Ear, Nose & Throat
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Question 11 of 180
A 54 year old woman with a history of hypertension presents to the Emergency Department. She gives a 6 hour history of epistaxis that she has not been able to control with conventional first aid measures. On examination you note a bleeding point in Little's area. You cauterise the bleeding point using silver nitrate. Which of the following is a complication of this treatment that should be considered?
Answer:
A possible complication of nasal cautery treatment is septal perforation due to a direct effect of the cautery causing decreased vascular supply from the perichondrium— this is a risk particularly if cautery is attempted at the same location on both sides of the septum.Epistaxis
Ear, Nose & Throat
Last Updated: 14th April 2023
Epistaxis is bleeding from the the nostril, nasal cavity or nasopharynx. Epistaxis may occur at any age but peaks in incidence occur in children < 10 years and adults > 45 years.
- Anterior bleeds
- In most cases (80 – 95%), epistaxis originates from Little’s area on the anterior nasal septum, which contains the Kiesselbach’s plexus of vessels (formed from arterial anastomoses between branches of the greater palatine, sphenopalatine, superior labial and anterior ethmoidal arteries).
- Posterior bleeds
- Less commonly, epistaxis originates from branches of the sphenopalatine artery in the posterior nasal cavity. Posterior nosebleeds usually occur in older people, are more profuse, result in bleeding from both nostrils, and the bleeding site cannot be identified on examination.
Causes
Blood vessels in the nose (particularly in Little's area) are superficial and therefore easily damaged. Most epistaxis is self-limiting and harmless, and the cause of damage to the blood vessels is not identified.
- Local causes of damage to blood vessels include:
- Trauma — injury from nose-picking, nasal fractures, septal ulcers or perforations, foreign body, or blunt trauma (such as falls in children)
- Inflammation — infection, allergic rhinosinusitis, or nasal polyps
- Topical drugs — for example cocaine, topical decongestants, or topical corticosteroids
- Vascular causes — for example hereditary haemorrhagic telangiectasia or Wegener's granulomatosis
- Postoperative bleeding — for example following ENT surgery; maxillofacial surgery; or ophthalmic surgery
- Tumours — benign (such as angiofibroma) or malignant (such as squamous cell carcinoma)
- Nasal oxygen therapy — causes drying of the nasal mucosa
- More general causes include:
- Atherosclerosis
- Increased venous pressure from mitral stenosis
- Haematological conditions — such as thrombocytopenia, platelet dysfunction, Von Willebrand disease, leukaemia, and haemophilia
- Environmental factors — temperature, humidity, and altitude, exposure to irritants
- Systemic drugs — including anticoagulants and antiplatelet drugs
- Excessive alcohol consumption
Complications
Complications include:
- Of nasal bleeding
- Hypovolemia
- Anaemia
- Aspiration
- Death
- Of nasal packing treatment
- Sinusitis
- Septal haematoma or abscess (due to traumatic packing)
- Pressure necrosis (due to excessively tight packing)
- Toxic shock syndrome (from prolonged packing)
- Apnoeic episodes (associated with bilateral anterior or posterior nasal packs)
- Of nasal cautery
- Septal perforation (due to a direct effect of the cautery caused decreased vascular supply from the perichondrium— this is a risk particularly if cautery is attempted at the same location on both sides of the septum)
Assessment
- Assessment of a patient with a history of bleeding, even if it appears to have stopped, must start with an initial ABC assessment concentrating on the airway and haemodynamic status. If the patient is still actively bleeding and there is evidence of haemodynamic compromise, then both resuscitative and first aid measures should be started immediately.
- If the person is not haemodynamically compromised, ask:
- When the bleeding started and from which nostril.
- How much blood has been lost. This is difficult to estimate, but establish whether the bleeding is light or heavy. If bleeding is heavy, ask the person how many cups (each equates to approximately 250 mL) they think they have lost. Significant blood loss may necessitate admission to hospital.
- Whether a temporary pack (such as cotton wool) has been used before seeking medical help. These are not always easily visible, and formal nasal packing can push foreign bodies further into the nose.
