Epistaxis

Author Credentials 

Zara M. Patel, MD
Assistant Professor
Director of Endoscopic Skull Base Surgery
Department of Otolaryngology
Stanford University Medical Center
801 Welch Road
Stanford, CA 94305
Email : zmpatel@stanford.edu

Julia Noel, MD
Resident,
Department of Otolaryngology
Stanford University Medical Center
801 Welch Road
Stanford, CA 94305
Email : jtomlin2@stanford.edu

Acknoweldgement and thanks to Dr. Michael Sillers who made significant previous contributions to this module.

Module Summary

Epistaxis is frequently encountered in an otolaryngology practice in both pediatric and adult populations. A variety of underlying disease, systemic, and therapeutic factors can cause bleeding. Being able to recognize the severity of blood loss, having an understanding of vascular anatomy, and the ability to quickly and appropriately select which is the best therapeutic option for each patient will lead to the successful treatment of epistaxis.

Module Learning Objectives 
  1. Describe the pertinent vascular anatomy of the nasal cavity as it relates to epistaxis.
  2. Recognize the various causes of epistaxis and their impact on the patient’s overall health.
  3. Explain how to appropriately triage a bleeding patient.
  4. Describe how to accurately evaluate and treat the epistaxis patient via conservative, surgical, and endovascular approaches.
  5. Discuss the potential complications of treatment.

Anatomy

Learning Objectives 
  1. Know the vascular anatomy of the nasal septum, paranasal sinuses, and lateral nasal wall.
  2. Understand the relationship between the location of the bleeding and its most probable anatomic source.
References 
  1. Wormald, PJ, Bailey, BJ, Johnson, JT, Newlands, SD. "Epistaxis". Head & Neck Surgery: Otolaryngology. Lippincott Williams & Wilkins; 2006:505-514.

Pathogenesis

Learning Objectives 
  1. Understand the demographic and disease variables associated with epistaxis.
  2. Enumerate the acquired systemic conditions that are implicated in epistaxis.
  3. onsider the different sinonasal tumors or lesions that could lead to epistaxis.
  4. Recognize the influence of anticoagulation agents.
References 
  1. Abrich V, Brozek A, Boyle TR, Chyou P-H, Yale SH. Risk Factors for Recurrent Spontaneous Epistaxis. Mayo Clin Proc. 2014;89(12):1636-1643.
  2. Gökdoğan O, Akyildiz I, Sayin BY, Okutucu S, Tanalp AC, Arslan N. The Rate of Epistaxis Incidence in New-Generation Anticoagulants and Perioperative Approach in Otorhinolaryngological Practices. J Craniofac Surg. 2017;28(2):e178-e182.
  3. Patel ZM, Lin FY eds. ENT Board Prep – High Yield Review for the Otolaryngology Inservice and Board Exams. Springer, New York, NY. 2013.
  4. Newton E, Lasso A, Petrcich W, Kilty SJ. An outcomes analysis of anterior epistaxis management in the emergency department. J Otolaryngol - Head Neck Surg. 2016;45(1):24.

Incidence

Learning Objectives 
  1. Know the incidence of epistaxis as it pertains to age, gender, and the location of bleeding.
  2. Recognize different etiologies based on the demographics of presenting patients.
  3. Recognize the seasonal variation of epistaxis.
References 
  1. Comelli I, Vincenti V, Benatti M, et al. Influence of air temperature variations on incidence of epistaxis. Am J Rhinol Allergy. 2015;29(6):e175-81.
  2. Chaaban MR, Zhang D, Resto V, Goodwin JS. Demographic, Seasonal, and Geographic Differences in Emergency Department Visits for Epistaxis. Otolaryngol Head Neck Surg. 2017 Jan;156(1):81-86.

Genetics

Learning Objectives 

Be familiar with the hereditary disease states associated with epistaxis.

References 
  1. Kumar R, Carcao M. Inherited abnormalities of coagulation: hemophilia, von Willebrand disease, and beyond. Pediatr Clin North Am. 2013;60(6):1419-1441.
  2. Rimmer J, Lund VJ. Hereditary haemorrhagic telangiectasia. Rhinology. 2015;53(3):195-203.

Patient Evaluation

Learning Objectives 
  1. Prioritize the assessment of airway and circulatory status.
  2. Recognize the value of anterior rhinoscopy and nasal endoscopy in determining the site of bleeding as it relates to treatment.
  3. Consider coagulation studies in patients taking Warfarin or in recurrent pediatric cases.
References 
  1. Schlosser RJ. Epistaxis. N Engl J Med. 2009;360(8):784-789.
  2. Spielmann PM, Barnes ML, White PS. Controversies in the specialist management of adult epistaxis: an evidence-based review. Clin Otolaryngol. 2012;37(5):382-389.

