OTOLARYNGOLOGY FOR THE INTERNIST 0025-7125/99 $8.00 + .

OO

EPISTAXIS
Luke K. S. Tan, MD, MMedSci, FRCS,
and Karen H. Calhoun, MD, FACS

Patients presenting with epistaxis are anxious and fear bleeding to death.
Although death from epistaxis is rare, it can occur, and significant morbidity is
relatively common.5,34 Although most pediatric epistaxis is treated on an outpa-
tient basis, older patients (>60 years old) more often require hospital admis-
sion.25,44 Initial management of epistaxis is directed at stopping the bleeding,
and long-term treatment is directed at discovering and correcting the underlying
cause. This article updates current management options.

ANATOMIC CONSIDERATIONS IN EPISTAXIS

The blood supply to the nose arises from the internal maxillary and facial
arteries via the external carotid and the anterior and posterior ethmoid arteries
via the internal carotid artery. The anteroinferior septum (Little’s area) is sup-
plied by a confluence of both systems (Kisselbach‘s plexus). Little’s area is a
common site of epistaxis because it is ideally placed to receive environmental
irritation (cold, dry air, cigarette smoke) and is easily accessible to digital trauma.
This area is easy to access and treat. Bleeding arising further within the nasal
cavity can be difficult to reach. Surgical ligation of the contributing arteries can
be challenging because of their deep location and complex anatomy.

PATHOPHYSIOLOGY

Much epistaxis ceases with pressure (digital or packing) over the bleeding
point. An intact coagulation system with accumulation of platelets and clot
formation is required. Abnormal platelet numbers or function or any abnormal-

From the Department of Otolaryngology, University of Texas Medical Branch (KHC,

LKST), Galveston, Texas; and Department of Otolaryngology, National University of
Singapore, Singapore (LKST)

MEDICAL CLINICS OF NORTH AMERICA

VOLUME 83 * NUMBER 1 JANUARY 1999 43

44 TAN & CALHOUN

ity in the coagulation cascade leads to failure of clot formation and persistent
bleeding.

CAUSE

Epistaxis results from an interaction of factors, damaging the nasal epithelial

(mucosal) lining and vessel walls. The major causative factors include environ-
mental factors (humidity, temperature), local factors (trauma, anatomic abnor-
malities, inflammation, allergies, iatrogenic, tumors), systemic factors (hyperten-
sion, platelet and coagulation abnormalities, renal failure, alcohol abuse), and
medications affecting clotting (anticoagulants, nonsteroidal anti-inflammatory
drugs [NSAIDs]).

Environmental Factors

Cold, dry air increases cases of epistaxis. In countries with seasonal climates,
hospital admissions for epistaxis increase during the winter months.24,44, h1 Pa-
tients were admitted at a rate of 0.829 patients per day for temperatures less
than 5°C compared with 0.645 patients per day for temperatures between 5.1"C
and 10°C.61Most had some form of dry air heating, without humidification, in
their homes.
Nasal ciliary activity decreases as temperature drops. Normal ciliary activity
(at 32°C to 40°C) occurs at about 15 Hz frequency, dropping to less than 5 Hz
below 20"C.lh Although extremely dry air is known to promote epistaxis, the
exact humidification as a preventive measure remains undefined. Temperatures
of above 52°C have been associated with cellular damage.56

Local Factors

Trauma
Nose picking and accidental injury are the commonest traumatic causes of
epistaxis. Except with severe facial trauma, such as motor vehicle accidents, this
epistaxis is usually from an anterior nasal source and easily treated.lR

Nasal Septa1 Deviation

Nasal septal deviation is common, but its role in epistaxis is not certain. In
one study, 16% of patients with severe refractory epistaxis had marked septal
deviation.z3In another study of patients with recurrent epistaxis, 81% had septal
deviation versus 31%)in the control The epistaxis group also had a
higher incidence of radiologically demonstrated septal deviation compared with
the control group (62% versus 37% [P<.02]). The bleeding tended to occur from
the side to which the septum was deviated. Exactly how a septal deviation
could cause bleeding is not clearly established. Because septal deviations do
cause nasal obstruction turbulent air flow, this may cause abnormal mucosal
drying, making the mucosa more susceptible to bleeding.
 EPISTAXIS 45

Iatrogenic
Septal, turbinate, nasal, sinus, or orbital surgery can be followed by epi-
staxis. Blood-stained nasal discharge is common in the initial week or two after
surgery. Severe epistaxis can occur, especially after partial turbinate resection
(0.9% to 8.9%).14Management of such patients is aimed at controlling the bleed-
ing and contacting the surgeon to provide appropriate follow-up.