- About any previous episodes of epistaxis and how they were treated.
- Examine both nasal passages (ideally with adequate lighting and a nasal speculum).
- Where clinically appropriate, ask the person to gently blow the nose to clear old blood and large clots (or use gentle suction). Look for a bleeding point. It will look like a small red dot (less than 1 mm) and may not be actively bleeding (note: active bleeding may prevent accurate assessment).
- Suspect a posterior bleed if bleeding is profuse, from both nostrils, the bleeding site cannot be identified on speculum examination, and/or if bleeding first started down the throat (however, be aware that if bleeding commenced while the person was supine, blood is likely to have drained to the throat regardless of bleeding site).
- Determine if there may be an underlying cause, particularly in children younger than 2 years of age as epistaxis is unusual in this age group. Ask about/consider:
- A history of surgery or recent trauma (consider the possibility of non-accidental injury).
- Symptoms suggestive of a tumour including nasal obstruction, rhinorrhoea, facial pain, hearing loss, persistent lymphadenopathy, and/or evidence of cranial neuropathy (for example facial numbness or double vision).
- Other nasal symptoms that may be suggestive of allergic rhinitis or bacterial rhinosinusitis, nasal polyps, or nasal foreign body.
- Current medications (for example aspirin, warfarin, or nasally-administered drugs).
- If the person is taking warfarin, check the INR (international normalized ratio) or admit to hospital if bleeding is difficult to control.
- Conditions predisposing to bleeding (such as haemophilia or leukaemia).
- Symptoms or family history of bleeding disorders (such as hereditary haemorrhagic telangiectasia — suggested by red or purple spots on the fingertip pads, lips, lining of the nose, gut and occasionally the ears and face).
- Environmental factors (such as cold, dry weather, low humidity).
Management
To manage epistaxis, sequentially:
- Consider the need for personal protective equipment - blood contamination beyond gloves occurs in over half of clinicians treating epistaxis.
- Assess the person's airway, breathing, pulse, and blood pressure; consider placing IV access and sending blood for FBC, U&Es, clotting and G&S. Consider epistaxis a circulatory emergency, especially in high risk patients and with deranged vital signs.
- First aid measures
- Ask the person to sit with their upper body tilted forward and their mouth open. They should avoid lying down, unless they are feeling faint. Leaning forward decreases blood flow through the nasopharynx, allows spitting out of blood, and minimises swallowing blood that drains into the pharynx.
- Advise the patient to pinch the cartilaginous part of the nose (not the nasal bones!) firmly and hold it firmly for 10 – 15 minutes without releasing the pressure, while breathing through their mouth.
- Sucking on an ice cube has also been shown to reduce nasal blood flow and applying an ice pack ice directly to the nose may help.
- If bleeding stops with initial simple measures, observe for a further 15 minutes, and then consider discharge with self-care advice. Consider applying a topical antiseptic preparation to reduce crusting and vestibulitis: prescribe Naseptin® (chlorhexidine and neomycin) cream to be applied to the nostrils four times daily for 10 days.
- If bleeding does not stop after 10–15 minutes of nasal pressure, consider nasal cautery or nasal packing.
- Nasal cautery
- If a bleeding point is identified (small red dot), nasal cautery can be attempted.
- Ask the person to blow their nose to clear any clots and allow local anaesthetic to be applied. Gentle suction may also be used to clear the site.
- Use a topical local anaesthetic spray, preferably with a vasoconstrictor (such as lidocaine with phenylephrine [Co-phenylcaine®]), prior to cauterising the area. Wait 3–4 minutes for the full effect. The vasoconstrictor may stop the bleeding, but once the effects have worn off, the bleeding may start again.
- To cauterise, lightly apply the silver nitrate stick or electrocautery equipment to the bleeding point for 3–10 seconds until a grey-white colour develops. If bleeding is too brisk for the cautery to be effective, cauterising the four quadrants immediately around it (doughnutting the bleeding site) may be an option. Only ever cauterise one side of the septum to avoid nasal septal perforation, and avoid touching any areas which do not need treatment.