Imaging

Learning Objectives 

Recognize when angiography may be useful in the assessment/treatment of epistaxis.

References 
  1. Krajina A, Chrobok V. Radiological diagnosis and management of epistaxis. Cardiovasc Intervent Radiol. 2014 Feb;37(1):26-36.

Pathology

Learning Objectives 

Recognize the typical pathologic appearance on histology of JNA.

References 
  1. Patel ZM, Lin FY eds. ENT Board Prep – High Yield Review for the Otolaryngology Inservice and Board Exams. Springer, New York, NY. 2013.

Treatment

Learning Objectives 
  1. Recognize the appropriate application of noninvasive, minimally invasive, and surgical treatment of epistaxis in the adult and pediatric population.
  2. Be familiar with the various packing and hemostatic agents that may be applied.
  3. Establish a treatment algorithm for managing refractory bleeding.
References 
  1. Douglas R, Wormald P-J. Update on epistaxis. Curr Opin Otolaryngol Head Neck Surg. 2007;15(3):180-183.
  2. Leung RM, Smith TL, Rudmik L. Developing a laddered algorithm for the management of intractable epistaxis: a risk analysis. JAMA Otolaryngol Head Neck Surg. 2015;141(5):405-409.
  3. Qureishi A, Burton MJ. Interventions for recurrent idiopathic epistaxis (nosebleeds) in children. In: Burton MJ, ed. Cochrane Database of Systematic Reviews. Chichester, UK: John Wiley & Sons, Ltd; 2012.

Medical Therapies

Learning Objectives 

Employ the appropriate reversal agents or transfusions in patients taking anti-thrombotic medications.

References 
  1. Musgrave KM, Powell J. A systematic review of anti-thrombotic therapy in epistaxis. Rhinology. 2016;54(4):292-391.

Surgical Therapies

Learning Objectives 
  1. Recognize when procedural intervention is necessary for control of refractory epistaxis.
  2. Be familiar with the surgical and radiologic procedures available. 
References 
  1. Lin G, Bleier B. Surgical Management of Severe Epistaxis. Otolaryngol Clin North Am. 2016;49(3):627-637.
  2. Willems PWA, Farb RI, Agid R. Endovascular Treatment of Epistaxis. Am J Neuroradiol. 2009;30(9):1637-1645.
  3. http://www.american-rhinologic.org/videos (Surgical dissection videos on the ARS website, for members. ARS membership is FREE for residents.)

Case Studies

  1. A 79 year old man presents to the emergency department with an acute episode of epistaxis. He reports intermittent epistaxis in the past, which has always resolved spontaneously. This time, however, the bleeding has persisted for more than an hour despite application of Oxymetazoline and external pressure. You find him in no distress, sitting upright with a steady trickle of blood from the left nare. Anterior rhinoscopy shows diffuse oozing from the anterior septum. A focused history reveals he takes Warfarin for atrial fibrillation. What is your initial strategy in managing this patient’s epistaxis? What packing and/or hemostatic agents could be utilized? What additional work up might be useful?
  2. A 44 year old otherwise healthy woman presents to the emergency department after being involved in a motor vehicle accident. She has an isolated nasal bone fracture and is discharged. 5 days later she develops brisk epistaxis from the right side. An anterior pack is placed, but she continues to bleed. Upon your arrival, you find her tachypneic on a non-re-breather, and she is coughing up large blood clots. What is the first consideration in evaluating this patient? What intervention do you pursue knowing she has failed anterior packing?
    1. She is intubated and you are able to stabilize her with posterior packing. The packing is removed 3 days later and she re-bleeds. Describe the options for the next step in management and discuss the risks and benefits of each intervention.

Complications

Learning Objectives 

Enumerate the potential complications of epistaxis and its treatment modalities.

References 
  1. Hanks JE, Hunter D, Goding GS, Boyer HC. Complications from office sclerotherapy for epistaxis due to hereditary hemorrhagic telangiectasia (HHT or Osler-Weber-Rendu). Int Forum Allergy Rhinol. 2014;4(5):422-427.
  2. Villwock JA, Jones K. Recent Trends in Epistaxis Management in the United States. JAMA Otolaryngol Neck Surg. 2013;139(12):1279.

Review

Review Questions 
  1. What is the location of the vast majority of epistaxis cases? What is the name of the anastamotic region and which arteries comprise this network?
  2. Name at least 3 hereditary conditions that may manifest with epistaxis.
  3. When evaluating a patient with epistaxis, what additional history or patient factors are important to elicit?
  4. What is the most effective surgical intervention for control of posterior epistaxis?
  5. What risks should the physician be aware of when pursuing arterial embolization?
Resources 

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  1. Annual Meeting Webcasts (AMW):
  2. Clinical Practice Guideline (Cpg):
  3. ​Patient Management Perspectives (Pmp):
  4. Surgical Videos: