pressure. • Control of bleeding should be done as before with nasal pre paration and direct treatment. In extreme haemorrhage, early packing may buy time, particularly if transfer is required. Anterior packing is often not sufficient, and combined anterior/ posterior packing should control bleeding. • Packing of the postnasal space is uncomfortable; it can be done with balloon catheters. It is limited as a stabilizing measure before theatre or transfer. • Correct coagulation abnormalities, sedation may help with agitation and hypertension. • Plan transfer of patient or consider surgical intervention. A more accurate examination and treatment is possible with specialist equipment (e.g. rigid nasal endoscopes). The following is done after preparation of the nose as above. • Rigid nasoendoscopy with a 0° or 30° endoscope to identify the source of bleeding. It allows for direct visualization of treatment throughout the nose. This can be done with diathermy or fibrin glue. • Local packing directed to the bleeding site can be used if directed treatment fails. • Surgical intervention should be for cases that are resistant to treatment. This should not be left until the patient is so compromised that anaesthesia carries significant risk. It aims to correct the structural abnormality or ligate the feeding vessel. • Examination of the nose under general anaesthesia, with direct treatment as before, is simplest. More definitive packing can be placed, and a septoplasty allows better access if the cartilage is deformed. • Arterial ligation should be considered if this fails. • Sphenopalatine artery ligation, when the bleeding is from the lower two-thirds, can be done endonasally with endoscopic assistance. • The external ethmoidal artery can be tied via an external in cision medial to the medial canthus. This is reserved for high nasal bleeds. • External carotid ligation is infrequently required if ligation of these branches fails; this is done via the neck. • Embolization under angiographic assistance can be done safely in experienced hands. This is virtually impossible if the
Mild epistaxis Minor recurrent idiopathic epistaxis seen by a GP or in the Accident and Emergency Department is an example of mild epistaxis. Assessment • Exclude potential nasal, systemic or malignant causes. • Consider investigation to exclude abnormal coagulation. Treatment • Nasal antiseptic creams are as effective as cautery in children. They are frequently used in adults, although there is little evidence to support their use. • Treatable causes (e.g. hypertension, antiplatelet medication) should be addressed. • Advice regarding first aid compressing the soft lower half of the nose over Little’s area firmly for 20 minutes. One study has shown that <50% of trained Accident and Emergency staff, and 35% of untrained staff, knew the correct manoeuvre for epistaxis first aid. • Specialist opinion should be considered if simple treatment fails. Moderate epistaxis An uncompromised bleeding patient seen by a GP or in the Accident and Emergency Department is an example of moderate epistaxis. Assessment • Haemodynamic assessment, monitoring of pulse and blood pressure. • Concurrent medical conditions and their treatments. • Blood count, grouping and coagulation if indicated. Treatment • Simple nasal compression. • Nasal preparation by removal of clots from the nose by suction, or forceful blowing of the nose. • Anaesthetizing the mucosa with a vasoconstrictive or anaesthetic agent. Historically, this was done with cocaine, but has been replaced with alternative preparations (e.g. cophenylcaine). • Sedation may be required in the agitated patient.
SURGERY 24:9
297
© 2006 Elsevier Ltd. All rights reserved.
Head and neck
external carotid artery is ligated. It also carries a significant risk of complication (up to 25%), which includes stroke. • Ligation of the maxillary artery was used before spheno palatine artery ligation. The artery traverses the pterygomaxillary fossa, and is done through a sublabial incision, accessed via the maxillary sinus.
base should be excluded before packing to prevent cerebral damage. Warfarin and other anticoagulation – abnormal anti coagulation levels should be corrected. If bleeding continues, further correction must be balanced against the risk of this reduction. Thrombocytopenia – platelet cover may be needed to stop bleeding, and again on removal of packing if used. Consider the opinion of a haematologist. ◆
Post-treatment advice: the following should be avoided in the recovery period (7–21 days): • nose blowing • strenuous activity • exposure to heat (including hot bathing or hot drinks) • alcoholic drinks • recreational drugs • nasal steroids • flying.
Further reading McGarry G W. Nosebleeds in children. Clinical evidence. London: BMJ Publishing, 2005. www.clinicalevidence.com Pope L E, Hobbs C G. Epistaxis: an update on current management. Postgrad Med J 2005; 81: 309–14. Roland N J, McRae R D R, McCombe A W (Editors). Key topics in otolaryngology. 2nd edition. Oxford: BIOS, 2001. Shin E J, Murr A H. Managing epistaxis. Curr Opin Otolaryngol Head Neck Surg 2000; 8: 37–42.
Special considerations Traumatic epistaxis can be a challenging problem if it does not settle with first aid. Fractures of the face and skull
SURGERY 24:9
298
© 2006 Elsevier Ltd. All rights reserved.
