Epistaxis: Outpatient Management

 

Am Fam Physician. 2018 Aug 15;98(4):240-245.

  Patient information: See related handout on nosebleeds.

Author disclosure: No relevant financial affiliations.

Epistaxis is a common emergency encountered by primary care physicians. Up to 60% of the general population experience epistaxis, and 6% seek medical attention for it. More than 90% of cases arise from the anterior nasal circulation, and most treatments can be easily performed in the outpatient setting. Evaluation of a patient presenting with epistaxis should begin with assessment of vital signs, mental status, and airway patency. When examining the nose, a nasal speculum and a good light source, such as a headlamp, can be useful. Compressive therapy is the first step to controlling anterior epistaxis. Oxymetazoline nasal spray or application of cotton soaked in oxymetazoline or epinephrine 1:1,000 may be useful adjuncts to compressive therapy. Directive nasal cautery, most commonly using silver nitrate, can be used to control localized continued bleeding or prominent vessels that are the suspected bleeding source. Finally, topical therapy and nasal packing can be used if other methods are unsuccessful. Compared with anterior epistaxis, posterior epistaxis is more likely to require hospitalization and twice as likely to need nasal packing. Posterior nasal packing is often associated with pain and a risk of aspiration if it is dislodged. After stabilization, patients with posterior packing often require referral to otolaryngology or the emergency department for definitive treatments.

Epistaxis is one of the most common otolaryngologic emergencies, occurring in up to 60% of the general population, with one in 10 of those affected seeking medical attention. It accounts for one in 200 emergency department visits.1,2 Epistaxis has a bimodal age distribution, peaking in children younger than 10 years and in adults between 70 and 79 years of age.1,3 Males are slightly more likely to experience epistaxis than females.4

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Compressive therapy should be the first intervention to stop anterior epistaxis.

C

12, 13

Silver nitrate and electrical desiccation are effective at stopping anterior epistaxis in patients when compressive therapy is unsuccessful.

C

10, 14

When available, endoscopic artery ligation may be the best initial treatment for posterior epistaxis because it is more effective than packing and less costly than endovascular embolization.

B

20, 22, 23


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Compressive therapy should be the first intervention to stop anterior epistaxis.

C

12, 13

Silver nitrate and electrical desiccation are effective at stopping anterior epistaxis in patients when compressive therapy is unsuccessful.

C

10, 14

When available, endoscopic artery ligation may be the best initial treatment for posterior epistaxis because it is more effective than packing and less costly than endovascular embolization.

B

20, 22, 23


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

Anatomy

Approximately 90% of epistaxis cases arise from the anterior part of the nasal septum; this is known as anterior epistaxis.57 Anterior bleeding most commonly occurs from the rich vascular supply at the Kiesselbach plexus (Figure 1).8 This plexus is formed by terminal branches of the internal carotid artery (anterior and posterior ethmoidal arteries) and external carotid artery (sphenopalatine, superior labial, and greater palatine arteries).3,6,9

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FIGURE 1.

Vascular anatomy of the nasal cavity.

Reprinted with permission from Kucik CJ, Clenney T. Management of epistaxis. Am Fam Physician. 2005;71(2):305.


FIGURE 1.

Vascular anatomy of the nasal cavity.

Reprinted with permission from Kucik CJ, Clenney T. Management of epistaxis. Am Fam Physician. 2005;71(2):305.

Posterior epistaxis typically occurs along the nasal septum or lateral nasal wall, and originates from branches of the internal maxillary, sphenopalatine, and descending palatine arteries.3,10 The posterior ethmoid artery provides a small contribution.10 Because hemostasis is more difficult to achieve with posterior bleeding, the distinction between anterior and posterior epistaxis guides management.11

Etiology

The Authors

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JASON P. WOMACK, MD, is an assistant professor in the Department of Family Medicine and Community Health at Rutgers University Robert Wood Johnson Medical School, New Brunswick, N.J. Dr. Womack is also the director of the sports medicine fellowship....

JILL KROPA, MD, is an assistant professor in the Department of Family Medicine and Community Health at Rutgers University Robert Wood Johnson Medical School.