Inflammation (Infection and Allergy)

Epistaxis can result from nasal lining inflammation, with acute respiratory
infections, chronic sinusitis, or allergic rhinosinusitis. In children and the men-
tally disabled, intranasal foreign bodies cause unilateral foul-smelling discharge
that can be accompanied by epistaxis. Children with both nasal allergy symp-
toms and positive skin tests have more frequent epistaxis (20.2%) than those
with symptoms alone (9.9%),positive skin test alone (3.4%),or neither symptoms
nor positive skin test (2.1%). This study suggests that allergic rhinitis predisposes
to epistaxis, either by mucosal irritation or possibly by the atopic state contribut-
ing to a hemostasis

Tumors
Epistaxis can be the only symptom in patients with a nasal tumor. In
adolescents, the most serious cause of recurrent epistaxis is the intranasal tumor,
juvenile angiofibroma. Other neoplastic causes of pediatric epistaxis include
papillomas, polyps, and meningoceles or encephaloceles (infants).8 In adults,
almost any benign or malignant intranasal tumor can present with epistaxis.
Intranasal lesions can sometimes be seen by looking in the nose with the
otoscopic ear piece. Biopsy of intranasal lesions is approached with caution
because biopsy of highly vascular lesions, such as a juvenile angiofibroma, can
cause significant blood loss and morbidity.

Chemicals
Many airborne irritants and toxic chemicals (sulfuric acid, ammonia, gaso-
line, chromates, gl~taraldehyde)~~irritate or harm the nasal mucosa, resulting in
epistaxis. Cigarette smoke, primary or secondary, is another common irritant.

Systemic Factors

Hypertension
Although hypertension is often cited as a cause of epistaxis, several large
studies have shown no higher rate of underlying hypertension among epistaxis
patients than in patients without epi~taxis.~’, b7 Hypertension patients taking
diuretic or methyldopa medications may have more epistaxis than those taking
P-blockers (60Y0).~Hypertension at the time of epistaxis treatment may be anxiety
related, returning to normal on control of the epistaxis and r e a s s u r a n ~ eEpi-
.~~
staxis patients with hypertension must be followed after control of the bleeding,
to ensure that blood pressure returns to normal on control of epistaxis because
some are found to have underlying hypertension requiring ongoing treatment.
46 TAN & CALHOUN

Renal Disease
Persistent epistaxis may be encountered in chronic renal failure patients
undergoing hemodialysis, but the true incidence remains unknown." Contribut-
ing causative factors may include elevated prostacyclin levels (platelet antiag-
gregatory activityy and prolonged use of low-molecular-weight heparin.54An
8% incidence of septa1 perforations has been noted in renal failure patients.
Localized irritation caused by turbulent air flow around the perforation could
also contribute to epistaxis in these patients.'

Alcohol
Heavy alcohol consumption increases the risk of epistaxis. The same platelet
reactivity inhibition that provides a protective effect for the coronary arteries
may also increase bleeding time, making epistaxis more difficult to 50

Bleeding risk, however, was not linearly related to alcohol consumption, with
those consuming 1 to 10 alcoholic drinks per week most affected and those
drinking more than 10 drinks per week less affected. Rebound of platelet activity
may explain this finding, but the mechanics have yet to be elucidated. The use
of NSAIDs did not confer an additional risk of increased bleeding

Coagulation and Vascular Abnormalities

Patients with hereditary conditions, such as hemophilia, von Willebrand's
disease, and thrombocytopenia, frequently experience epistaxis. Thrombocyto-
penia can also occur with hematologic malignancy, chemotherapy, or viral infec-
tions, such as dengue hemorrhagic fever2]and human immunodeficiency virus
(HIV),I5 or can be idiopathic.
Hereditary hemorrhagic telangiectasia patients are particularly prone to
epistaxis pr0b1ems.I~The abnormal vessel walls and focal endothelial degenera-
tion contribute to refractory epistaxis, which can be challenging to manage.
Treatment is aimed at decreasing the frequency of bleeds and need for transfu-
sion because permanent cure is not possible.

