Nose Bleed (epistaxis)

Author: Dr Andrew H Murr University of California San Francisco 2008-07-28

INTRODUCTION

Epistaxis is another name for a nose bleed. Nose bleeds are extremely common and are usually minor. However, some people experience either recurrent nose bleeds or persisting nasal bleeding that will not stop despite typical measures. If this happens, a visit to a doctor or even an emergency department may be necessary. Rarely, nose bleeds may be a sign of other disease processes that need attention. This Knol is dedicated to improving the understanding of factors that contribute to the fairly common phenomenon of nasal bleeding.

BACKGROUND

What is the function of the nose? The nose has several purposes. The American Rhinologic Society is an organization that boasts a membership consisting of numerous physicians who have a solid professional interest in the nose and is a good source of information regarding various disease processes and the six functions of the nose: http://www.american-rhinologic.org/patientinfo.purposeofsinuses.phtml

1. The nose is first and foremost an entry point for the air which we breathe.

2. However, the nose is also tasked with processing this air before it enters the lungs. It is a very efficient humidifier, which adds moisture to dry air.

3. It is also a filtration apparatus: the nose produces about two liters of mucous per day. This mucous traps particulate matter and prevents particles from entering the lungs. Instead, the mucous is swallowed and impurities breathed in through the nose are shunted to the stomach and safely expelled by the gastrointestinal system.

4. The nose is also a radiator which warms air, preventing frigid air from irritating the lungs.

5. The nose is the seat of the sense of olfaction which adds to our enjoyment of food and is connected to the most ancient brain centers which govern emotion. Olfaction is a very important sense, and affects well being. A glimpse at the perfume and food and beverage industries highlights the importance of olfaction in our society. Nevertheless, olfaction is often at its root a safety factor that prevents the ingestion of spoiled food that would cause illness.

6. Finally, the nose and sinuses add resonance to the voice.

In order to accomplish these six functions, the nose is extremely well supplied with arterial blood. In fact, the blood supply to the nose is from both the external carotid system and the internal carotid system. A large percentage of the blood circulated by the heart is sent to the carotid arterial system.The internal carotid system is a major blood supply to the brain.

The external carotid blood supply to the nose is somewhat variable from person to person, but in general there are two key main arterial sources: the internal maxillary artery and the facial artery. This website shows the external carotid, internal maxillary artery branches: http://en.wikipedia.org/wiki/Image:Gray511.png . The internal carotid artery supplies blood to the nose through the ophthalmic artery which gives off branches to the nose at the skull base. These branches are the anterior ethmoid artery and the posterior ethmoid artery. This website shows the branches of the internal carotid artery that supply the nose: http://en.wikipedia.org/wiki/Image:Gray514.png

The nasal septum is the midline wall of the nose that separates the left side from the right side. It is constructed of several bones, including the maxillary crest of the maxilla, the vomer, and the perpendicular plate of the ethmoid bone. In addition, the front of the septum consists of a piece of cartilage called the quadrangular cartilage. Although the external carotid artery and the internal carotid artery system supply blood to the nasal septum, because the septum is a midline structure, if the vascular supply becomes attenuated it is possible for the septum to become starved for blood. If this happens, a part of the septum will die away and leave a hole in the septum which is called a septal perforation. Nevertheless, the septum usually has a lot of small blood vessels supplying it; especially near the nostril or entrance to the nose, which doctors call the caudal septum. In fact, these vessels are so commonly seen on the front of the septum that the vessels themselves have a formal name: Kiesselbach’s plexus. The plexus is located in the front portion of the septum which is also named: Little’s Area. An indication of how common epistaxis occurs can be gleaned from the fact that these small details of anatomy carry formal names!

