Central Annals of Otolaryngology and Rhinology

Cite this article: Gökdoğan O, Ileri F (2016) Epistaxis: A Review of Clinical Practice. Ann Otolaryngol Rhinol 3(10): 1139.

*Corresponding author

Ozan Gökdoğan, Department of Otorhinolaryngology, Memorial Health Group Ankara Hospital, 06500 Balgat/Ankara/Turkey, Tel: 00905055966558; Fax: 00903122536635; Email:

Submitted: 07 September 2016

Accepted: 29 September 2016

Published: 01 October 2016

ISSN: 2379-948X

Copyright© 2016 Gökdoğan et al.

OPEN ACCESS

Keywords• Epistaxis• Nasal bleeding• Cauterization

Review Article

Epistaxis: A Review of Clinical PracticeOzan Gökdoğan*, and Fikret IleriDepartment of Otorhinolaryngology, Memorial Health Group Ankara Hospital, Turkey

Abstract

Introduction: Epistaxis is one of the most frequent problems in otorhinolaryngology practice and emergency medicine which occurs in up to 60% of the general population. Several risk factors are associated with epistaxis.

Objective: To review the anatomy of the anterior part of the nose and also discuss etiology and management of epistaxis.

Conclusion: Although most cases do not need any intervention, epistaxis may result in severe consequences. Every otorhinolaryngologist and emergency doctor must know etiology and management of epistaxis.

INTRODUCTIONEpistaxis is one of the most frequent problems in

otorhinolaryngology practice and emergency medicine which occurs in up to 60% of the general population [1]. Although it is a common health problem, most of the cases are minor and self-limiting with almost 6% requiring medical treatment [2] .Epistaxis both affect children and adults and has two peaks which takes place before the age 10 and between the ages 45 and 65 [3].

Anatomy of epistaxis

Little’s area, which is also known as Kisselbach’s plexus, is the most common bleeding region of the nose. Almost 80 to 90% of epistaxis originate from this area [4]. It is located in the anteroinferior part of the nose. This plexus is the area which interacts with respired air after the external nasal valve. This plexus has the functions of blood supply and mucosal immunity, as well as warming and humidifying the respired air.

Little’s area has an intense blood supply. Most of the vessels are located superficially in this area which can easily be affected by multiple factors. Both internal and external carotid artery supplies blood to this region. Branches of anterior and posterior ethmoidal arteries, superior labial artery, terminal branches of sphenopalatine artery and palatine artery supply this area with blood and form the Kisselbach’s plexus [3,4].

Etiology of the epistaxis

Although there are various factors involved in the development of bleeding from the nose, they can be basically classified into two groups as local and systemic factors.

Local factors;

• Infectious disorders, like rhinitis and sinusitis

• Inflammatory disorders, pathologies that result in rhinitis such as allergies, autoimmune disorders

• Trauma, which is especially important in childhood. Nasal picking or rubbing can both result in bleeding and create a tendency to cause bleeding. External trauma may also cause bleeding from the nose.

• Foreign bodies, although that the most common presentation of a nasal foreign body is unilateral purulent rhinorrhea foreign bodies may also result in bleeding from the ipsilateral especially in children.

• Anatomic disorders, nasal septal deviation effects vessels’ location in the mucosa and also effects airflow which may result in crusting. Also septal perforation effects nasal airflow and result crusting and sometimes epistaxis.

• Medications such as topical decongestants and cocaine. Topical decongestants are widely used all over the world. Regular usage over a week may result in rhinitis medicamentosa which causes crusting and bleeding inside the nose. Also in clinical practice incorrect use of intranasal corticosteroids, which is widely used for various forms rhinitis, may result in epistaxis.

• Environmental factors such as cold-hot and dry air may result in crusting and bleeding. Humidification is the duty of the nose. If the weather is very dry and cold or hot, crusting and finally epistaxis may develop.

• Malignancies may also be related to epistaxis which is generally ipsilateral.

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• Iatrogenic factors may be related with epistaxis. Nasalandparanasalsurgeriescreatecomplicationsofbleedingin both early and late postoperative period. Septalperforation after surgerymay present with crusting orepistaxis.

Systemic factorsaregenerally relatedwith the tendencyofbleedingalloverthebody,butgenerallymanifestwithepistaxis.

• Hematologicdisordersmaydeveloprecurrentepistaxis.During bleeding both platelets and blood cogulationfactors interact for clot formation locally. Any disorderwhicheffectsplateletorcoagulationfactorsmayresultinbleeding.

• Medications like antiaggregants or anticoagulantsmay develop epistaxis. Antiaggregant drugs suchas acetylsalicylic acid effects platelet aggregation.Anticoagulant drugs such as Coumadin effects plasmacoagulationfactorsandinhibitsclotformation[1-6].

