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Flashcards in 23 Epistaxis Deck (24):
1

Discuss the epidemiology of epistaxis.

Discuss the epidemiology of epistaxis.

Epistaxis commonly occurs in all age groups with a bimodal distribution in the young and the elderly. The vast majority of episodes are benign and self-limited. Epistaxis can be broadly categorized into childhood versus adult epistaxis, or primary versus secondary epistaxis, which is important for diagnostic and therapeutic decision-making.

2

What blood vessels supply the nasal mucosa?

What blood vessels supply the nasal mucosa?

Kiesselbach’s Plexus (Little’s Area)

  1. internal carotid ⇒ ophthalmic ⇒ anterior ethmoid
  2. external carotid ⇒ facial ⇒ superior labial
  3. external carotid ⇒ maxillary ⇒ descending palatine ⇒ greater palatine
  4. external carotid ⇒ maxillary ⇒ sphenopalatine (terminal branches)

 

Woodruff ’s Plexus

  • confluence of vessels on the lateral wall, posterior to the inferior/middle turbinates
  1. external carotid ⇒ maxillary ⇒ sphenopalatine
  2. external carotid ⇒ ascending pharyngeal

3

What is Kiesselbach’s plexus? What is Woodruff’s plexus? Where are they located?

What is Kiesselbach’s plexus? What is Woodruff’s plexus? Where are they located?

Kiesselbach’s plexus is a confluence of vessels arising from both the internal and external carotid artery systems. It supplies an area on the anterior-inferior nasal septum known as Little’s area, the most common site for epistaxis.

Woodruff’s plexus is a plexus of thin-walled veins located posteriorly in the inferior meatus. This area was previously thought to be arterial and also thought to be a main contributor to posterior bleeds, but this does not appear to be the case.

4

What is meant by “anterior” and “posterior” epistaxis?

What is meant by “anterior” and “posterior” epistaxis?

The majority of bleeds (90% to 95%) originate anteriorly; many of the anterior bleeds occur in Little’s area within Kiesselbach’s plexus. Occurring much more often than posterior bleeds because of their location (nose picking/local trauma, dryness), anterior bleeds are easily accessible and managed with conservative measures such as moisturization, pressure, decongestion, or topical cautery. Posterior bleeds are generally from the distribution of the sphenopalatine artery. The exact focus of origin is more challenging to identify, and these bleeds are therefore more likely to require nasal packing as part of intervention.

5

What should be included in the history evaluation of a patient with new-onset epistaxis?

What should be included in the history evaluation of a patient with new-onset epistaxis?

In the emergent setting, emphasis should be placed on managing airway, breathing, and circulation, with volume replacement as needed with crystalloid +/− blood products as needed, and a focused history to expedite locating the source by nasal endoscopy and controlling hemorrhage. In the nonemergent setting, a careful and thorough history and physical exam can be obtained. The history should include timing, frequency, sidedness, and severity of epistaxis (which can be quantified by volume of observed blood or number of tissues), exploring predisposing conditions:

  • trauma or recent surgery
  • coagulopathy
  • cancer
  • alcohol use
  • medications and illicit drug use
  • contributory chronic medical issues
  • current symptoms indicative of blood loss such as lightheadedness or dyspnea.
  • Family history

6

What are the initial measures utilized to control mild epistaxis?

What are the initial measures utilized to control mild epistaxis?

  1. Instruct the patient to gently blow the nose. This removes blood/clots.
  2. Intranasal administration of nasal decongestant spray such as oxymetazoline (a selective alpha-1 agonist/partial alpha-2 agonist).
  3. Instruct the patient to pinch the nasal alae against the septum to apply hemostatic pressure, and hold for 10 to 15 minutes, or longer if needed.
  4. Place a cold compress over the bridge of the nose, if available.

7

Why is it helpful to have the patient lean forward in addition to the measures suggested in the previous question?

Why is it helpful to have the patient lean forward in addition to the measures suggested in the previous question?

Having the head tilted posteriorly may result in posterior drainage of blood, increasing the potential for bloody aspiration and/or gastric irritation with resultant bloody emesis. Additionally, having the blood fall back into the throat and be swallowed makes it difficult to quantify the amount of bleeding.