The inferior turbinates are on the outside wall of the nasal cavity and are the mucosal covering of the inferior turbinate bone. If one tries to look into the nostril, this is the lump that is seen on the outside wall of the nostril. If enlarged, the inferior turbinate may be confused with a polyp or tumor. The primary function of the inferior turbinate is to humidify and warm air. It acts like a fin on a radiator designed to disperse heat. The inferior turbinate has venous lakes within it that allow it to function well. Whereas arteries carry blood in a high pressure system, the venous system is the one that returns blood to the heart after the oxygen has been removed. The venous system is a low pressure system. This website has some good anatomic information for those who are interested in further studying the details of anatomy of the nose and sinuses: http://www.dartmouth.edu/~humananatomy/part_8/chapter_52.html#chpt_52_nasal_cavity

TYPES OF NOSE BLEED

Epistaxis can be divided into anterior and posterior types. Anterior epistaxis is generally due to localized bleeding from the mucous membrane lining in the front or caudal part of the nose. Local irritation is often a main factor, and these bleeds are usually a little easier to control. Posterior epistaxis is generally more severe and often due directly to an arterial source. Emergency room consultation and more invasive treatments are often required due to the vigorousness of the bleeding and the blood volume loss.

CAUSES OF NOSE BLEED

Nose bleeds seem to be embarrassing. Why? In general, nose bleeds are commonly believed to be related to “nose picking” which is considered to be a vulgar habit by Western society. Sometimes, nose bleeds are due to nose picking. Children, especially, are not constrained by notions put forth by Western society and if they feel a mucous crust in their nose otherwise commonly termed a “booger” they simply use their finger to remove it. Job done! Check out this site for an extreme example: http://www.artie.com/20030826/arg-nose-picker-207x165-url.html Adults are usually more circumspect about removing mucous crusts from their nose, at least in public. Repetitive removal, especially with sharp finger nails, can traumatize the mucous membrane lining of the nasal septum with its rich blood supply. This can lead to scab formation which increases the amount of crusting experienced and becomes a set up for a repetitive cycle of manipulating the nose and the crusts. If a small nick occurs in the lining then bleeding will ensue. Clots form and create more crusting. This results in more awareness of nasal obstruction and discomfort and more activity to pick the nose to remove the crust. Again, it is embarrassing. This is termed anterior epistaxis which denotes an irritated anterior septum and nose picking resulting in trauma usually caused by a person’s own finger. Alternatively, repetitive nose blowing and wiping of the nose with a tissue or handkerchief can also begin to irritate the front of the nose and cause bleeding. This is often seen after several days of a typical viral cold which causes a stuffy or runny nose. Someone with a viral upper respiratory infection (cold) will often go through several boxes of tissues in a day during the height of their symptoms. Eventually, the septum can become irritated and bleeding may occur. The common denominator is that there is repetitive manipulation which causes trauma to the anterior or caudal septum which breaks the mucous membrane lining of the septum and results in bleeding. Because, society views nose bleeds as likely evidence of nose picking to the point of traumatizing the nose, there can be derisive humor associated with nose bleeds. The movie Weekend at Bernie’s has a memorable scene where a nose bleed occurs in a humorous setting. (http://movies.nytimes.com/movie/53753/Weekend-at-Bernie-s/overview) Because of the shame which accompanies the problem, patients often try valiantly to take care of the problem themselves. People will stuff Kleenex into their nose, hold pressure on their nose, place ice on the bridge of their nose, or even put a clothes pin on their nose. Holding pressure will often stop the acute bleed, but will not do much good for the underlying problem that caused the bleeding in the first place. In many parts of the United States, nose bleeds are known to be more common in the colder winter months. This is the time when homes are heated and the cold air in the atmosphere can be dry. This causes the nose to increase its need to provide a humidification and warming function and mucous membranes are apt to be dried out from this need to exchange more moisture with the air. People are often unaware of this phenomenon and may be slightly dehydrated because of it. During cold, dry weather extra fluid intake is important to counteract losses of moisture which are not readily apparent to the person in the environment. At least in the summer, people seem to know to drink more fluids when they sweat. Nevertheless, this is far and away the most common type of nose bleed: routine anterior epistaxis due to digital trauma on the anterior caudal septum known as Little’s Area from the bleeding vessels of Kiesselbach’s plexus.
Certain medical conditions or co-factors can take routine anterior epistaxis and turn it into a more severe or persistent problem. Patients taking aspirin (acetylsalicylic acid) for its cardiac benefits will have a mild tendency to bleed more. This anticoagulation is due to the salicylate affecting the platelet cells in the blood which are responsible for initiating the structure of blood clots. By inhibiting blood clot formation, aspirin initiates a condition where bleeding is more likely to persist and can be a factor when patients experience more severe nose bleeds. Many patients take commonly available forms of aspirin for other medical problems, such as arthritis, headaches, or sports related injury. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) like Advil or Motrin (ibuprofen), Naprosyn (naproxen), Toradol (ketorolac tromethamine) and many others have the same mechanism of action as aspirin.

