Epistaxis
Avinash V. Mantravadi
Chad A. Zender
Louis G. Portugal
Epistaxis is a common occurrence in the general population and most frequently is minor and self-limiting. In the intensive care setting, however, epistaxis may further destabilize an already unstable patient and may be life-threatening. Appropriate management of epistaxis requires careful evaluation and management of the patient’s hemodynamic status and prompt control of the source of bleeding.
Blood Supply of the Nose
The internal and external carotid arteries, with frequent free anastomoses within the nasal mucosa, provide a rich blood supply to the nose, and venous drainage parallels the arterial supply.
The internal carotid artery (ICA) supplies the nasal mucosa through the ethmoid branches of the ophthalmic artery. The ophthalmic artery, the first branch off of the ICA, enters the orbit through the optic canal and divides into anterior and posterior ethmoidal branches. Both anterior and posterior ethmoidal arteries exit the orbit through the medial orbital wall at the level of the frontoethmoid suture line, an important landmark in the operative management of epistaxis originating from these vessels. These arteries then pass medially through the roof of the ethmoid sinuses and enter the anterior cranial fossa, from which they descend through the cribriform plate to enter the nose. The anterior ethmoidal artery, the larger of the two, supplies the anterior nasal septum and lateral nasal wall. The posterior ethmoidal artery supplies the region of the superior turbinate and corresponding portion of the septum.
The external carotid artery (ECA) supplies the nose through two of its terminal branches, the facial artery and the internal maxillary artery. The facial artery, a major branch of the external carotid system, providing blood supply to most of the lower face and lips, supplies the superior labial artery, which enters the nose lateral to the anterior nasal spine and supplies the anterior nasal septum (Figs. 146.1 and 146.2).
The maxillary segment of the internal maxillary artery (IMA) is the primary contributor to the nasal blood supply, crossing the infratemporal fossa to the pterygopalatine fossa. At this point, it divides into multiple terminal branches that supply the nasal cavity primarily by the sphenopalatine artery (SPA). The SPA enters the nasal cavity through the sphenopalatine foramen at the lateral nasal wall posterior to the horizontal portion of the middle turbinate, and divides into multiples branches that supply the posterior septum, lateral nasal wall, and sinuses (Fig. 146.3).
On the anterior nasal septum lies Kiesselbach’s plexus or Little’s area, an abundant plexus of vessels consisting of the most prominent anastomoses between the external and internal carotid artery systems. It is at this region that anterior epistaxis most frequently originates, reported in up to 90% of cases [1,2]. Posterior epistaxis, on the other hand, most frequently occurs near the sphenopalatine foramen from branches of the SPA, frequently a result of prior surgery or trauma.
Causes of Epistaxis
Risk factors and causes of epistaxis may be divided into local and systemic etiologies (Table 146.1). In the intensive care unit (ICU) setting, epistaxis usually results from a combination of these etiologies; however, direct nasal trauma still plays a central role in its development. Trauma may result from digital manipulation by the patient or nasal fractures with subsequent mucosal disruption; however, in the ICU, nasal trauma is often iatrogenic from nasal oxygen, continuous positive airway pressure (CPAP), or particularly from nasal tube placement (nasogastric feeding tubes, nasal endotracheal tubes, etc.). Nasal cannulas in particular cause bleeding as a result of mucosal abrasions or mucosal drying from non-humidified high flow oxygen. A humidified face mask or face tent is preferred in particularly high-risk patients (history of epistaxis, long-term anticoagulation). Simply moving a nasal tube to the contralateral side may minimize or prevent progression of traumatic epistaxis resulting from tube placement.
Other causes of mucosal dryness include overuse of nasal decongestants or cocaine. Alterations in nasal airflow with subsequent drying may result from congenital or acquired anatomic abnormalities such as septal spurs and deviations, as well as septal perforations (which can themselves be caused by the potent vasoconstrictive effects of drugs such as cocaine). Epistaxis occurs more frequently during the winter months, presumably because of the lower humidity in ambient air. Because factors such as mucosal dryness and trauma most frequently affect the anterior nose, most epistaxis is anterior in nature.
Systemic factors and preexisting conditions place ICU patients at particularly high risk for epistaxis. Studies show that up to 45% of patients admitted for epistaxis have a comorbid condition that could cause or exacerbate bleeding [3]. Literature has identified patients older than 50 years as being particularly predisposed to severe epistaxis refractory to local measures of control, likely due to the effects of endothelial degeneration, atherosclerotic changes, and other systemic conditions. These include hypertension, atherosclerotic vascular disease, coagulopathies, and conditions requiring antiplatelet or anticoagulative medications (aspirin, clopidogrel, heparin, warfarin) such as deep vein thrombosis (DVT), pulmonary embolus (PE), cardiac arrhythmias, coronary artery disease (CAD), and vascular stent placement. Medications such as these all affect coagulation and may subsequently result in recurrent or refractory episodes of nasal bleeding. However, the conditions for which these agents are used present a particular challenge, as stoppage of these medications can be life-threatening.