MARISSA JIMENEZ STABILE, DO, is an assistant professor in the Department of Family Medicine and Community Health at Rutgers University Robert Wood Johnson Medical School.

Address correspondence to Jason P. Womack, MD, Rutgers University Robert Wood Johnson Medical School, 1 Robert Wood Johnson Pl., MEB 2nd Fl., New Brunswick, NJ 08903 (e-mail: womackja@rwjms.rutgers.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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2. Petruson B. Epistaxis. A clinical study with special reference to fibrinolysis. Acta Otolaryngol Suppl. 1974;317:1–73.

3. Kasperek ZA, Pollock GF. Epistaxis: an overview. Emerg Med Clin North Am. 2013;31(2):443–454.

4. Sarhan NA, Algamal AM. Relationship between epistaxis and hypertension: a cause and effect or coincidence? J Saudi Heart Assoc. 2015;27(2):79–84.

5. Béquignon E, Teissier N, Gauthier A, et al. Emergency department care of childhood epistaxis. Emerg Med J. 2017;34(8):543–548.

6. McLarnon CM, Carrie S. Epistaxis. Surgery (Oxford). 2012;30(11):584–589.

7. Villwock JA, Jones K. Recent trends in epistaxis management in the United States: 2008–2010. JAMA Otolaryngol Head Neck Surg. 2013;139(12):1279–1284.

8. Kucik CJ, Clenney T. Management of epistaxis. Am Fam Physician. 2005;71(2):305–311.

9. Koh E, Frazzini VI, Kagetsu NJ. Epistaxis: vascular anatomy, origins, and endovascular treatment. AJR Am J Roentgenol. 2000;174(3):845–851.

10. Viehweg TL, Roberson JB, Hudson JW. Epistaxis: diagnosis and treatment. J Oral Maxillofac Surg. 2006;64(3):511–518.

11. Ando Y, Iimura J, Arai S, et al. Risk factors for recurrent epistaxis: importance of initial treatment. Auris Nasus Larynx. 2014;41(1):41–45.

12. Middleton PM. Epistaxis. Emerg Med Australas. 2004;16(5–6):428–440.

13. Rector FT, DeNuccio DJ, Alden MA. A comparison of cocaine, oxymetazoline, and saline for nasotracheal intubation. AANA J. 1987;55(1):49–54.

14. Barnes ML, Spielmann PM, White PS. Epistaxis: a contemporary evidence based approach. Otolaryngol Clin North Am. 2012;45(5):1005–1017.

15. Kotecha B, Fowler S, Harkness P, Walmsley J, Brown P, Topham J. Management of epistaxis: a national survey. Ann R Coll Surg Engl. 1996;78(5):444–446.

16. Pérez F, Rada G. Is antibiotic prophylaxis in nasal packing for anterior epistaxis needed? Medwave. 2016;16(suppl 1):e6357.

17. Supriya M, Shakeel M, Veitch D, Ah-See KW. Epistaxis: prospective evaluation of bleeding site and its impact on patient outcome. J Laryngol Otol. 2010;124(7):744–749.

18. Shargorodsky J, Bleier BS, Holbrook EH, et al. Outcomes analysis in epistaxis management: development of a therapeutic algorithm. Otolaryngol Head Neck Surg. 2013;149(3):390–398.

19. Iimura J, Hatano A, Ando Y, et al. Study of hemostasis procedures for posterior epistaxis. Auris Nasus Larynx. 2016;43(3):298–303.

20. Kilty SJ, Al-Hajry M, Al-Mutairi D, et al. Prospective clinical trial of gelatin-thrombin matrix as first line treatment of posterior epistaxis. Laryngoscope. 2014;124(1):38–42.

21. Schlosser RJ. Clinical practice. Epistaxis. N Engl J Med. 2009;360(8):784–789.

22. Soyka MB, Nikolaou G, Rufibach K, Holzmann D. On the effectiveness of treatment options in epistaxis: an analysis of 678 interventions. Rhinology. 2011;49(4):474–478.

23. Dedhia RC, Desai SS, Smith KJ, et al. Cost-effectiveness of endoscopic sphenopalatine artery ligation versus nasal packing as first-line treatment for posterior epistaxis. Int Forum Allergy Rhinol. 2013;3(7):563–566.

 

 

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