Epistaxis
Cause
Peter D Ross
Local Idiopathic Infection Inflammatory
Leo G McClymont
Trauma Neoplasm Iatrogenic
The function of the nose is to humidify, filter and warm inhaled air for delivery to the lungs. It has a rich blood supply to provide the warmth and moisture required to enable this. Epistaxis (from Greek meaning ‘a dripping’) is blood flow from the nasal cavity, nasal sinuses or postnasal space. This bleeding varies in presentation from recurrent epistaxis to life-threatening haemorrhage.
Congenital Structural Systemic Iatrogenic
Blood supply of the nose
Haematological
• The blood supply comes from the internal and external carotid arteries. • The internal carotid artery gives two branches: anterior and posterior ethmoidal arteries. These branches originate from the ophthalmic artery within the orbit, entering the nose through the medial orbital wall. They supply the very upper extremes of the septum and lateral nasal wall. • Three branches come from the external carotid artery. The sphenopalatine is the largest and most significant. It arises from the maxillary artery, in the pterygomaxillary fossa, exiting through the sphenopalatine foramen, posterior to the origin of the middle turbinate. It supplies the lateral wall, as well as sending a posterior branch to supply most of the septum. • Bleeding can occur anywhere in the nose, but the anterior septum is the most common source. Here the nasal arteries form a plexus, known as ‘Little’s area’ (‘Kiesselbach plexus’). First aid is initially directed at this site.
Vascular Congenital
Miscellaneous
Sinusitis, nasal vestibulitis Rhinitis, allergies, environmental irritants Nose picking, nasal fracture, cocaine abuse Nasal and sinus tumours Surgery, nasal corticosteroid sprays, nasal oxygen Vascular abnormalities Perforation and deviation of septa Anticoagulants/antiplatelet agents Haemophilia, liver disease, thrombocytopenia Hypertension, atherosclerosis Hereditary haemorrhagic telangiectasia (Osler–Rendu– Weber) Constipation, prostatic hypertrophy, chronic cough
Table 1
Little’s area, but may also originate anterior to the inferior turbinate. Posterior hemorrhage originates from behind this area.
Investigations Further investigation may not be necessary if the bleeding has been minor and did not recur. Assessment of circulation, coagulation and systemic health are indicated in more significant cases.
Aetiology
Laboratory tests include: • full blood count • fluid balance and renal function • coagulation studies • blood typing in case transfusion is required.
Up to 85% of cases are idiopathic; the remaining causes split into local or systemic causes, and contributing factors (Table 1). Systemic factors are more frequently responsible in later life, with local factors more commonly responsible in younger patients. Neoplasia is a rare cause (Table 2).
Classification
Warning signs and symptoms that suggest neoplasia
Epistaxis is classified according to the site of the primary bleeding: anterior or posterior. Anterior bleeding is usually (90%) from
• Unilateral nasal blockage • Facial pain • Headaches • Facial swelling/deformity • Patient originating from South-east Asia (nasopharyngeal carcinoma) • Loose teeth
Peter D Ross MRCS(Glas) is a Specialist Registrar in Otolaryngology on the East of Scotland Rotation, UK. Leo G McClymont FRCS(Ed) is a Consultant Otolaryngologist and Head and Neck Surgeon at Raigmore Hospital, Inverness, UK.
SURGERY 24:9
Examples
Table 2
296
© 2006 Elsevier Ltd. All rights reserved.
Head and neck
Imaging: CT, MRI and angiography of internal and external c arotid circulation is required. It is reserved for treatment-resistant cases: • to help identify a bleeding point • if a malignant cause is suspected • to assess the surgical anatomy.
• Localize bleeding point using anterior rhinoscopy, and direct treatment to it. A variety of methods are used, including dia thermy or fibrin glue. Referral to an ear, nose and throat specialist may be required if this fails. • Packing should be reserved for cases that do not have access to a modern Ear, Nose and Throat Department. Anterior packing involves placing a tampon that applies local pressure within the nose, or stabilizes clot. Merocel is the most commonly used tampon. These should be placed along the floor of the nose to prevent injury to the cribiform plate (if angled vertically).
Management Management varies according to the severity of the bleeding and on local facilities. Modern equipment, particularly the nasal endoscope, has transformed the treatment of epistaxis. These instruments allow directed treatment to the bleeding point or to the supplying vessel. Indications for nasal packing are limited, particularly because the trauma inflicted on the nasal mucosa makes identification of the bleeding point difficult with the endoscope. However, many patients are seen without this equipment and expertise.