Medications

Numerous medications interfere with normal clotting. NSAIDs (including

aspirin) are probably the most common, with up to 75% of epistaxis patients
using one of these medication^.^^ One study found that 42% of epistaxis patients
were taking warfarin, dipyridamole, or NSAIDs versus 3% of the nonepistaxis
control group.hhThese medications interfere with the cyclooxygenase pathway
in arachidonic acid metabolism, inhibiting platelet a g g r e g a t i ~ n .One
~ ~ author
suggested that a history of epistaxis may be a relative contraindication to the
use of NSAIDS.~~ In addition, because 74% of aspirin use is self-administered,
the public needs to be made aware of the relationship between aspirin and
nosebleeds as potential side effects.2
Other medications associated with epistaxis include thioridazine, topical
hyperosmolar sodium chloride, and dipyridamole (Persantine). Epistaxis resolv-
ing when the drug is stopped has occurred with thioridazine. The nasal mucosal
drying from the anticholinergic effects of this low-potency phenothiazine, cou-
pled with home heating in the dry winter season in hypertensive patients was
thought to be the underlying cause of epistaxis.z2Dipyridamole inhibits adeno-
 EPISTAXIS 47

sine diphosphate and collagen-induced platelet aggregation, enhancing disag-

gregation and prolonging bleeding time.4zEpistaxis has also occurred in a patient
using hyperosmolar sodium chloride (2%) eye drops.2yThe patient developed
dry nasal mucosa, presumably from osmosis, when the eye drops arrived in the
nasal cavity via the nasolacrimal duct. The problem resolved when sodium
chloride ointment was substituted for the drops. Use of steroid nasal sprays can
also be complicated by epistaxis, which is usually mild and stops after cessation
of use of sprayz4

MANAGEMENT

There are three levels of epistaxis management: (1) first-aid measures, (2)
acute management, and (3) interventions.

First-Aid Measures

In one series of patients taking systemic anticoagulants, 25% had experi-

enced epistaxis in the previous year. Less than half of the patients”’ could think
of a single first-aid measure to stop nosebleeds. Clearly, additional education in
this at-risk population could reduce both morbidity and patient anxiety.
First-aid measures include the following:
1. Digital compression. Although so simple as to seem reflexic, fewer than
50% of emergency department personnel could describe the correct site
to apply digital pressure in a nosebleed (Fig. l).3RA swimmer’s clip has
also been used for epistaxis.62
2. Cotton or tissue plug in the nose. Patients often arrive in the office with
a piece of tissue pushed into the nostril that has been bleeding.
3. Bending forward at the waist. This position allows gravity to keep blood
flowing out the nostrils, rather than posteriorly down the throat.”
4. Spitting out any blood that trickles down the back of the throat. The
patient is prevented from swallowing large amounts of blood.

Figure 1. Digital compression over the nasal alar and anterior septa1 area is effective
against most anterior bleeds.
48 TAN & CALHOUN

