Epistaxis: the common and not-so-common nosebleed

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Epistaxis, or acute hemorrhage from the nostril, nasal cavity, or nasopharynx, sends many children and adults to primary-care or emergency-department clinicians. Such patients may be seeking treatment for a first, minor nosebleed, or for a recurring, severe event.

Epistaxis falls into one of two categories based upon the location of the bleeding: anterior bleed or posterior bleed. (Table 1.) Treatment depends on the clinical picture, the experience of the treating provider, and the availability of ancillary services.¹

Overview The inner nasal membrane is rich with blood vessels that lie close to the surface and are prone to injury. This vascular supply originates from the ethmoid branches of the internal carotid arteries and the facial and internal maxillary divisions of the external carotid arteries.2 Epistaxis occurs when the nasal membrane lining is disturbed or irritated and causes abnormal bleeding. Most (approximately 90%) cases of epistaxes are anterior, originating from Kiesselbach’s plexus. Anterior epistaxis is characterized by unilateral, steady, nonmassive bleeding.  In contrast, posterior epistaxis generally arises from the posterior nasal cavity through branches of the sphenopalatine arteries.2,3

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Such bleeding usually occurs behind the posterior portion of the middle turbinate or at the posterior superior roof of the nasal cavity. Posterior bleeding may be asymptomatic or may present insidiously as nausea, hematemesis, anemia, hemoptysis, or melena. Infrequently, larger vessels are involved in posterior epistaxis; this can result in sudden, massive bleeding.²

An estimated 90% of epistaxis cases seen in family practice and in the emergency department can be treated successfully by the providers in those settings, with the remaining 10% of cases requiring referral to an otolaryngologist^2,4 With the proper training and equipment, any provider can treat minor causes of epistaxis.

Table 1. Epistaxis CPT Codes

Control hemorrhage, anterior, simple	30901
Control hemorrhage anterior, complex	30903
Control hemorrhage, posterior, initial	30905
Control hemorrhage, posterior, subsequent	30906

Patient self-management

Most cases of anterior epistaxis can be controlled at home. The patient should be advised to assume a sitting (but not prostrate) position in order to decrease venous pressure, and to lean forward to avoid swallowing blood. The tip of the nose should be pinched between the thumb and index finger, with that pressure applied continuously for 5 to 15 minutes.⁵

Ice can be applied over the pinch to the nose and cheeks, and should be wrapped in a towel or other covering to avoid direct contact with the skin.

If the bleeding does not stop after 20 minutes, the patient should seek medical help.

Evaluation of the patient

Because most episodes of epistaxis are not life-threatening, they can be evaluated and treated in the practitioner’s office or in the emergency department.

History. When establishing the medical history of a person with epistaxis, the clinician’s questions should be designed to determine whether the cause of the nosebleed is mechanical, attributable to undiagnosed comorbidities, or medication-related.

Sources of mechanical trauma leading to epistaxis are trauma to the body such as from violence or an accident, digital manipulation, insertion of foreign bodies into the nose, nasal polyps, nasal irritants (including nasal sprays, allergens, and infection), dry air, and injuries related to changes in water or barometric pressure (barotrauma).⁶

Comorbidities associated with epistaxis are inherited, acquired, or iatrogenically induced coagulopathies; renal, hepatic, or atherosclerotic disease; hypertension; and acquired immunodeficiency syndrome (AIDS).⁶

Medications that may cause epistaxis include aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), warfarin, clopidogrel, and some herbal offerings (garlic, ginseng, and ginkgo).⁶

Physical exam. When examining a person with epistaxis, the clinician must be sure that the person has a stable airway and that hemodynamic stability is established if needed.