- After cautery, dab the cauterised area with a clean cotton bud to remove excess chemical or blood and apply a topical antiseptic preparation to the area. Use Naseptin® (chlorhexidine and neomycin) cream first line, applied to the nostrils four times daily for 10 days). Do not routinely pack the affected side.
- If cautery is effective, observe the patient for 15 minutes after the procedure to ensure bleeding is controlled, prior to discharge.
- N.B. Topical nasal antiseptic cream is as effective as silver nitrate cautery in preventing recurrent nosebleeds in children with epistaxis.
- In adult patients, especially on antiplatelet drugs, treatment with topical application of TXA soaked cotton pledget (500 mg TXA in 5 ml) is a painless, rapid and effective approach to achieving haemostasis in anterior epistaxis who fail direct pressure and can be tried prior the placement of an anterior nasal pack with no evidence of serious adverse effects.
- Nasal packing
- If nasal cautery is unsuccessful, a bleeding point cannot be identified or there is bilateral bleeding, nasal packing can be performed.
- Prior to packing, anaesthetise the nasal cavity with topical local anaesthetic spray, preferably one with a vasoconstrictor (for example lidocaine with phenylephrine [Co-phenylcaine®]), if this has not already been done. Wait 3–4 minutes for the full effect.
- Packing may be achieved with nasal tampons (e.g. Merocel®), inflatable packs (e.g. Rapid-Rhino®), or ribbon gauze impregnated with Vaseline® or bismuth-iodoform paraffin paste. N.B. when packing the anterior nose, inflatable balloon tampons (e.g. Rapid Rhino) are the least painful to insert and easiest to remove.
- Insert the packing according to the manufacturers' instructions. Pack the person's nostril whilst they are sitting with their head tilted forward. Ensure that the person is holding a receptacle to spit blood out in, and is breathing through the mouth. Secure the pack (for example Merocel® packs have a string attached which can be taped to the cheek), and ensure there is no pressure on the cartilage around the nostril as this can cause a cosmetic defect.
- Once an anterior pack has been placed it is important to observe the patient for a minimum of 30 minutes to check no further leakage occurs either from the nose or posteriorly into the pharynx. Make sure to re-examine the oropharynx for blood diversion or posterior epistaxis. Bilateral nasal packs can be placed to provide further pressure.
- Most patients can be discharged home following insertion of an anterior nasal pack, provided they have been given appropriate discharge instructions and follow-up. The anterior nasal pack should be left in place for 24-48 hours and follow-up arranged with the ENT department for its removal and further assessment. There is no evidence that routine antibiotic cover is required for patients with an anterior nasal pack in place for less than 48 hours.
- Posterior nasal bleed
- Failure of an anterior nasal pack to stop epistaxis is most likely due to bleeding arising from the posterior nasal cavity.
- In this situation a variety of management options are available including endoscopy with cauterisation, ligation of the sphenopalatine artery and posterior packing. The further management of posterior epistaxis is the province of the ENT department.
- If there is likely to be a significant delay before specialist input or the patient's haemodynamic status is deteriorating, then Foley catheters can be used as a temporary solution in the ED. Size 12 or 14 gauge catheters should be advanced one at a time through the nostril, along the floor of the nose into the nasopharynx until seen in the pharynx. Each balloon should be inflated with 5-10 mls water and gentle traction applied. N.B. Insertion of foley catheters to stop uncontrolled posterior bleeding is a technique of last resort when immediate specialist help is unavailable.
Patient advice
No follow-up is necessary for patients in whom the epistaxis has either stopped spontaneously or by first aid measures or cautery alone. However it is important to provide advice to prevent recurrence of the nosebleed and first aid measures for future episodes.
Advise that for 24 hours after bleeding, where practical, the person should avoid activities which may increase the risk of rebleeding. These include:
- Blowing or picking the nose
- Heavy lifting
- Strenuous exercise
- Lying flat
- Drinking alcohol or hot drinks
Advise the person that if bleeding restarts and does not respond to first aid measures (as above) they should seek urgent medical advice.
If there is a concern of an underlying cause or a history of recurrent epistaxis, consider whether referral for further assessment is necessary.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