5. Cold compress on nasal bridge. This practice has a vasoconstrictive ef-

fecV5

Acute Management

Hypotension associated with epistaxis can precipitate acute myocardial

events or aspiration, sometimes leading to death. The patient with an actively
bleeding nose is apprehensive and often has reactive hypertension, accentuating
the bleeding. The basics of airway, breathing, and circulation remain key princi-
ples. Securing the airway via endotracheal intubation or trachesotomy in the
severely injured unconscious patient allows suctioning and packing of the nose
and, if necessary, the oral cavity and pharynx. Oxygen ensures good systemic
oxygenation, especially important in patients with underlying cardiopulmonary
disease. Intravenous access is established in all patients presenting with active
epistaxis because significant bleeding has usually occurred before the patient
seeks medical attention. When inserting the intravenous line, it is usually conve-
nient to obtain blood for complete blood count and, if clinically indicated, type
and screen, coagulation profile, and electrolytes (in anticipation of surgical
intervention).
An assessment of the amount of blood lost is made from the history,
including the onset of the bleeding, precipitating factors, duration and quantity
(i.e., number of soaked towels), past history of epistaxis and treatment, and
history of blood dyscrasias. In adults, a history of medication (including
NSAIDs, anticoagulants), hypertension, ischemic heart disease, diabetes mellitus,
and alcohol abuse may influence management. In children, a history of epistaxis
with unilateral nasal discharge alerts the physician to the possibility of an
intranasal foreign body. Consent for blood transfusion is recommended. The
vital statistics (blood pressure and pulse) of the patient should be charted.
The patient is supplied with folded gauze 4 X 4 pads to soak up blood
trickling from the nose. A chart is started to keep track of the number of pads
required, as further assessment of the amount of blood lost.

Local Compression
Thumb and index finger nasal compression pressure is used as the first
measure by the physician while other treatments are being instituted. Local
finger compression should be employed for at least 5 minutes to allow formation
of a hemostatic plug over the bleeding vessel.

Cauterization
Most epistaxis originates in the anterior nasal cavity, often in Little’s area.
Effective local vasoconstrictive measures include pseudoephrine (Afrin), phenyl-
ephrine (Neo-Synephrine), or epinephrine (1:10,000) applied to the area on
cotton pledget.
The area of bleeding can be cauterized. Silver nitrate is the most convenient
cauterization agent, available in ready-made sticks. Local anesthesia with 4%
lidocaine solution (applied by cotton pledget for 5 minutes) can reduce the
stinging of cautery. Accurate identification of the bleeding points and a good
light for intranasal examination are the keys to successful cauterization. The
temptation to cauterize a large area of the septum to cover all bleeding points
should be resisted. The authors routinely use a cotton-tipped applicator to
 EPISTAXIS 49

mop up residual silver nitrate after application, to prevent local damage to the
underlying perichondrium. Postcautery, antibiotic cream or ointment is applied
to the cauterized area twice a day for 5 days to prevent crusting and infection.
Both sides of the septum should not be cauterized at the same time because of
the risk of septal perforation. Repeated cauterization in the same area can also
lead to septal perforations.

Other Measures
Other local measures include
1. Electrocautery.
2. Other chemical cautery (trichloroacetic acid).
3. Light packing with petroleum jelly (Vaseline) gauze.
4. Direct endoscopic electrocautery (detailed later).
5. Hemostatic chemical agents (thrombin-soaked absorbable gelatin pow-
der [Gelfoam], oxidized cellulose [Surgicel],microfibrillar collagen [Avi-
tene], porcine fat, oxymetazoline, or calcium alginate fiber [Kaltostat]).
6. Oxymetazoline hydrochloride (an imidazole derivative) is a topical va-
soconstrictor commonly used as a nasal decongestant.28Of 60 patients
coming to an emergency department with epistaxis, there was a 65%
success rate with oxymetazoline alone. A further 18% of patients re-
quired silver nitrate cautery, and the remaining 17% required nasal pack-
ing.
7. Cryotherapy. This procedure for applying cold temperatures within the
nose to control epistaxis reportedly has less morbidity than other local
methods.zo It requires a machine capable of delivering the necessary
temperature to freeze the target tissues.
8. Hot-water irrigation. Success in treatment of epistaxis has been reported,
although patient compliance is variable.5h
9. Desmopressin (1-desamino-8-D-arginine vasopressin) spray. Desmopres-
sin spray has been effective in decreasing the duration of e p i s t a x i ~and
~~
Ehlers-Danlos syndrome.s7
10. Laser therapy, diathermy, septodermoplasty, and other surgery. Surgery
has been advocated for hereditary hemorrhagic telangiectasia with vari-
able success.'", 4y, 63

