Epistaxis

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Epistaxis

  1. Definition: Epistaxis is defined as acute hemorrhage from the nostril, nasal cavity, or nasopharynx.
  2. Pathophysiology: The classification of epistaxis is based on the primary origin of the bleeding which can be from the anterior or posterior nasal cavity. Anterior bleeding is the most common and originates from the Kiesselbach plexus, an anastomotic network of vessels found in the anterior nasal septum. Another origin for anterior nasal hemorrhage is anterior to the inferior turbinate. Posterior hemorrhage on the other hand is less common and originates from branches of the sphenopalatine artery in the posterior nasal cavity or nasopharynx.
  3. Epidemiology: epistaxis is believed to occur in approximately 14% of the US population although accurate numbers are difficult to ascertain because most episodes resolve with self-treatment and, therefore, are not reported. Age distribution is bimodal and peaks at ages 2-10 years and 50-80 years. Morbidity is usually related to nasal packing which can be bothering to the patient, or in certain cases cause airway compromise or infection. Mortality is rare and is associated with prolonged and/or massive hemorrhage.
  4. Causes:
    1. Trauma: due to nasal picking which is usually encountered in children and causes anterior septal mucosal ulceration and bleeding; facial trauma; nasal surgery
    2. Nasal mucosal irritation due to dry, hot weather or nasal sprays
    3. Septal deviations causing abnormalities in nasal airflow thus leading to mucosal dryness
    4. Bacterial, viral or allergic mucosal inflammation
    5. Granulomatous disease leading to mucosal inflammation
    6. Tumor
    7. Arteriovenous malformation
    8. Hereditary hemorrhagic telangiectasia (HHT)
    9. Blood dyscrasias
    10. Idiopathic causes
  5. Diagnosis: Visualization of the nasal cavity usually identifies the anterior portion as a source of epistaxis in 90% of cases. In the event where massive epistaxis cannot be differentiated from hemoptysis or hematemesis, a nasal source is confirmed with blood seen dripping from the posterior nasopharynx. It is usually useful to ask the patient to blow her/his nose to clear blood clots prior to speculum exam. Intranasal vasoconstrictors can be administered to reduce bleeding and topical anesthesia can be applied to reduce pain from the exam and nasal packing. In certain cases, CT scanning and MRI may be used to help the diagnosis, i.e when a tumor is suspected. Nasopharyngoscopy may also be utilized. Angiogram studies may be merited for patients with recurrent episodes of epistaxis in order to rule out the possibility of an AVM or vascular abnormality in association with HHT (Hereditary Hemorrhagic Telangiectasia)
  1. Treatment:
    1. Maintaining airway patency and ventilation as well as fluid resuscitation and blood transfusion in cases of hemodynamic compromise are crucial following massive hemorrhage. As mentioned previously, topical anesthetics and vasoconstrictors, such as 4% lidocaine and 0.05% oxymetazoline administered via aerosolizing spray or cotton pledgets are essential. If a source of bleeding can be identified, chemical cauterization with silver nitrate or electric cauterization can be tried.
    2. If non-responsive to cautery, epistaxis can be treated with nasal packing. Anterior packing should be tried first along with prophylactic antibiotics; packings should not be kept for more than 3 to 4 days. If this approach fails, posterior packing can be attempted in addition to anterior packing. In such cases, inflatable balloon devices may be used. Patients with posterior packing should be admitted to the ICU.
    3. When all these options fail, surgical or endovascular intervention may be necessary. Surgery involves open or endoscopic ligation of arteries such as the external carotid, internal maxillary or ethmoidal artery.
    4. Endovascular intervention entails embolization and occlusion of the bleeding source and is yet another safe and effective therapeutic modality which may not necessitate general anesthesia. Access to the external carotid artery is gained through the femoral artery in which a catheter system is introduced under local anesthesia. Angiography of the internal and external carotid arteries is usual performed to rule out vascular anomalies that would prevent moving on with the procedure. A microcatheter is then advanced selectively into the desired artery (usually the internal maxillary) which is visualized with selective angiography. Embolization can then be performed at the appropriate location using a number of embolic tools, including polyvinyl alcohol (PVA) particles, Embospheres, n-BCA glue, and Onyx, as well as coils. The appropriate tool depends upon the pathology. Most often, epistaxis in the absence of a discrete pseudoaneurysm, direct vessel injury, or malformation may be treated with PVA or embospheres. In a study by Scaramuzzi et al, 83% of embolized patients had immediate and permanent resolution of epistaxis. Technical success was 100%. No major complications were noted. Nonetheless, recurrences can occur even with perfect angiographic results. Length of hospital stay after embolization is usually 24 hours.
    5. During endovascular treatment of epistaxis, it is critical to verify that the blood supply to the retina is not put at any risk by the procedure.
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