Many patients take Coumadin for various medical problems. Coumadin affects the clotting cascade and prevents clots from forming on indwelling stents and heart valves. Coumadin is also used to prevent spontaneous clot formation called emboli in patients who have a tendency toward this problem. The benefit of Coumadin in preventing problems relating to these disorders may also cause routine anterior epistaxis to become more severe than typically expected.

Certain herbal medications or supplements may also perpetuate bleeding such as Gingko Biloba. If nose bleeding is becoming a problem, it is important to disclose to your doctor all supplements that are a part of one’s daily routine because it is possible that they may be part of the underlying problem. A comprehensive review of precautions when taking Gingko Biloba can be found at http://www.umm.edu/altmed/articles/ginko-biloba-000247.htm#Precautions

High blood pressure may be a factor in epistaxis. The association may be like a chicken and egg analogy, in other words, is the high blood pressure the cause of the bleed or did the development of the bleed cause the patient to have a spike in the blood pressure? In any case, in a patient who has a tendency toward nasal bleeding, medical control of the high blood pressure is necessary to allow the best chance of controlling the bleed.

Foreign bodies may lead to nose bleeding. In children or mentally disabled adults, a foreign object may be placed into the nose and may not be recovered. In children, plastic parts from toys or even food may be placed into the nasal cavity and may be lost. Usually, infection and foul unilateral nasal drainage will occur. The drainage may be bloody or cause frank erosion of the nasal lining, which in turn causes more acute bleeding. In the hospital setting, foreign bodies such as oxygen catheters or nasogastric or nasotracheal tubes may be a source of erosion inside the nose and lead to bleeding. Sometimes, traumatic placement of a tube may also result in a tear in the lining of the nose and subsequent bleeding.

A dry environment will place a greater demand on the humidification function of the nose and may lead to insensible fluid losses. Insensible loss is dehydrating fluid loss that is not apparent to the individual. Because the person does not realize that they are becoming dehydrated, they do not adequately replace fluid and the dryness is perpetuated. This can lead to crusting of the nose, trauma, and then subsequent bleeding.

Systemic diseases: certain types of systemic diseases can cause nasal conditions that lead to epistaxis. The common factor in these diseases is that they lead to nasal crusting and dryness, although the ultimate cause of the underlying diseases are different. Patients with sarcoid can have nasal and sinus involvement that leads to crusting and even septal perforation. Wegener’s is a granuloma type of disease that can involve the nasal lining and destroy the internal function of the nose. Sjogren’s syndrome is manifested by decreased salivary gland function and can lead to dryness with nasal implications.  Often, these types of systemic diseases will be suspected if the nasal bleeding is persistent and if nasal examination reveals unusual crusting or drying of the nasal lining.