Anterior Nasal Packing

Packing is needed when local measures are unsuccessful in controlling
epistaxis. Nasal packing is an uncomfortable procedure and can have life-
threatening complications, anterior packing less so than combined anterior-
posterior packing. Classic anterior packing is performed with Vaseline-impreg-
nated narrow gauze, placed in the nose until sufficient pressure exists to tampon-
ade the bleeding. Although the tidy textbook diagrams of layered packing are
somewhat misleading, the general goal is to place the packing from the back
and bottom of the nose forward. A training model for nasal packing has been
reported to improve confidence and competence in the procedure.5y
Other options for anterior nasal packing include synthetic sponge packs
(tampons) such as Merocel that expand when moistened or balloon packing.
Merocel packs are easy and quick to insert and can be used for bilateral epistaxis
as well. The success rate of such packing exceeds 90%, even when performed
50 TAN & CALHOUN

by inexperienced physician^.^^ Both nasal tampons and gauze packing are effi-
cacious and well t~lerated.~
After anterior packing, the oropharynx is inspected. If blood is still visible
trickling from the nasopharynx, either the anterior pack is suboptimally placed,
or there is a posterior nasal bleeding source. The nasal cavity measures about
7 cm from columella to nasopharynx, so the most common error in anterior
nasal packing is failure to pack adequately the posterior aspects of the anterior
nasal cavity.
Adequate lighting and long forceps (bayonet or Tilley's nasal packing for-
ceps) are necessary for placement of an effective anterior gauze pack. Gauze
coated with BIPP (bismuth iodoform paraffin paste) can be left in the nasal
cavity for up to a week with low risk of infection. Vaseline gauze packing is
usually removed by 72 hours. Antibiotic prophylaxis is usually administered.
Elderly or frail patients with anterior nasal packing and most patients with
posterior nasal packing should be hospitalized for oxygen supplementation,
intravenous hydration, bed rest, and mild sedation. Because bilateral nasal
packing obstructs the nose and prevents nasal breathing, it often causes hypo-
oxygenation. Anterior-posterior nasal packing with sedation is accompanied by
decreased arterial oxygen tension and altered pulmonary mechani~s.~ Oxygen is
usually administered via face mask with anterior and posterior packing (unless
the carbon dioxide is elevated). Sedation is carefully titrated, keeping in mind
the patient's cardiopulmonary status.
Other materials used for nasal packing include Kaltostat, Ativene, and
porcine fat (salt pork). A randomized trial comparing Kaltostat and bismuth
tribromophenate (Xeroform) showed similar efficacy and patient a c c e p t a n ~ e . ~ ~
Ativene successfully controlled 77% of idiopathic anterior epistaxis and can be
useful in hereditary telangiectasia epistaxis60Salt pork has been used for nasal
packing in patients with thrombocytopenia, commonly secondary to renal failure
or medications. Homogenates of salt pork contain an aqueous factor that serves
as a platelet substitute, inducing platelet aggregation and enhancing adenosine
diphosphate and collagen-induced aggregation. The pork fat is less irritating to
the mucosa on removal than gauze This material is not used in patients
who avoid pork for religious reasons.

Posterior Nasal Packing

Only about 5% of epistaxis originates from a posterior nasal source." The
posterior nasal space is cylinder shaped, opening anteriorly into the nasal cavity
and posteriorly into the nasopharynx. Packing in this space tends to fall back
and down, into the oropharynx. To pack the posterior nasal cavity, a conforming
pack is first placed in the nasopharynx, secured anteriorly near the nostrils.
Gauze or other anterior packing can then be firmly placed against this resistance.
Classically a posterior pack is made of rolled gauze secured with umbilical
tape, although balloon packs are sometimes used (Foley catheter, Brighton Bal-
loon, Simpson Balloon). Posterior pack insertion begins with passing a rubber
catheter through each nostril, into the oropharynx. They are grasped here and
brought out anteriorly through the mouth. Long ties attached to each side of the
gauze pack are attached to the catheters, and the catheters are gently withdrawn
through the nose, leaving a gauze pack held in the physician's hand, with the
attached long ties entering the mouth and exiting both nostrils. With gentle
traction on the nostril ends, the pack is pulled and pushed into the oropharynx,
then tucked up into the nasopharynx. The mouth ends of the ties are left long,
to be grasped later and used in pack removal. The nostril ends are secured
 EPISTAXIS 51