Management

Mostbleedingoriginatesfromtheanteriorpartofthenose.Posterior bleedings are generally caused by serious problemsandmustbeevaluatedandtreatedwithcaution.

Mostoftheepistaxisaremildandstopspontaneouslyorwithanteriornasalpressure.

Inactivebleedingasanyemergentdiseaseinthebody,ABCofemergencymanagement–airway,breathingandcirculation,taking priority in any emergent situation. If necessary,intravenous hydration must be done and hypo/hypertensionmustbecontrolled.Aftervitalfunctionsarecontrolled,bleedingmustbestopped.

Themanagement of epistaxis always start with anteriorpressure. If epistaxis continues ,evenanteriorpressure, topicaldecongestants sprays and topical solution with cotton orgauze stripsmust be used respectively. Topical decongestantssuch as 1:1000 adrenalin (epinephrine), 0,5% phenylephrinehydrochloride, 4% cocaine or 0.05% oxymetazoline solutionwith cotton or gauze strips are used for epistaxis [7]. If thebleeding stops with topical decongestants, further treatmentshouldbediscussedwiththepatientaccordingtotheseverityofthebleeding.Ifthebleedingrecursfrequentlyandiftheamountof bleeding is very high in every episode, cauterization shouldbe recommended. Timing of cautery should be discussed. Ifthe patient has stopped bleeding it is better towait untill themucosal healing and to perform more focused cautery withbettervisualization.

Themainaimofcauterizationistodestroythemucosaofthenasal septum. In thehealingprocessof the cauterizedmucosa,it is expected to healwith scar tissuewith decreased vascularstructures insteadofnormalmucosa.Silvernitrate tip coveredsticksandelectrocauteryaregenerallyusedforcauterization[8].

Silvernitrateisastrongoxidizingagent.Whensilvernitrateinteractswith liquids, it precipitates and releases free radicals[9].Thischemicalprocessoxidizesmucosaanddestroysmucosalstructures. The concentration of silver nitrate in sticks varies

from75%to95%[10].Theimportantpointincauterizationistodestroyallpartsofmucosatothecartilage.Surfacecauterizationsaregenerallyinadequateandtendtorecur.Indeepcauterizations,generally the vessels bleed and afterpacking a cottonpiece tothebleedingareaforafewminutes,cauterizationcanbefinishedthrough destroying the deeper levels of the mucosa. Usuallytwosticksareenough;generallyoneisusedforsurfaceandthesecondisusedfordeepcauterization.

Forsilvernitratecauterization,itisgenerallyrecommendedtostartmakingacirclearoundthebleedingregioninquestion,during which the vessel is located at the centre of the circle.Cauterization is continued distally to the centre with circularmovements. The vascular structure in question is cauterizedfinally in both surface and deep part of the mucosal layers.Forthebloodsupplyof thecartilaginousstructureof thenasalseptum, perichondrium is the key structure. Cauterization ofdeep structures of mucosa may result in prolonged crusting.Also bilaterally cauterization of the perichondrium may beriskyforbloodsupplyofthecartilaginoustissue,butifonesideofperichondriumispreserved, it isgenerallyenoughforbloodsupplyforthecartilaginoustissue[8-10].

The second common cauterizationmethod is cauterization(bipolar or suction monopolar). The cauterization systemuses thermal energy to destroy the selected region. It has theadvantageofmorespecificregioncauterizationratherthansilvernitratesticks.Butitisnoteasilyavailablewhencomparedwithsilvernitratesticksanditisalsoanexpensivetreatmentmodalitywhencomparedtosilvernitratestickcauterization.

Because bleeding is generally single sided, cauterization isrecommendedtobeperformedonthebleedingside.Inbilateralbleedings,bilateralcauterizationmaycreatethecomplicationofnasalseptalperforation.Cautiousbipolarcauterizationbytryingnottocauterizetheoppositesidesmaybeusedinselectedcases.Butgenerallythesecondsidecauterizationisrecommendedafterthe recoveryperiod of the previous side. This recoveryperiodisaffectedbymultipl factorsbutgenerally2-3weeksperiod isnecessaryforhealing[11].

In the follow-up period after cauterization, local ointmentwithsalinegelorpantenolmustbeappliedtopreventcrustingandre-bleeding.Completerecoveryisgenerallyachievedinoneortwoweeks.Duringthistimelocaloilointmentsmustbeused.Silvernitratecauterizationhasasuccessrateof75%-85%.