Benign tumors : polyps of different etiologies may develop in the nose and may eventually cause bleeding. The most common nasal polyp is an inflammatory type of nasal polyp. It is very difficult to discern the exact cause of nasal polyps in most individuals. If a polyp becomes desiccated or is traumatized, bleeding can develop. Associated symptoms of this type of inflammatory polyp include bilateral nasal obstruction, nasal pressure and fullness, and decreased sense of smell. Another type of nasal tumor that is relatively common is called an inverted papilloma. Inverted papilloma is related to the Human Papilloma Virus. This type of benign polyp occurs typically on only one side and may present with bleeding and one-sided nasal obstruction. Biopsy is necessary for diagnosis. Other types of papilloma may also occur, including fungiform papilloma, which is similar to a common wart. Juvenile Nasopharyngeal Angiofibroma is a type of tumor that appears exclusively in males and can present with vigorous nasal bleeding from an anterior nasal mass. This tumor is generally derived from the artery branches of the internal maxillary artery and the treatment of the problem usually involves surgical resection of the tumor.

Cancer : there are different types of cancers that can occur in the nose but there are also types of cancer that affect the blood cells and set up conditions that can cause bleeding. Cancers that originate in the nose are of varying types. Adenocarcinomas are known to occur in people exposed to sawdust and wood particles. Melanomas are rare in the nasal lining, but can present with bleeding as a primary symptom. Squamous cell carcinoma can occur in the nose or arise from a previously benign polyp or papilloma. Lymphomas, especially T-cell types, can occur in the nose. All of these types of tumors can have bleeding as an associated symptom, but they usually have other symptoms as well, like nasal obstruction or blockage. Cancers associated with blood cells include many different types of leukemia. When the leukemia affects the ability of the body to produce functioning platelet cells, spontaneous and persistent bleeding can occur from many sites of the body. Nose bleeds in a person with easy bruising, fatigue, black and blue marks, and easily bleeding gums may raise the question of the existence of leukemia or another type of blood disease.

Nasopharyngeal cancer is a special type of tumor that occurs in the space behind the nose, near the opening of the Eustachian tube. This type of cancer is typically an undifferentiated type and is related to the Epstein-Barr virus. It is very common in parts of Asia, especially the southern provinces of China. The World Health Organization has divided nasopharyngeal carcinoma into two main types: Type 1 is a regular squamous cell carcinoma and is sporadic. Type 2 is classified as Type 2A or 2B and is related to Epstein-Barr virus infection, with Asian geographic distribution. Nasopharyngeal carcinoma can present as nasal bleeding and is often accompanied by one-sided hearing loss due to fluid forming behind the eardrum on the affected side. Nasal obstruction on one side especially is also a symptom consistent with nasopharyngeal carcinoma. The World Health Organization has some interesting information pertaining to the eventual development of vaccines to treat Epstein-Barr virus related problems: http://www.who.int/vaccine_research/diseases/viral_cancers/en/index1.html
Physical Trauma: trauma to the nose, whether from a fist or from participating in sports, or as a result of falls can lead to immediate nasal bleeding. This bleeding is often quite vigorous but can usually be stopped by holding pressure on the nose and by placing ice on the nasal bridge. The mechanism of the bleeding is often related to nasal septal fracture combined with a tear in the nasal lining. If blood accumulates under the nasal septal lining, a septal hematoma can occur. A septal hematoma is an emergency because the presence of blood under the nasal lining balloons up the septum and starves it from oxygen that is delivered to the septal cartilage from its lining. If a septal hematoma is not drained, loss of the septal cartilage is likely. Assuming that a septal hematoma does not develop, the management of a septal fracture is usually to just observe it over time. Occasionally, nasal obstruction will occur and a person will seek surgical correction or improvement of a deformity that results from severe trauma. Almost always, the bleeding is self limited and does not continue to bother people long term.

