Otolaryngology: Epistaxis

Anterior Epistaxis (90% – Most Common)

Source

  • Kiesselbach Plexus (Superficial Mucosal Vessels)
    • Anastomotic Site of Three Vessels:
      • Septal Branch of Anterior Ethmoidal Artery
      • Lateral Nasal Branch of Sphenopalatine Artery
      • Septal Branch of Superior Labial Branch of Facial Artery

Causes

  • Trauma – Most Common Cause
    • Nose Picking
  • Dryness – Central Heating without Humidification
  • Allergic Rhinitis
  • Foreign Body
  • Chronic Excoriation (Cocaine, etc.)

Treatment

  • Initial Treatment: Direct Pressure (Pinch Alae Tightly for 10 Minutes)
    • Consider Oxymetazoline (Afrin) Spray – Cause Vasoconstriction
  • Other Options:
    • Cautery
    • Unilateral Nasal Packing
      • Nasal Tampon (with/without) Tranexamic Acid
      • Anterior Nasal Balloon
      • Gauze
  • If Fails: Bilateral Nasal Packing
  • If Still Fails: Consider Posterior Epistaxis

Posterior Epistaxis

Source

  • Posterolateral Branch of Sphenopalatine Artery #1
    • From Internal Maxillary Artery or Ethmoid Artery

Risk Factors

  • Hypertension
  • Atherosclerosis
  • Anticoagulation
  • Bleeding Disorders

Differentiating from Anterior Epistaxis

  • Often Difficult to Differentiate
  • Rhinoscopy Can Identify Source
  • Indications of Anterior Source:
    • Minor Bleeding
    • Stops with Direct Pressure
    • Stops with Nasal Packing
  • Indications of Posterior Source:
    • Volume and Rate are Generally Not Useful to Differentiate
    • Brisk Bleeding Despite Proper Packing

Treatment

  • Initial Treatment: Posterior Packing or Balloon Tamponade
  • If Fails: Percutaneous Embolization vs Endoscopic Artery Ligation