Coagulopathies such as von Willebrand disease and hemophilia must be considered in patients with recurrent or refractory disease. Failure to identify these conditions may result in a delay in administration of medical therapies such as factor VIII or desmopressin acetate that can aid in reversing the underlying disease process.
 Figure 146.1. Blood supply of the lateral nasal wall. |
In the ICU setting, it is most often a combination of a number of the above factors that results in epistaxis. Identifying and addressing the various contributing factors is of central importance when managing epistaxis in the ICU.
Management
Initial evaluation of the ICU patient with epistaxis should first and always be guided by the rules of Airway, Breathing, and Circulation, with a quick determination of the severity of the bleed. In case of a severe bleed in an unstable patient, the airway should be secured (by intubation) and two large bore intravenous (IV) lines should be placed if not already established. If the patient already has a tracheostomy tube in place, the cuff should be inflated to prevent passage of blood products and protect the airway. Frequent suctioning of the pharynx can assist in reducing aspiration. Once the airway is secured and hemodynamic status addressed, efforts can be focused on the control of bleeding. Typically, most patients are hemodynamically stable and are able to protect their airway, allowing for a more thorough examination.
In patients who are hemodynamically stable, a short and focused history, including information regarding nasal trauma, duration, and amount of blood loss is invaluable. After the severity has been assessed, one can discern laterality, history of coagulation and hemodynamic disorders, and iatrogenic factors that may be contributing. In the ICU setting, patients are frequently unable to provide a history such that nursing, family members, and other ancillary staff are needed to provide crucial information. It is also necessary to determine if a bleed is originating anteriorly in the nasal vault or more posteriorly (e.g., copious amounts of expectorated blood, hematemesis), which is typically more severe and is not easily stopped with local pressure or topical cauterization. One must exercise caution when suctioning the nasopharynx to avoid dislodgment of clot into the hypopharynx and larynx, which may result in airway compromise.
 Figure 146.2. Blood supply of the nasal septum. |
Vital signs should be assessed and hypertension controlled to reduce the bleeding. The nasal examination may then be undertaken, best accomplished with good lighting, a nasal speculum, and suction. If a discrete source of bleeding is easily visualized, then local coagulation with silver nitrate applicators may suffice. However, diffuse bleeding is often noted, and a vasoconstrictive agent such as oxymetazoline or phenylephrine may be sprayed to decrease bleeding and improve visualization.
The first step in attempted control of epistaxis should consist of a topical vasoconstrictive agent (oxymetazoline or phenylephrine) sprayed liberally on the side of bleeding (if localized) or bilaterally, followed by uninterrupted external digital pressure for 15 to 20 minutes. Pressure should be applied with a tight pinch, compressing the nasal alae against the nasal septum in such a manner as to prevent passage of nasal airflow. During this time, the oropharynx should be examined to evaluate for
continued bleeding, which may raise suspicion for a posterior source. One should be aware that only minimal anterior bleeding may occur with significant posterior epistaxis.
continued bleeding, which may raise suspicion for a posterior source. One should be aware that only minimal anterior bleeding may occur with significant posterior epistaxis.
 Figure 146.3. Course and branches of the internal maxillary artery. |
Table 146.1 Etiologies of Epistaxis | ||||||
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Because the majority of bleeding is anterior on the septum, a topical vasoconstrictive agent and external pressure will frequently achieve hemostasis and is sometimes all that is necessary. Krempl et al. found that up to 65% of cases of epistaxis were controlled with a topical vasoconstrictor and pressure alone [4]. If these measures are successful, measures should be taken to decrease mucosal drying and subsequent recurrence, including placement of a humidified face tent, topical vasoconstrictive agent twice daily for a maximum of 5 days (to prevent complications such as rebound nasal congestion and septal perforation), frequent topical saline sprays, application of lubricating ointment (e.g., neomycin/polymyxin) to the nasal septum twice daily, and control of hypertension.
Laboratory tests should be considered in patients with significant or recurrent epistaxis. A complete blood cell count, coagulation studies, and a bleeding time should be performed. In patients with severe bleeding or those who are severely anemic, one should consider a crossmatch with the initial blood draw due to the time necessary to prepare blood products. Liver function tests may help elucidate the cause and identify patients with coagulopathies as a result of impaired hepatic function.