Septal perforation is a term used to describe a hole between the left and right sides of the nose through the midline wall or septum. A septal perforation can lead to chronic bleeding because the flow of inspired air can become turbulent due to the perforation. This decrease in organized air flow can dry out the edges of the perforation and cause crusting and irritation of the nasal lining. Chronic bleeding in relatively small amounts can result. Septal perforations can be caused by trauma, past nasal surgery, illicit substance use in the nose, systemic diseases, overuse of over-the-counter decongestants, or chronic nose picking or manipulation. It may be possible for septal perforations to occur spontaneously due to a poor vascular supply. Placement of nasal packing or tubes in the nose may also result in perforation of the septum. Septal perforations may cause symptoms including nasal obstruction, crusting, whistling of air, or bleeding, but they may also be completely asymptomatic.

Liver dysfunction due to hepatitis, alcoholism, liver cancer, or other hepatic diseases can affect the production of clotting factors and secondarily predispose patients to bleeding from the nose.

Hemophilia is a specific disorder of blood clotting that can prolong bleeding from any site in the body. A minor amount of trauma to the nose that occurs in people with hemophilia may lead to persistent bleeding out of proportion to the inciting incident.

Hereditary Hemorrhagic Telangiectasia - Weber, Osler, Rendu Syndrome is a genetic disease that usually runs in families. A support Web site exists for this problem: www.hht.org/ This disorder is characterized by small blood vessel abnormalities resulting in many small knots of vessels called telangectasias that form all over the body. For some reason, they have a propensity to occur on the nasal septum. The telangectasias lack a smoothe muscle layer in the wall of the blood vessels and are easily traumatized causing chronic and recurrent nosebleeds. Patients with this disorder will have a lifetime history of recurrent nose bleeds that tend to worsen with advancing age. Often they will have a history of multiple emergency department visits, multiple episodes of nasal packing and manipulation, and even a history of multiple blood transfusions.

Illicit substance use in the nose can destroy the nasal lining and septum. Illicit drugs like cocaine, methamphetamine, and heroin are often “cut” with noxious chemicals like boric acid and other white powder substances. Even so, these substances cause constriction of blood vessels which lead to a chronically poor blood supply to the nose. Eventually, the structure of the nose slowly dissolves causing septal perforations and an inability of the nose to perform its humidifying and warming functions. Chronic bleeding may result. In addition, because drugs like cocaine anesthetize the nose, people who abuse the drug often unconsciously manipulate the nose, which can lead to repetitive trauma and bleeding.

Over-the-counter medications like oxymetazaline or neosynephrine or other nasal-inhaled drugs also cause chronic constriction of blood vessels and over time can lead to septal perforation and nasal bleeding. Direct irritation of the nasal lining by spraying the drug may also cause direct trauma to the nasal lining with subsequent bleeding.

Prescription drugs delivered via nasal inhalation such as topical nasal steroids or antihistamines or other inhaled drugs can case direct mechanical drying or direct trauma to the nasal lining which can lead to nasal bleeding.

Smoking may be a risk factor for nasal bleeding due to its drying effect, especially in winter time. Smoking may also increase the risk of atherosclerotic deposits in blood vessels, including those that supply the nose. If these plaques erode, nasal bleeding can result. This risk is long term.

Vascular malformations such as arteriovenous malformations or hemangiomas can occur in the nose and cause bleeding.

Nasal surgery such as septoplasty, rhinoplasty, sinus surgery, or adenoidectomy may result in post-operative nasal bleeding due to the direct manipulation that occurred during the surgery.

Sinusitis is not typically a cause of nasal bleeding, but nasal manipulation with tissues or nasal irrigation of the nose favored by some sinus sufferers may cause local nasal trauma that can lead to bleeding.

Non-humidified oxygen delivery , especially if done via nasal cannula, can dry the nasal lining, traumatize it, and lead to nasal bleeding.