anteriorly, usually around the columella. Care is taken to pad and protect
the columella from excessive pressure that could cause ischemic necrosis. This
unpleasant procedure can be performed under mild sedation, but use of general
anesthesia when possible is a kindness to the patient. Posterior packs are usually
left in place for 48 to 72 hours because earlier removal is associated with an
increased risk of rebleeding.
An alternative to posterior packing with gauze is balloon catheters inserted
in the nasopharynx via the nostrils and inflated with sterile water. The balloons
are secured anteriorly using a clamp (e.g., umbilical cord clamp). Either Foley
catheters or balloons designed specifically for the nasopharynx can be used. The
balloons have a tendency to deflate with time, and volume can drop by 30% or
more in 72 The authors usually deflate the balloons at 48 hours and
remove both anterior and posterior packings at 72 hours.

Complications of Nasal Packing

Nasal packing can be complicated by death.5 Aspiration of blood, cardiopul-
monary failure secondary to hypoxia, and toxic shock syndrome have led to
mortality in patients with epistaxis. Complications in nasal packing include
1. Nasal trauma from the packing.
2. Nasal-vagal response (bradycardia, hypotension, apnea).
3. Dislodged packing.
4. Aspiration.
5 . Persistent bleeding.
6. Infection, toxic shock syndrome.
7. Hypoxia resulting from nasal obstruction-may result in myocardial in-
farction, disorientation.
Most complications can be avoided if anticipated. Firm and gentle packing
avoids excessive nasal mucosal trauma. Sedation is kept to the minimum neces-
sary to decrease aspiration risk and respiratory suppression. Oxygen should be
given when there are no contraindications. All patients receive prophylactic
antibiotics.
Toxic shock syndrome occurring with nasal packing can cause significant
morbidity and mortality. More than one third of patients undergoing nasal
packing are Staphylococcus aureus carriers. Comparison of NuGauze packs to
Merocel packs removed from patients’ noses revealed NuGauze grew out sub-
stantially more s. a ~ r e u s This
. ~ may occur because Merocel is a single homoge-
neous structure, whereas NuGauze packing has interstices and folds of varying
sizes that more readily pool secretions. Toxic shock syndrome begins with fever,
vomiting, diarrhea, hypotension, and body rash secondary to the production of
TSST-1, the primary toxin causing toxic shock syndrome. S. aureus is often
sensitive to bacitracin, so use of this intranasally can help prevent toxic shock
syndrome. Oxytetracycline and polymyxin B can also decrease the number of
bacterial strains cultured from packing used for nasal packs.”

Interventions

Surgery
Endoscopic Cauterization. Endoscopes have revolutionized sinonasal sur-
gery over the past two decades. In the management of epistaxis, use of the
52 TAN & CALHOUN