Examination is difficult to accomplish during active bleeding, so the provider should first try to stop the bleeding by gently cleaning the nares and, if possible, suctioning out the blood. In combination with direct pressure, topical solutions such as oxymetazoline, phenylephrine, or topical 4% cocaine can be applied either as a spray or on a cotton swab to help stop the bleed. These topical solutions serve as anesthetics as well as vasoconstrictors.⁵

The patient should pinch the tip of the nose between thumb and forefinger to apply continuous pressure to the nose for 10 to 15 minutes; the clinician may first insert gauze soaked with a vasoconstrictive agent into the nasal passage. The nasal passages of the nose should be reexamined using a nasal speculum and a bright head lamp or head mirror.²

Laboratory tests. Laboratory tests to evaluate epistaxis and possible underlying medical problems may be ordered depending on the clinical picture at the time of presentation. If the bleeding is minor and not recurrent, laboratory tests may not need to be ordered.

If a patient has a history of persistent heavy bleeding or recurrent epistaxis, labs should include a complete blood count with differential (checking platelet count and hematocrit/hemoglobin), bleeding time (platelet function), international normalized ratio (INR)/prothrombin time (PT), and an activated partial thromboplastin time (aPTT) to rule out bleeding disorders. PT/INR should always be checked when a patient is on warfarin to verify the INR level (typically between 2.0 to 3.0).

Table 2. Minor and major causes of epistaxis

Minor	Major
Dry, heated, low-humidity air	High blood pressure
Chronic upper respiratory infections and sinusitis	Nasal tumors Leukemia
Trauma Vigorous nose-picking Insertion of foreign body	Atherosclerotic disease
Medications that thin the blood Aspirin Nonsteroidal anti-inflammatory drugs(NSAIDs) Warfarin Plavix	Von Willebrand disease Hemophilia Thrombocytopenia
Allergies Nasal polyps	Renal disease
Prior facial or nasal surgery	Liver disease

Treatment of anterior epistaxis

Cotton pledgets soaked with a vasoconstrictor and anesthetic should be placed in the anterior nasal cavity, and direct pressure should be applied at both sides of the nose for at least 5 minutes. The pledgets can then be removed for reinspection of the bleeding site.⁷ 

Other treatment options include hemostatic packing with absorbable gelatin foam or oxidized cellulose. Use of desmopressin spray may be considered for a patient with a known bleeding disorder.^7,8

Larger vessels tend to require more aggressive treatment than direct pressure and topical solutions. If the site of bleeding can be visualized, silver nitrate or electrocauterization can be used to cauterize the bleeding vessel.

However, electrocauterization must be performed cautiously to avoid excessive destruction of healthy surrounding tissues. Use of electrocauterization on both sides of the septum may increase the risk of septal perforation.^2,9

If the above treatments fail to stop an anterior bleed, the nasal cavity will have to be packed from posterior to anterior using ribbon gauze impregnated with petroleum jelly or bacitracin zinc–neomycin sulfate–polymyxin B sulfate ointment.

Nonadherent gauze impregnated with petroleum jelly and 3% bismuth tribromophenate also works well for this purpose.² Each layer should be pressed down firmly before the next layer is inserted. Once the cavity has been packed as completely as possible, a gauze “drip pad” can be taped over the nostrils and changed periodically.²

If more aggressive packing is needed, a nasal tampon can be used.¹⁰ After a topical anesthetic is applied to the patient’s nasal cavity, the nasal tampon can be inserted along the floor of the cavity. The tampon will expand when it comes into contact with blood or fluids. Saline may have to be applied to the nasal tampon to help it achieve full expansion.²

Another version of nasal packing employs an anterior balloon tampon made of carboxymethylcellulose, a hydrocolloid material. The carboxymethylcellulose acts as a platelet aggregator and also forms a lubricant upon contact with water.

The balloon tampon has a cuff that is inflated by air. The hydrocolloid reportedly preserves the newly formed clot during tampon removal.¹¹ When applied in the outpatient setting, nasal packing may be left in place for 3 to 5 days to ensure adequate clot formation.^2,10

Complications associated with nasal packing procedures can range from minor to severe. Minor complications include the packing falling out, anosmia, breathing difficulties, nasal septal hematomas, and nasal septal perforations.