POSTERIOR EPISTAXIS

Posterior Epistaxis is nasal bleeding that originates from the back of the nose. An excellent resource, especially for physicians to understand this problem, is available at http://entlink.net/education/COOL/epistaxisintro2.cfm A posterior epistaxis incident is presumed to occur when an anterior source of bleeding cannot be identified and when the bleeding is quite vigorous and consistent with an arterial source. Posterior epistaxis is generally thought to be caused by an erosion of a branch of the internal maxillary artery or by erosion of the anterior or posterior ethmoid artery. Typically, posterior epistaxis cannot be completely controlled by direct pressure or other local means to stem the bleeding and an emergency room or doctor’s office visit ensues.

Atherosclerosis deposits in the arterial supply vessels of the nose are thought to predispose to vessel wall erosion and be a risk factor for posterior epistaxis.

THE DOCTOR’S OFFICE VISIT

People who suffer from repetitive but nonemergent nose bleeds will often seek the advice of a doctor. A good site that describes expectations for the initial visit is at http://familydoctor.org/onlinefamdocen/home/healthy/firstaid/basics/132.html In the doctor’s office, an exam will usually include a brief inspection of the nose and throat. Tests that can be ordered by the doctor to investigate bleeding include blood tests to check on the hemoglobin level, blood tests to check platelet and other blood cell count numbers, tests of the coagulation cascades, and tests to check of liver function. Sometimes, your blood will be typed and cross-matched in order to have information ready if a blood transfusion becomes a consideration. A sinus computerized tomography (CT) x-ray may be ordered to check the nasal and sinus structure. If the nasal bleeding remains a problem, a consult with an otolaryngologist-head and neck surgical sub-specialist may be ordered. The otolaryngologist will take a history and perform a directed physical examination. Often, the otolaryngologist will look inside the nose and throat with a flexible fiberoptic endoscope to allow better inspection of the nasal lining, nasal septum, and the nasopharynx. An otolaryngologist is likely to order CT imaging if problems persist to look for structural or other abnormalities of the nose.

TREATMENT OF EPISTAXIS

ANTERIOR EPISTAXIS

Nonemergent: Recommendations for treating epistaxis usually center on reversing the dryness and other mitigating factors that lead to the conditions that set up the bleeding in the first place. Recommendations to hydrate with water, to use a humidifier at the bedside, and to stop taking aspirin or other NSAIDs are first steps. Use of Vaseline-based nasal ointments, some of which contain antibiotics, are frequently recommended. The ointment is placed on a Q-tip and smeared onto the front of the septum twice per day. This helps moisten crusts and heal abrasions. Decreasing Coumadin or removing other drugs that predispose to thinning blood may be recommended. Use of topical vasoconstricting over-the-counter medication such as neosynephrine or oxymetazoline may be recommended for short periods of time. Testing for platelet cell dysfunction or other blood disorders may be done at this time. If bleeding persists, usually an otolaryngology-head and neck surgery consult is recommended. The otolaryngologist can emphasize the above treatment but can also accomplish an examination that helps to rule out some of the more esoteric disease processes listed above. Diseases like nasopharyngeal cancer, Weber-Osler-Rendu syndrome, and sarcoid will have directed treatments that are beyond the scope of this discussion. For anterior epistaxis due to local problems, a visual inspection may find prominent blood vessels in Little’s Area or local drying conditions that need directed treatment. Treatment may consist of cauterization of the nose, a process by which the blood vessels are sealed through surgical burning. This can be done with electrical cautery, lasers, or even silver nitrate cautery sticks. Nasal packing may be recommended using certain types of hemostatic gels or other products. A CT scan may reveal a nasal or other mass, or evidence of a septal abnormality or deformity. Inspection of the other parts of the airway like the larynx may rarely reveal the presence of an unexpected mass or lesion. Surgery is sometimes recommended to accomplish a laser cautery or for biopsy of a mass or lesion.

