Epistaxis is best considered in two settings, the paediatric and the adult patient.
This is a common problem in the paediatric population and is usually more of a nuisance than a health risk. It can usually be treated in the office situation. Bleeding almost always occurs from vessels on the anterior nasal septum (Little's area). This site is an area of anastamosis of blood vessels supplying the anterior nasal septum and is commonly quite vascular. The site of bleeding can frequently be cauterised with local anaesthetic in the cooperative child. In situations of non-cooperation, cauterisation under general anaesthetic may be resorted to if the problem is troublesome enough.
This is a rare event in the paediatric population. It is so unusual that it requires the exclusion of conditions causing abnormal bleeding. Tests include the exclusion of blood conditions such as acute leukaemia, clotting factor deficiencies, platelet abnormalities and thrombocytopaenia and unsuspected disorders such as von Willebrand's disease.
Rare conditions such as tumours need to be considered. Rhabdomyosarcoma is a malignant tumour that affects the paediatric population and sometimes occurs at the back of the nose or in the nasopharynx. Angiofibroma is an unusual tumour usually affecting adolescent males. It is benign, but highly vascular, and usually presents with severe epistaxis. The diagnosis must be suspected because biopsy is contraindicated due to the potential for severe life-threatening haemorrhage. The appearance on CT scanning and angiography is diagnostic.
Minor nosebleeds in the adult population are very common. It is worthwhile remembering that many adults take aspirin as a preventive for heart disease or stroke and they do not regard this as a medication. It must, therefore, be specifically asked about, as it may not be mentioned when enquiries are made about medication history. The epistaxis can usually be controlled without the need to withdraw aspirin.
In young adults, the usual site is again the anterior nasal septum, and cauterisation under local anaesthesia usually controls the problem. In the older adult, particularly those with hypertension, the bleeding may be further back in the nasal cavity and more difficult to reach. Cauterisation under local anaesthetic is usually sufficient.
Cauterisation usually involves the application of silver nitrate or alternatively electrocautery if available.
Severe epistaxis is more commonly seen in the older adult population. It can, on occasion, be a life-threatening situation. The following steps should be taken in the assessment and management of an adult with severe epistaxis:
Make an assessment of the general condition of the patient, the degree of blood loss and whether there is a need for immediate resuscitation and blood volume replacement.
Take a brief history and enquire as to the following:
- Medications and, in particular, anticoagulants and aspirin
- Hypertension, and whether it is well controlled
- Other illnesses/conditions which may affect blood clotting, such as alcoholism, liver disease, blood disorders
- The presence of a heart condition which may be aggravated by blood loss and may require treatment as well as epistaxis
- Whether epistaxis is recurrent. This may suggest abnormalities such as Osler's Disease (hereditary haemorrhagic telangiectasia). In this condition, multiple small arteriovenous malformations in the nose can cause frequent recurrent severe epistaxis.
Thorough examination of the nose with adequate light and instrumentation is necessary. Often the bleeding source can be seen and dealt with. Packing the nasal cavity usually provides control. Most emergency departments have specialised packing devices, inflatable balloons or packing material for this purpose. Thorough topical anaesthesia is required for nasal packing as the procedure can be very uncomfortable and/or painful. The pack is usually left in for 2 days and antibiotics given to prevent nasal infection.
If packing fails to control the epistaxis, a firmer pack may need to be inserted under general anaesthetic. Better examination of the nasal cavity can be done at this time and the nose examined further back for the possible presence of a bleeding vessel that could be cauterised.
During examination, unusual conditions such as tumours are obvious and are dealt with after the acute bleeding is controlled.Special investigations and techniques are usually not required. Contrast angiography to determine the bleeding vessel is almost always unsuccessful. Balloon occlusion of main vessels supplying the nose, such as the internal maxillary artery, have occasionally been resorted to for severe life-threatening epistaxis. Surgical ligation of the internal maxillary artery and, occasionally, ligation of the external carotid artery have been resorted to for severe epistaxis.