Cautery
The majority of nosebleeds arise from Kiesselbach’s plexus on the anterior nasal septum, and cauterization may be performed either with silver nitrate applicators or electrocautery to the bleeding site if unresponsive to topical vasoconstrictors and pressure. In stable patients with mild to moderate bleeding, a nasal endoscope (0-degree telescope with light source) can aid in visualizing bleeding sites and focus cauterization more precisely on the source, but a nasal speculum remains a viable alternative. In the awake patient, topical anesthesia should be used (such as 4% lidocaine or tetracaine) that may be mixed with the topical vasoconstrictor being applied, to decrease pain and improve examination conditions. Silver nitrate, when in contact with water in blood, precipitates and is reduced to neutral silver metal, which releases reactive oxygen species to coagulate tissue. Silver nitrate use is useful for minor bleeds, but may be inadequate with more severe bleeds as heavy blood flow washes away the silver nitrate before it can act.
Overly aggressive cauterization or bilateral cautery should be avoided to prevent ulceration, which may subsequently cause re-bleeding or result in a septal perforation in the long term. Injudicious cautery may also lead to synechia (scar) formation between the septum and the turbinate/lateral nasal wall,
which can later impair the patient’s breathing and result in abnormal airflow.
which can later impair the patient’s breathing and result in abnormal airflow.
An additional tool in initial control in patients with evidence of significant posterior bleeding includes transpalatal vasoconstriction of the sphenopalatine artery, utilizing a 25-gauge needle bent at 2.5 cm and injecting 1 to 2 mL of 1% lidocaine with epinephrine (1:100,000) in the descending palatine foramen, located just medial to the upper second molar. This procedure may slow bleeding enough to allow for improved examination [5].
Nasal Packing
Nasal packing, which is typically described as anterior or posterior, should be considered as the next step in management after failure of local and medical measures such as external pressure and cautery. Packing can also be used in cases where the source of bleeding is not evident on physical examination, or when the bleeding is severe and must be temporized until further definitive management can be performed.
Anterior Nasal Packing
Anterior nasal packing is generally performed for epistaxis originating from the anterior nasal cavity to tamponade the vessel at the source, as well as to provide coverage of the bleeding site, allowing the primary stages of healing to occur in the absence of further local trauma and desiccation that can result in re-bleeding. As most epistaxis occurs anteriorly, this form of packing is usually sufficient. Many different types of packs are now available, utilizing a variety of both absorbable and nonabsorbable materials. The choice of anterior packing material is based on clinician preference and comfort level, as well as product availability in the hospital.
Common absorbable materials used for anterior packing include gelatin foam (e.g., GelFoam®-Pfizer, Inc, New York, NY) and oxidized cellulose (e.g., Surgicel®-Ethicon, Inc, Somerville, NJ), which encourage platelet aggregation and protect bleeding sites from further trauma and desiccation. Other materials include microfibrillar collagen (e.g., Avitene©-Davol Inc, Cranston, RI) and thrombin-gelatin combinations (Floseal®-Baxter International, Deerfield, IL) that can be instilled in the nasal cavity as a slurry. The advantages of these products include their ease of use, decreased patient pain, elimination of the need for pack removal, and improved conformity to the irregular contours of the nasal cavity. However, these products may not be effective in control of brisk arterial bleeding as they apply only low pressure to the nasal mucosa, and they are significantly more expensive than traditional packs.
Traditional nasal packing has involved the use of 0.5-in by 72.0 petroleum jelly strip gauze, layered with a bayonet forceps from inferior to superior along the length of the nasal cavity (Fig. 146.4). Over the years, the use of nonabsorbable sponges composed of hydroxylated polyvinyl acetate that expands when wet (e.g., Merocel® Medtronic Inc, Mystic, CT) has gained popularity due to their ease of use and applicability by hand without the need for additional instruments. The sponge is coated in antibiotic ointment prior to placement primarily for lubrication to ease application and decrease further septal trauma, but there is no published evidence to support a decrease in infectious complications [5,6]. Using a bayonet forceps or by hand, the sponge is then placed in the nasal cavity on the side of bleeding, sliding along the nasal septum to avoid the turbinates and ensure tamponade of the septal bleeding source. The packing should slide easily and should not require a high degree of force to decrease further mucosal trauma. Once in place, the sponge is copiously impregnated with a vasoconstrictive agent or sterile saline. Subsequent swelling of the sponge provides high pressure against the site of bleeding resulting in hemostasis. At this point, the oropharynx should be inspected to evaluate for continued bleeding posteriorly. Persistent anterior bleeding around the pack may necessitate repositioning or augmenting the pack. Anterior nasal packing has been shown in randomized, controlled trials to successfully control bleeding in up to 80% of cases [7,8]. The use of the Merocel® has published success rates up to 92% [9].
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