endoscope can permit identification of posterior bleeding sites, which can then
be directly cauterized, avoiding packing.12,51 It is especially useful in patients
who continue to bleed through well-placed nasal packs.
For these patients, the packings are usually removed when the patient is
under general anesthesia. The nasal cavity is cleansed and endoscopically exam-
ined. Common bleeding sites include the region of distribution of the sphenopal-
atine artery, posterior end of inferior turbinate, posterior-inferior septum, and
anterior sphenoid face. The suction electrocautery is useful. In the rare cases in
which no bleeding sites are located, Merocel packs are placed for 48 hours.
The authors have been using endoscopic examination in the outpatient
setting with selected patients. Using good topical anesthesia and mild sedation
and a suction/electrocautery unit, some more posteriorly placed bleeding points
can be identified and cauterized with minimal patient discomfort. Many of these
patients would traditionally have required nasal packing and hospitalization, so
avoidance of this is popular with both patients and managed care companies.
Arterial Ligation. Arterial ligation decreases arterial blood flow to the
bleeding area. Commonly ligated supplying branches include the internal maxil-
lary artery (terminating as the sphenopalatine artery) and the anterior ethmoidal
artery. Ligation of the external carotid artery is also possible, although uncom-
monly needed.
Posterior epistaxis is usually supplied by the terminal branches of the
internal maxillary artery. The third part of the internal maxillary artery courses
behind the maxillary antrum to the sphenopalatine foramen at the superomedial
sinus. As the internal maxillary artery exits the sphenopalative foramen, it
divides into medial (to the sphenoid/septum) and lateral (lateral nasal wall)
divisions. The transantral (via the maxillary antrum) approach allows ligation
just before the terminal branching. Traditionally the transantral approach in-
volved the removal of anterior wall of the maxillary sinus (Caldwell Luc) for
surgical access.hThe microscope is used for dissection behind the posterior wall
of the antrum. The endoscope has provided an alternative approach with less
morbidity, although it is technically more difficult (Fig. 2).68
Ethmoidal arterial ligation is performed when bleeding arises in the supe-
rior nose (above the middle turbinate). Ethmoidal artery ligation uses a curved
incision around the medial canthus. The globe is retracted away from the lamina
papyracea, and the anterior ethmoidal artery is encountered about 24 mm from
the anterior lacrimal crest. The vessels are clipped and ligated under direct
vision. Patients with intractable epistaxis without an identifiable bleeding point
may benefit from ligation of both the anterior ethmoidal artery and the internal
maxillary artery.
Embolization. An alternative to surgical ligation is embolization of external
carotid artery branches.", 26, 58 This procedure is particularly useful in patients at
high risk for a general anesthetic or with unfavorable anatomy (small maxillary
antra).47Embolization is successful in up to 96% of cases, although vascular
anatomic variations limit application in some cases. One benefit of embolization
over arterial ligation is that more selective blockade of smaller branches is possi-
ble.
Complications of embolization include up to 6% of neurologic sequelae. The
risk of particulate material embolization to the internal carotid systems has been
minimized by the current use of microcoils.13

Blood Transfusion
With the risk of disease transmission through blood products increasing,
epistaxis is treated to minimize the need for transfusion. Nasal packing has been
 EPISTAXIS 53

Figure 2. A, Endoscopic view of the posterior wall of a left maxillary sinus that has been
opened showing the internal maxillary artery ligated by clips. B,Schematic diagram of A.

the first-line treatment of patients whose bleeding cannot be managed on an

outpatient basis. Packing provides a tamponade and encourages thrombosis of
vessels. There have been signs of this shifting toward early and prophylactic
One study compared the cost of hospitalization with nasal pack-
ing to hospitalization with surgical intervention and reported a higher cost and
complication rate with surgical intervention. These patients, however, received
surgical intervention only after failing nasal packing. There was a 27% transfu-
sion rate (3 units per patient) with nasal packing compared with 41% (5.8 units
per patient) with nasal packing failure and subsequent surgery. Another study
also noted a greater transfusion requirement with surgical intervention than
without (0.91 units versus 2.93 units, P<.01).53These authors suggest that pa-
54 TAN & CALHOUN

tients requiring more than 3 units of blood should be considered for surgical
intervention. The cost a n d risk of surgical intervention m u s t be weighed against
the risks of transfusion a n d compromised cardiovascular status if rebleeding oc-
curs.
Dealing with a patient w i t h active severe epistaxis can be bloody. The
authors recommend universal precautions for all health care personnel involved
in the care of these patients, including face mask with shields, gowns, hair
coverage, a n d double-gloving.

SUMMARY

Epistaxis is a common clinical problem. The widespread availability of

endoscopic equipment is shifting management philosophy toward targeting the
bleeding point. This shift may have a significant impact on decreasing length of
stay a n d blood transfusion rates. Advances i n interventional radiology have also
reduced the risk of embolization. Patient education, especially teaching first-aid
measures to patients a t high risk for nosebleeds, also encourages more effective
use of health care resources.

ACKNOWLEDGMENTS
The authors thank Carol Chan for her assistance with the illustrations.

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Address reprint requests to

Karen H. Calhoun, MD
Department of Otolaryngology
University of Texas Medical Branch
Galveston. TX 77555-0521