Emergent anterior epistaxis : if bleeding is so vigorous that the individual can not stop it with pressure or local home measures, an emergency room or doctor’s office visit is necessary. Before going to the emergency room, several maneuvers can be tried to stop the bleeding. Pressure can be held on the nostrils to try to stem the flow of blood. Ice can be placed on the bridge of the nose to try to constrict the blood vessels supplying the nose. Over the counter vasoconstrictive spray such as neosynephrine ½% or oxymetazolene spray can be applied topically to the nasal lining to help stop the bleeding. Sometimes, blowing your nose to remove the clots is beneficial to try to help stop the bleeding. In the emergency room setting, an intravenous catheter will be placed and fluids will be given to replace lost blood volume and to re-hydrate. Laboratory values will be checked to ascertain the number of platelet cells, the hemoglobin level, and the clotting cascade function. Liver function studies should be drawn to look into liver disease. Often, patients will be blood typed and blood replacement will be lined up if a need for transfusion arises. Blood pressure will be taken and controlled if elevated. The first step in managing emergent epistaxis is to blow or suction blood clots out of the nose into a towel and to spray a vasoconstrictor like neosynephrine spray into the nose, and then hold pressure. This will stop most bleeding. Inspection may or may not reveal an obvious anterior bleeding source. If a source is found, cautery can be used to help control the bleed. If a source is not found and local pressure does not stop the bleeding, packing may be considered. Nasal packing consists of a variety of substances that are designed to hold direct pressure in the nasal lining. Traditional packing consists of ½ inch by 72 inch Vaseline gauze packing placed on each side of the nose. That is, 6 feet of packing on each side of the nose. This website has a nice diagram of the placement of Vaseline gauze packing: http://www.emedicine.com/proc/images/79926-79932-80526-109942.jpg More modern packing materials consist of different types of manufactured sponges that expand when exposed to a liquid such as saline or neosynephrine and gently hold pressure on the septum and lateral wall of the nose. These two website show nice diagrams of sponge type packing: http://www.xomed.com/xomed_products_meropack.html and http://www.shippertmedical.com/makepage.php?key%5B1%5D=library&key%5B2%5D=art_pachist . Dissolvable packing materials are also available that do not need to be physically removed after placement. Hemostatic gels can be helpful in stopping troublesome nose bleeds. If packing does not work, pressure balloons are sometimes used. Pressure balloons consist of catheters with a balloon attachment. The balloon is deflated in the package and so the catheter can be placed into the nose and then expanded with either air or saline. The direct pressure of the balloon on the nasal lining will stop the vast majority of nasal bleeding. Surgery for nasal bleeding can consist of a trip to the operating room to allow controlled conditions. A variety of lasers and other cautery equipment can be used to attempt to discretely locate sources of bleeding and to treat them. Often, endoscopic visualization is used to allow the best possible examination. Surgery designed to clip individual blood vessels through a variety of approaches can also be accomplished if necessary.

POSTERIOR EPISTAXIS

posterior epistaxis presents in a similar fashion to anterior epistaxis except the arterial flow of blood is often more obviously severe and the afflicted individual will often make a much earlier decision to seek emergency care for the problem because the loss of blood is instinctively frightening. A posterior epistaxis diagnosis is cinched when routine nasal packing does little to stem the flow of blood. When this occurs, posterior packing of the nose is indicated. In most centers, posterior packing consists of placing a balloon catheter into the far posterior portion of the nasal cavity and then inserting an anterior nasal pack in front of the balloon. The balloon is often left in place for a day or two, and often the patient is admitted to the hospital for observation. Treatment for continuous posterior nasal bleeding or recurrent posterior nasal bleeding involves a couple of different potential technologies. Interventional neuroradiologists are able to cannulate the external carotid vessels and block them from an intravascular route, a very successful method of taking care of persistent problems. Not all medical centers have this technology, however. Otolaryngologists have developed several different approaches to surgically clip end branches of the external carotid system. Endoscopic approaches to the internal maxillary artery branches have good results in some medical centers. To approach the anterior and posterior ethmoid vessels which are branches from the internal carotid system, usually a skin incision next to the eye is necessary, although some promising endoscopic approaches are now in development that do not require a skin incision. Unfortunately, interventional approaches cannot cannulate the anterior and posterior ethmoid arteries. Typically, the internal maxillary arteries are clipped or occluded and if the bleeding problem persists (which happens about 10% to 15% of the time) a surgical approach to the ethmoid vessels will be recommended.