Moderate complications include abscesses from traumatic packing, sinusitis, neurogenic syncope during packing, and pressure necrosis secondary to excessively tight packing.

A more severe complication is that of toxic shock syndrome, which can occur with prolonged nasal packing. Using a topical antistaphylococcal antibiotic ointment on the packing materials might reduce this risk.^2,10,12

Posterior epistaxis

Epistaxis caused by posterior bleeding is much less common than that caused by anterior bleeding. Posterior epistaxis usually is associated with atherosclerotic disease and hypertension.⁵

Typical sites for a posterior bleed are: Woodruff’s plexus, on the posterior aspect of the lateral wall of inferior meatus; the posterior part of the lateral nasal wall near the sphenopalatine foramen; the posterior end of inferior turbinate; the middle turbinate and its medial surface; the middle and posterior parts of the septum; and the floor of the nose beneath the inferior turbinate.^2,13

Treatment of posterior epistaxis is difficult due to the inaccessible location of the bleed. Typically, invasive methods are required to visualize and to treat the bleed. Two methods typically performed by an otolaryngologist are anteroposterior packing and use of balloon systems.

Anteroposterior packing is performed by passing a catheter through one nostril, past the nasopharynx, and out the mouth. Gauze is attached to the catheter and pulled through until it is situated in the posterior choana, creating pressure on the bleed site. This type of packing is uncomfortable, bleeding may persist, and vasovagal syncope is quite possible; the patient may have to be hospitalized for monitoring.⁵

The balloon system approach is less complicated than the anteroposterior packing procedure. After topical anesthesia is administered, the double-balloon device is passed into the affected nostril until it reaches the nasopharynx and sits in the posterior nasal cavity to tamponade the bleeding source. Next, the anterior balloon is inflated to prevent retrograde travel of the posterior balloon and subsequent airway obstruction.²

Follow-up and patient-care instructions

After nasal packing is placed, whether with or without cauterization, it is usually left in place for 2 to 4 days (typically 48 hours), unless the patient is intolerant to the packing or complications arise. The clinician should advise the patient not to be too active and to stay on the couch or in bed, with head elevated to about 30 degrees, even during sleep. 

Nose-blowing should be avoided, and sneezing should be done with the mouth open. A humidifier can be used to add moisture to the air. The patient should not smoke, as smoking contributes to nasal dryness.

Once the packing is removed and scabs begin to form, the person should avoid picking his or her nose. He or she also must avoid heavy lifting and vigorous exercise until 1 to 2 weeks have passed with no evidence of bleeding. The person also should avoid flying until receiving approval from the medical provider.

The patient should be aware of the follow-up visit schedule, but also must be advised to contact a provider if he or she experiences a fever greater than 101°F, if bleeding continues or if bleeding breaks through the packing and travels down the throat, if the packing falls out, if the patient feels severe pain, or if the patient experiences nausea or vomiting.

Because epistaxis is associated with some nausea, often as a result of blood draining into the stomach or the pressure felt from the nasal packing, the patient should drink clear liquids until feeling less nauseated.

Patient education and prevention are as important as medical intervention. Most episodes of epistaxis occur during the winter and in dry climates. Use of a humidifier, petroleum jelly, or a saline nasal spray will help keep the nasal mucosa moist and limit new or recurrent episodes of epistaxis.

Conclusion

In most cases, epistaxis can be handled in the clinician’s office or the emergency department by a trained provider with the proper equipment. Patients who suffer from profound epistaxis or recurrent episodes need to be evaluated for an underlying medical condition. 

When less aggressive treatments have failed, refer the patient to an otolaryngologist for more aggressive treatment and further workup.

David Areaux, MPAS, PA-C, is an assistant professor in the Western Michigan University Department of Physician Assistant in Kalamazoo, Mich.