8

What are the key components of the initial physical examination for an epistaxis patient?

What are the key components of the initial physical examination for an epistaxis patient?

Initial physical evaluation should include ensuring patency of the airway, appropriate breathing and circulation (ABCs), obtaining vital signs, and checking mental status. Check for signs of shock (anxiety, cool/clammy skin, oliguria or anuria, weakness, pallor, diaphoresis, altered mentation), and signs of coagulopathy, such as petechiae or purpura.

9

How is the nose examined in the epistaxis evaluation?

How is the nose examined in the epistaxis evaluation?

Anesthesia can be provided by using anesthetic/analgesic-soaked topical sprays or cotton strips, with preparations such as 2% lidocaine or 4% cocaine. Oxymetazoline can also be given for its vasoconstrictive action; phenylephrine spray may alternatively be used. The patient may expectorate blood/clots as tolerated to better visualize the nasal cavity, and maintain the sniffing position.

A nasal speculum should be used initially, and suction can be used to help remove blood and clots. Inspect relevant anatomic locations such as Kiesselbach’s plexus, septum, and turbinates. In addition to bleeding, the clinician can discover ulcerations, excoriations, and erosion of the mucosa. This will be sufficient for most anterior bleeds, but may not be for many posterior bleeds. Endoscopy should be utilized if:

  • the source of bleeding is not clear on anterior rhinoscopy
  • posterior epistaxis is suspected on history
  • conservative measures have not been successful
  • tumor or lesion is suspected on history.

10

Should you obtain bloodwork in the above evaluation?

Should you obtain bloodwork in the above evaluation?

It is not currently recommended to obtain routine CBC or coagulation studies in the initial assessment, unless the history is suggestive of significant blood loss, repeated large episodes, suspicion of coagulopathy, or current use of anticoagulant medication.

11

What is primary versus secondary epistaxis?

After determining if the bleed is primary or secondary in nature, how should you proceed?

What is primary versus secondary epistaxis?

After determining if the bleed is primary or secondary in nature, how should you proceed?

Primary (idiopathic) epistaxis is a spontaneous bleed without any identified precipitant, while those with an identified cause are termed secondary. Primary epistaxis with an identified source, especially when anterior, should be treated with direct therapy measures such as topical emollients, application of topical hemostatic agents, and/or focal cauterization if necessary. Posterior primary bleeds can be treated with nasal packing, chemical and/or electrocautery, arterial ligation or embolization.

In secondary epistaxis, the underlying disorder needs to be addressed in addition to resuscitative efforts and local modalities. Common causes of secondary epistaxis include liver disease, hematologic disorders (e.g., leukemia), anticoagulant medications such as warfarin or antiplatelet agents (see Controversies section for further discussion). Other causes of secondary epistaxis include trauma, recent surgery, hereditary disorders, and neoplasms.

12

Describe the treatment of epistaxis in the pediatric population.

Describe the treatment of epistaxis in the pediatric population.

In children with recurrent epistaxis, a recommended treatment option is antiseptic cream (chlorhexidine/neomycin). Unilateral cauterization with silver nitrate also seems to be safe and effective. It is rare for children to require surgical intervention.

13

Describe the placement of an anterior nasal pack.

Describe the placement of an anterior nasal pack.

Anterior packing can be performed with either gauze or nasal tampons that expand with the addition of saline. A nasal tampon is placed by first applying topical anesthetic/analgesic intranasally, and coating the pack with antibiotic ointment (this serves as both lubrication and possibly prevention of toxic shock syndrome), sliding the tampon into place, and expanding with saline application. Balloon/merocel combinations have also been utilized, and are another effective method for temporary epistaxis control. Petroleum-impregnated gauze can also be used with antibiotic ointment, placed intranasally with bayonet forceps and layered top to bottom/back to front until tamponade is achieved.

Other custom-fashioned hemostatic packs can be used in similar fashion, such as an absorbable gelatin sponge wrapped in oxydized cellulose dressing.