Ifthebleedingisnotcontrolledbyinitialinterventions,nasalpackagingwhichcanbecotton,gauze,orcommerciallyfabricatedmerocel (Medtronic ENT, Jacksonville, Florida, USA), RapidRhino(AppliedTherapeutics,Tampa,Florida,USA),Spongostan(Johnson and Johnson Ethicon Inc, USA), Surgicel (Ethicon,USA),Nasopore(Polyganics-Groningen,TheNetherlands)canbeused.Spongostan (Johnson and Johnson Ethicon Inc, USA is anabsorbablehaemostaticgelatinspongewhich isbiodegradable.Nasopore(Polyganics-Groningen, The Netherlands is alsobiodegradable synthetic polyurethan foam. This materialsprovide strong initial compressive mechanical proporties,whereashydrophiliccomponenttakes-upthewaterorbloodandisgraduallyfragmented.

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Generally, the anterior packaging is adequate for mostbleedings. If the anterior packaging cannot stop bleeding,posteriorpackagings,whichincludegauzepackagesorcatheterslike Pope nasal packing (Medtronic ENT, Jacksonville, Florida,USA) Epistat, Postpac (Medtronic ENT, Jacksonville, Florida,USA),canbeused.Anteriorpackingareremovedaftertwodays,butposteriorpackingmaystayuptofivedaysaccordingtothepatients’generalconditions.Antibiotictreatmentshouldbeuseduntil theremovalofnasalpackagingforpreventingtoxicshocksyndrome which is related with with staphylococcal toxins.Nasal packing have also complications of nasal discomfort,pneumocephalus, etc. Generallywe recommend analgesicwithantibiotictreatment.Theusageofhaemostaticcompoundshaveincreasedintherecentyears,suchasFloseal(BaxterHealthcareCorp, Deerfield, Illinois, USA) [6]. Although there are severalstudieswhichshowtheirbenefit inepistaxis, theirusehasnotbecomewidespread.Floseal (BaxterHealthcareCorp,Deerfield,Illinois, USA) has gelatin granules which swell to produce atamponade effect. Also high concentration of human thrombinin Floseal (Baxter Healthcare Corp, Deerfield, Illinois, USA)convert fibrinogenintofibrinmonomerswhichaccelaratesclotformation.

Epistaxiswhichcannotbecontrolledbypackagingmustfirstbe evaluated in the operating room under general anesthesia.Possible bleeding areas must be cauterized or vessels mustbe ligate [12]. Endoscopic approach the first line treatmentof ligation if epistaxis can not be controlled by conventionalapproachs.Ethmoidal artery, sphenopalatinearteryor internalmaxillaryarterycouldbeligatedeasilyifnecessary.Openligationofanteriorethmoidartery,facialartery,internalmaxillaryarteryorevenexternalcarotidarteryisrarelyusedforepistaxisaftertheevaluationofendoscopicnasalsurgery.Interventionalradiologymay be helpful in intractable epistaxis cases. Angiography andselectedembolisationofthevesselmaybenecessaryinselectedcases. Altough highly selective embolization could bemade byinterventional radiology, there are some complications relatedwith this approach. The complications including stroke andblindnessmustbediscussedbeforeembolisationprocedurewithpatient[13].

Medical therapy in epistaxis is not used commonly.Antifibrinolytics,suchasaminocaproicacidandtranexamicacidare used as inhibitors of fibrinolysis. This drugs stop plasminformationwithbindingtotheprecursorenzymesorplasminoge[14]. In severe epistaxis or patientswith coagulopathies, freshfrozenplasmamustbeused[15].

Sclerotherapy, septodermoplasty, hormonal therapy(speciallyincasesofhematologicaldiseases)arerecommendedin chronic epistaxis. Sodium tetradecyl sulfate is used forsclerotherapyinchronicepistaxis[16].Septodermaoplastyistheremovalofaffectednasalepitheliumanditsreplacementwithaplit thicknessskingraft [17].Systemicestrogen-progestroneatdosesfororalcontraceptionmaybehelpfulinchronicepistaxis[18].

Because of reflexive flexion of the head during epistaxis,blood from nose goes down through the face. Plenty of bloodrunningdownthefaceandthebodymayalsoresultinsomevagalsymptomssuchashypertension,rhythmproblemsofheartand

even fearofdeath. Hypertension results inhigheramountsofbleeding.Thisviciouscirclealsocreatesbleeding.

CONCLUSIONEpistaxis is a common health problem which effects large

populationsallovertheworld.Althoughmostepistaxiscasesareselflimiting,sometimesbleedingmayresultinsevereconditions.Anatomy,etiologyandmanagementofepistaxismustbeknownby every otorhinolaryngologist and emergency doctor becauseof thehigh incidenceratesofepistaxis.Newtreatmentoptionssuch as haemostatic compounds or haemostatic packages helpphysicians’management.Surgicalinterventionandembolisationare the options in cases in which failure of conservationalmanagementmethodsfail.

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Gökdoğan O, Ileri F (2016) Epistaxis: A Review of Clinical Practice. Ann Otolaryngol Rhinol 3(10): 1139.

Cite this article

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