How is anterior epistaxis treated?
Learn six steps to stop epistaxis, as well as the management techniques used by clinicians.

Epistaxis is bleeding from the nasal mucosa and is the most prevalent emergency in otorhinolaryngology.

Epistaxis is of two types, anterior and posterior epistaxis, both of which have a prevalence of 10 to 12 percent. Kiesselbach's plexus (also called Little's area) on the anterior nasal septum (the partition between the two nostrils) is the cause of 90 percent of anterior epistaxis (nosebleed).

Though epistaxis may be frightening, most of the time it can be treated at home; however, it is advised to seek medical attention to address the root cause.

6 steps to stop epistaxis

  1. Sit upright and pinch the nostrils firmly for at least 10 to 15 minutes.
  2. Never tilt the head back because it drains the blood back into the throat, which can cause choking.
  3. Lean forward and breathe through the mouth so that the blood drains into the nose.
  4. Cover the bridge of the nose with an ice pack or a bag of frozen vegetables.
  5. Stay upright rather than reclining down because it reduces blood pressure in the nose's blood vessels and discourages further bleeding.
  6. If the bleeding ultimately stops, the patient won't need to see a doctor. However, in rare circumstances, the patient may require additional treatment from the doctor or in a hospital.

Clinical management of epistaxis

Resuscitation

Primary first aid, which comprises the airway, breathing, and circulation (ABCs) of resuscitation, is a priority in a patient with epistaxis.

Clinicians examine patients for a pulse and respiratory rate, as well as indications of shock, such as low blood pressure, sweating, and pallor.

  • The patient will be seated upright in the case of an active bleed and nostrils are pinched while taking precautions to prevent the backflow of the blood into the throat.
  • A large-bore intravenous cannula is inserted, and blood grouping could be done if necessary. The patient may be referred to an ear, nose, and throat (ENT) specialist.

Assessment

Once the bleeding stops, the assessment is done to identify the root cause.

  • The doctor examines the nostrils of the patient to find any abnormalities.
  • To gain a good view, the patient may need to blow their nose and eliminate any blockages. One should be careful because this may result in a return of bleeding. However, it may help locate the source of the bleeding.

Using a nasal speculum in one hand, the doctor observes the nasal cavity while suctioning with the other. A thorough inspection of the nasal cavity is required. The septum and Little’s area are inspected for scabs or excoriated areas in the case of anterior epistaxis.

Cauterization

An anterior bleed may typically be managed safely in primary care, assuming suitable equipment and follow-up are available. If direct pressure fails to stop the bleeding, cautery or nasal packing may be used.

  • Cautery sticks contain silver nitrate, which interacts with the mucosal lining to cause a chemical burn.
  • Bilateral cautery must be performed with caution to avoid septal perforation, and therapy should only be delivered to a limited region surrounding the bleeding site. 
  • Following cauterization, patients should be treated with a nasal moisturizer, such as Kenacomb or paraffin.

Nasal packing

If cauterization fails to stop the bleeding or no bleeding site is visible on inspection, nasal packs are provided.

Anterior nasal packs function by putting direct mechanical pressure on the area where the bleeding is occurring. Traditionally, lubricant or antibiotic-soaked ribbon gauze is used. However, new packs have been produced for easy insertion and are effective.

In case of severe epistaxis, a special inflating balloon called Rapid Rhino is inserted into the nose. The balloon is coated with a chemical that functions as a platelet aggregator. After insertion, the balloon is inflated to tamponade bleeding and can be retained in place for up to three to four days.

Nasal packing should be done with extreme caution. The precise positioning will allow the doctor to insert the whole length of the pack.

Complications of nasal pack

The usage of nasal packs may result in complications. While the packs are in place, oral antibiotics are frequently recommended as a preventative step against toxic shock syndrome. The duration and usage of oral antibiotics are determined by the consultant, physician, and department. There is little compelling evidence in the literature to support the use of prophylactic antibiotics.

Other side effects of nasal packs include:

Patients who have posterior packing, as well as bilateral packing, are more likely to have:

Arterial ligation

Surgical procedures may be considered if epistaxis persists despite packing.

External carotid artery, internal maxillary artery, and sphenopalatine artery (SPA) ligations are the three basic surgical options. The selection of the artery to ligate will be determined by the location of the bleeding and its major source. The goal will be to ligate as near as possible to the bleeding location.

SPA ligation may be indicated if the anterior epistaxis does not settle after 24 hours. SPA is located with the help of an endoscope.

  • The patients are sedated, which is followed by an incision in the lateral nasal wall.
  • A mucosal flap is raised, and the SPA is identified.
  • A surgical technique, diathermy is used to cut, split or coagulate the vessel. Recognizing anatomical variation is crucial to the effectiveness of this surgery.

Embolization

Another way of reducing bleeding in epistaxis is angiographic embolization. Embolization is an invasive procedure where a blood vessel is blocked using a plugging material.

  • The bleeding point is identified and a catheter is inserted into the internal maxillary artery, and the bleeding vessel is embolized.
  • This technique has a high success rate, but it is not without danger.
  • Significant problems, such as cerebrovascular accidents and blindness, can occur in up to four percent of patients.
  • This procedure is usually done in patients who had a failed SPA ligation or are medically unfit for general anesthesia.

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What is the aftercare following epistaxis treatment?

  • The patients are advised not to use the following drugs for about four to five days following epistaxis treatment
    • Blood thinners
    • Nonsteroidal anti-inflammatory medicines
  • Usually, anterior packs remain in place for three to five days
  • Nasal tampons should be moistened with water or saline three times each day
  • Antibiotics are prescribed to eliminate the risk of:

19 causes of anterior epistaxis

The principal causes of epistaxis or nasal bleeding are roughly classified as local and systemic causes.

Epistaxis usually begins right within the nostril, on the central harder section of the nasal septum. Because the blood vessels in this area are delicate, they readily rupture and begin to bleed.

The following things may trigger epistaxis:

  1. Deformities of the anatomical structure
  2. Nasal sprays and long-term nasal steroids use (particularly prolonged or improper use of nasal steroids)
  3. Middle ear barotrauma as a result of an abrupt shift in pressure
  4. Repeated nose picking
  5. Strong nose blowing
  6. Long durations of exposure to warm, dry air
  7. Rhinitis caused by allergies
  8. Nasal septum deviation or perforation
  9. Cocaine abuse
  10. Alcohol use
  11. High blood pressure
  12. Infectious illness, such as cold or flu
  13. Diseases of the connective tissue
  14. Blood thinners, such as aspirin, warfarin, and others
  15. Maternity (rare, due to hypertension and hormonal changes)
  16. Bleeding disorders
  17. Chemicals, such as ammonia, which irritate airways
  18. Deficiency in vitamins C and K
  19. Hereditary hemorrhagic telangiectasia, which causes repeated nosebleeds

Who are at risk of anterior epistaxis?

Epistaxis is frequent, and most individuals will encounter them occasionally.

A nosebleed can happen to anybody although it most commonly affects:

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Medically Reviewed on 4/13/2022
References
Image Source: iStock Image

Cleveland Clinic. Nosebleed (Epistaxis). https://my.clevelandclinic.org/health/diseases/13464-nosebleed-epistaxis

Science Direct. Epistaxis. https://www.sciencedirect.com/topics/medicine-and-dentistry/epistaxis

The University of Iowa. Nose Bleed Management and Epistaxis Control. https://medicine.uiowa.edu/iowaprotocols/nose-bleed-management-and-epistaxis-control