14

How is silver nitrate chemical cautery applied?

How is silver nitrate chemical cautery applied?

Bleeding must be of minimal severity for silver nitrate to be successful, and ideally unilateral to avoid bilateral cauterization which can carry a risk of septal perforation. The mucosa needs to be relatively dry for the silver nitrate to take effect, so topical decongestant and pressure is applied first to slow bleeding. The silver nitrate stick should be focally placed at the origin of the bleed, holding the tip of the applicator stick against the mucosa until the mucosa becomes gray, working from the periphery to the center of the bleeding site; it should not take any longer than 10 seconds until graying occurs. Silver nitrate works by cauterizing superficial blood vessels in the nose. Topical saline or decongestant is applied to halt the chemical reaction once the desired effect is achieved.

15

Describe the placement of posterior packs and their associated complications.

A posterior pack can be performed with insertion of a cotton pack or Foley catheter. A small red rubber tube is carefully inserted in the nose, passed through the oropharynx, and the end is retrieved through the mouth using a ring forceps. On the oral end of the tube, a cotton pack is attached with silk ties. The tube is gently pulled anterio-inferiorly from the nasal side until the pack passes through the oropharynx to a resting place in the nasopharynx and posterior choana. The anterior nasal cavity may be packed subsequently, and the tube is fastened externally while care is taken not to exert excessive pressure on the nasal ala. The patient should be admitted for telemetry and pulse oximetry, and antibiotic therapy.

Potential complications include pain, discomfort, respiratory difficulty (including aspiration of the packing material), infection (as well as toxic shock syndrome, sinusitis from blocking outflow tracts), alar/septal necrosis, and pharyngeal fibrosis/stenosis. Supplemental oxygen may be required; telemetry monitoring is required given the risk of arrhythmia and syncope.

16

What are surgical interventions for persistent epistaxis?

What are surgical interventions for persistent epistaxis?

Endoscopic diathermy, laser photocoagulation, septal surgery, arterial ligation, and embolization can be used for persistent bleeding. Endoscopic sphenopalatine artery ligation or even internal maxillary artery ligation is now frequently used in the management of posterior epistaxis. In the past, the transantral approach was used but is associated with avoidable complications such as oroantral fistula and dysesthesia. Endoscopic sphenopalatine artery ligation has been highly successful as well as cost-saving for overall hospitalization when compared to nasal packing or embolization.

17

How do SPA ligation and embolization compare in the management of epistaxis?

How do SPA ligation and embolization compare in the management of epistaxis?

Embolization results in almost twice the hospital cost compared to that of surgical ligation, and does not carry the same effectiveness in bleeding control. Although it carries a low risk of major complication, embolization may be a nice alternative in patients who cannot tolerate general anesthesia or are otherwise not good surgical candidates.

18

List a broad differential for new-onset nasal bleeding.

List a broad differential for new-onset nasal bleeding.

  • Environmental: Cold air/dry air can be compounded by central heating systems for rooms that are not humidified (dryness results in mucosal irritation)
  • Trauma: Most commonly digital trauma (nose picking), but can also be from other local trauma/facial trauma, foreign body, surgery
  • Inflammatory/Autoimmune (exacerbated by upper respiratory infections, sinusitis, environmental or other allergies, drugs/chemicals)
  • Medications: Antiplatelet agents or anticoagulants, nasal sprays
  • Vascular: Arterial aneurysm or pseudoaneurysm
  • Congenital/Developmental: Septal abnormality such as deviation or perforation
  • Genetic: Osler-Weber-Rendu syndrome/hereditary hemorrhagic telangiectasia (HHT)
  • Systemic disorders: Arteriosclerosis, hypertension, blood dyscrasias (von Willebrand, paraneoplastic effects, liver disease, hemophilias, thrombocytopenia)
  • Neoplastic: Benign or malignant processes

19

What are some medications, including complementary and alternative medicines, that may contribute to epistaxis?

What are some medications, including complementary and alternative medicines, that may contribute to epistaxis?

Aspirin, clopidogrel, warfarin or other forms of anticoagulation; intranasal steroids; nasal cannula oxygen; chemotherapy.