Serious nasal haemorrhage Patients can die from epistaxis. Early treatment focuses on stabilizing the patient, correcting losses and reducing nasal blood loss. Definitive treatment can follow thereafter. Treatment • Resuscitation using large-bore intravenous access and fluids. Blood may be required. • Constant monitoring of pulse and blood pressure. • Control of bleeding should be done as before with nasal pre paration and direct treatment. In extreme haemorrhage, early packing may buy time, particularly if transfer is required. Anterior packing is often not sufficient, and combined anterior/ posterior packing should control bleeding. • Packing of the postnasal space is uncomfortable; it can be done with balloon catheters. It is limited as a stabilizing measure before theatre or transfer. • Correct coagulation abnormalities, sedation may help with agitation and hypertension. • Plan transfer of patient or consider surgical intervention. A more accurate examination and treatment is possible with specialist equipment (e.g. rigid nasal endoscopes). The following is done after preparation of the nose as above. • Rigid nasoendoscopy with a 0° or 30° endoscope to identify the source of bleeding. It allows for direct visualization of treatment throughout the nose. This can be done with diathermy or fibrin glue. • Local packing directed to the bleeding site can be used if directed treatment fails. • Surgical intervention should be for cases that are resistant to treatment. This should not be left until the patient is so compromised that anaesthesia carries significant risk. It aims to correct the structural abnormality or ligate the feeding vessel. • Examination of the nose under general anaesthesia, with direct treatment as before, is simplest. More definitive packing can be placed, and a septoplasty allows better access if the cartilage is deformed. • Arterial ligation should be considered if this fails. • Sphenopalatine artery ligation, when the bleeding is from the lower two-thirds, can be done endonasally with endoscopic assistance. • The external ethmoidal artery can be tied via an external in cision medial to the medial canthus. This is reserved for high nasal bleeds. • External carotid ligation is infrequently required if ligation of these branches fails; this is done via the neck. • Embolization under angiographic assistance can be done safely in experienced hands. This is virtually impossible if the
Mild epistaxis Minor recurrent idiopathic epistaxis seen by a GP or in the Accident and Emergency Department is an example of mild epistaxis. Assessment • Exclude potential nasal, systemic or malignant causes. • Consider investigation to exclude abnormal coagulation. Treatment • Nasal antiseptic creams are as effective as cautery in children. They are frequently used in adults, although there is little evidence to support their use. • Treatable causes (e.g. hypertension, antiplatelet medication) should be addressed. • Advice regarding first aid compressing the soft lower half of the nose over Little’s area firmly for 20 minutes. One study has shown that <50% of trained Accident and Emergency staff, and 35% of untrained staff, knew the correct manoeuvre for epistaxis first aid. • Specialist opinion should be considered if simple treatment fails. Moderate epistaxis An uncompromised bleeding patient seen by a GP or in the Accident and Emergency Department is an example of moderate epistaxis. Assessment • Haemodynamic assessment, monitoring of pulse and blood pressure. • Concurrent medical conditions and their treatments. • Blood count, grouping and coagulation if indicated. Treatment • Simple nasal compression. • Nasal preparation by removal of clots from the nose by suction, or forceful blowing of the nose. • Anaesthetizing the mucosa with a vasoconstrictive or anaesthetic agent. Historically, this was done with cocaine, but has been replaced with alternative preparations (e.g. cophenylcaine). • Sedation may be required in the agitated patient.
SURGERY 24:9
297
© 2006 Elsevier Ltd. All rights reserved.
Head and neck
external carotid artery is ligated. It also carries a significant risk of complication (up to 25%), which includes stroke. • Ligation of the maxillary artery was used before spheno palatine artery ligation. The artery traverses the pterygomaxillary fossa, and is done through a sublabial incision, accessed via the maxillary sinus.
base should be excluded before packing to prevent cerebral damage. Warfarin and other anticoagulation – abnormal anti coagulation levels should be corrected. If bleeding continues, further correction must be balanced against the risk of this reduction. Thrombocytopenia – platelet cover may be needed to stop bleeding, and again on removal of packing if used. Consider the opinion of a haematologist. ◆
Post-treatment advice: the following should be avoided in the recovery period (7–21 days): • nose blowing • strenuous activity • exposure to heat (including hot bathing or hot drinks) • alcoholic drinks • recreational drugs • nasal steroids • flying.
Further reading McGarry G W. Nosebleeds in children. Clinical evidence. London: BMJ Publishing, 2005. www.clinicalevidence.com Pope L E, Hobbs C G. Epistaxis: an update on current management. Postgrad Med J 2005; 81: 309–14. Roland N J, McRae R D R, McCombe A W (Editors). Key topics in otolaryngology. 2nd edition. Oxford: BIOS, 2001. Shin E J, Murr A H. Managing epistaxis. Curr Opin Otolaryngol Head Neck Surg 2000; 8: 37–42.
Special considerations Traumatic epistaxis can be a challenging problem if it does not settle with first aid. Fractures of the face and skull
SURGERY 24:9
298
© 2006 Elsevier Ltd. All rights reserved.