This patient has a posterior balloon catheter in place after failing an interventional artery occlusion.  An external ethmoid artery ligation incision is shown by the black arrow.  The white arrow shows the balloon catheter:

References

Textbooks:

1: Gluckman JL and de Vries EJ, “Epistaxis” in Donald PJ, Gluckman JL, Rice DH, editors, The Sinuses, Raven Press, New York, 1995, p. 623-640.

2: Massick D and Evan JT, “Epistaxis”, Chapter 40, in Cummings CW, Flint PW, Harker LA, et. Al., Cummings Otolaryngology Head and Neck Surgery, 4th edition, Elsevier/Mosby, Philadelphia, 2005, p. 942-961.

Articles:

1: Behrens DC. Treatment of epistaxis in the emergency department. Emerg Med J. 2006 Mar;23(3):241.
No abstract available. PMID: 16498176 [PubMed - indexed for MEDLINE]

2: Chiu TW, McGarry GW. Prospective clinical study of bleeding sites in idiopathic adult posterior epistaxis.
Otolaryngol Head Neck Surg. 2007 Sep;137(3):390-3. PMID: 17765763 [PubMed - indexed for MEDLINE]
3: Christensen NP, Smith DS, Barnwell SL, Wax MK. Arterial embolization in the management of posterior epistaxis.
Otolaryngol Head Neck Surg. 2005 Nov;133(5):748-53. PMID: 16274804 [PubMed - indexed for MEDLINE]

4: Damrose JF, Maddalozzo J. Pediatric epistaxis. Laryngoscope. 2006 Mar;116(3):387-93.
PMID: 16540895 [PubMed - indexed for MEDLINE]
5: Douglas R, Wormald PJ. Update on epistaxis.Curr Opin Otolaryngol Head Neck Surg. 2007 Jun;15(3):180-3.
Review. PMID: 17483687 [PubMed - indexed for MEDLINE]

6: Nouraei SA, Maani T, Hajioff D, Saleh HA, Mackay IS. Outcome of endoscopic sphenopalatine artery
occlusion for intractable epistaxis: a 10-year experience. Laryngoscope. 2007 Aug;117(8):1452-6.
PMID: 17607148 [PubMed - indexed for MEDLINE]
7: Pletcher SD, Metson R. Endoscopic ligation of the anterior ethmoid artery. Laryngoscope. 2007 Feb;117(2):378-81.
No abstract available. PMID: 17204990 [PubMed - indexed for MEDLINE]
8: Randall DA. Epistaxis packing. Practical pointers for nosebleed control. Postgrad Med. 2006
Jun-Jul;119(1):77-82. Review. PMID: 16913650 [PubMed - indexed for MEDLINE]

9: Umapathy N, Quadri A, Skinner DW. Persistent epistaxis: what is the best practice? Rhinology. 2005
Dec;43(4):305-8. PMID: 16405277 [PubMed - indexed for MEDLINE]

10: Walker TW, Macfarlane TV, McGarry GW. The epidemiology and chronobiology of epistaxis: an investigation
of Scottish hospital admissions 1995-2004. Clin Otolaryngol. 2007 Oct;32(5):361-5.
PMID: 17883556 [PubMed - indexed for MEDLINE]
11: Gurney TA, Dowd CF, Murr AH. Embolization for the treatment of idiopathic posterior epistaxis.
Am J Rhinol. 2004 Sep-Oct;18(5):335-9. PMID: 15586807 [PubMed - indexed for MEDLINE]