Herbal medicines that confer antiplatelet effects or affect the liver’s CYP3A4 enzymes, including fish oil, evening primrose, garlic, cranberry juice, vitamin E, echinacea, ginseng, St. John’s wort, ginkgo biloba, ginger, kava, and saw palmetto.

20

What is Osler-Weber-Rendu syndrome/hereditary hemorrhagic telangiectasia (HHT)?

What is Osler-Weber-Rendu syndrome/hereditary hemorrhagic telangiectasia (HHT)?

HHT is an autosomal dominant disorder characterized by vascular malformations that does not manifest at birth but rather as one ages. Diagnostic criteria include:

  1. spontaneous/recurrent epistaxis
  2. mucocutaneous telangiectasias
  3. visceral involvement (e.g., hepatic, pulmonary, cerebral, gastrointestial arteriovenous malformations)
  4. affected first-degree relative (known as Curacao criteria).

Generally, epistaxis is the first manifestation of the disease, occurring during childhood. Epistaxis management includes utilization of topical emollients, topical cautery or packing in acute events, laser photocoagulation or oblation of lesions, septodermoplasty, or nasal closure in extreme cases. Newer experimental therapies including antiangiogenic medications and sclerotherapy are being investigated.

21

A patient presents with epistaxis from a nasal mucosal ulcer. What is the differential diagnosis? Describe the workup.

A patient presents with epistaxis from a nasal mucosal ulcer. What is the differential diagnosis? Describe the workup.

Nasal cavity ulcerations should be treated conservatively and worked up if they do not spontaneously resolve, or when suspicion for underlying tumor is present (pain, numbness, smoking history). Epistaxis may be the first sign of malignancy, granulomatosis with polyangiitis, sarcoidosis, lupus, syphilis, leprosy, tuberculosis, and occupational irritants.

Nasal biopsies should always be performed when a malignancy is suspected, and when an underlying autoimmune disorder is suspected. Recent studies have suggested that biopsies to rule out autoimmune disease are not mandatory in the absence of any nasal or systematic signs of vasculitis, and with negative c-ANCA and ACE test results.

22

What is the recommended medical management for an epistaxis patient currently on anticoagulation for cardiac disease?

What is the recommended medical management for an epistaxis patient currently on anticoagulation for cardiac disease?  Controversy

  1. Obtain a complete blood count including platelets, +PT/INR if taking warfarin, for all patients.
  2. If the patient has a metal heart valve, INR dictates warfarin administration (if overanticoagulated, hold until INR is therapeutic; if INR is therapeutic, continue current regimen).
  3. If life-threatening bleeding occurs in a patient with a metal heart valve, care planning should be discussed with the cardiologist prior to discontinuing aspirin if a coronary stent is in place, as platelet transfusions may be utilized.
  4. For all other patients (without metal heart valve), aspirin or clopidogrel should be continued, but if a life-threatening bleed occurs discussion with the cardiologist about the utility of platelet transfusion should also occur.
  5. These patients should also continue warfarin if therapeutic and have it withheld if overanticoagulated.

23

What is the role of antibiotic prophylaxis with nasal packing?

What is the role of antibiotic prophylaxis with nasal packing?  Controversy

It is controversial whether or not to administer systemic antibiotics prophylactically for prevention of toxic shock syndrome in patients who undergo nasal packing. Toxic shock syndrome is an extremely rare complication and as a result, appropriate studies are lacking. Although controversial, antibiotic administration with nasal packing is commonly performed. If used, the antibiotic chosen should have staphylococcal coverage (e.g., amoxicillin-clavulanate).

24

What is the link between hypertension and epistaxis?

What is the link between hypertension and epistaxis?

Several case series demonstrate a relationship between hypertension and epistaxis, although population-based studies have not confirmed this relationship. Even if not a causative factor, elevated blood pressure may be associated with patient anxiety surrounding epistaxis and intervention, and may slow resolution. The best approach is to offer reassurance and treat the hypertension if possible, as this may worsen the epistaxis if left untreated.

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