Epistaxis (Nosebleeds)

Jeffrey D. Suh MD
Rohit Garg, MD, MBA

Introduction
Epistaxis is defined as bleeding from the nostril, nasal cavity, or nasopharynx. Nosebleeds are due to the bursting of a blood vessel within the nose. This may be spontaneous or caused by trauma. Nosebleeds are rarely life threatening and usually stop on their own. Nosebleeds can be divided into 2 categories, based on the site of bleeding: anterior (in the front of the nose) or posterior (in the back of the nose).

Approximately 60% of the population will be affected by epistaxis at some point in time, with 6% requiring professional medical attention. The cause of nosebleeds are typically idiopathic (unknown), but they may also result from trauma, medication use, tumors, or nasal/sinus surgery.

Treatment of epistaxis may include the use of local pressure (ie pinching the nose - low over the fleshy portion, not high over the bony portion), decongestant nasal sprays, chemical or electric cautery (burning the vessel shut), hemostatic agents (topical therapies to stop bleeding), nasal packing, embolization (a procedure to place material within the vessel to block it off), and surgical arterial ligation (tying off the vessel). There is no single definitive treatment for the management of nosebleeds and many factors including severity of the bleeding, use of anticoagulants, and other medical conditions can play a role in which treatment is utilized.


Anatomy
The nasal cavity is extremely vascular, meaning it has a large blood supply. Blood is supplied via both the internal and external carotid systems. The major blood arteries in the nasal cavity include the anterior and posterior ethmoid arteries and the sphenopalatine arteries. Over 90% of nose bleeds occur in the anteroinferior (front bottom) nasal septum (wall that divides your nose between left and right sides) in an area known as Kiesselbach’s plexus, named after Wilhelm Kiesselbach, a German otolaryngologist. Keisselbach's plexus is located over the anterior nasal septum and is formed by anastomoses (coming together) of 5 arteries:
  • Anterior ethmoidal artery (from the ophthalmic artery) (Figure 1)
  • Posterior ethmoidal artery (from the ophthalmic artery)
  • Sphenopalatine artery (terminal branch of the maxillary artery) (Figure 2)
  • Greater palatine artery (from the maxillary artery)
  • Septal branch of the superior labial artery (from the facial artery)
Approximately 5% to 10% of epistaxis is estimated to arise from the posterior nasal cavity, in an area known as Woodruff’s plexus. Woodruff's plexus is located over the posterior middle turbinate and is primarily made up of connection of branches of the internal maxillary artery, namely, the posterior nasal, sphenopalatine, and ascending pharyngeal arteries. Posterior bleeds usually originate from the lateral wall and more rarely from the nasal septum.


Figure 1: Endoscopic View of the Anterior Ethmoid Artery. Image courtesy of Drs. Alexander Chiu, MD and James N. Palmer, MD.


Figure 2: Endoscopic View of the Nasal Septal Artery. Legend: ST: Septum, NS: Nasal Septum, *: Nasal Septal Branch of the Sphenopalatine Artery. Image courtesy of Dr. Vijay Ramakrishnan, MD.


Etiology
Causes of epistaxis can be divided into local causes (eg, trauma, mucosal irritation, septal abnormality, inflammatory diseases, tumors), systemic causes (eg, blood disorders, arteriosclerosis, hereditary hemorrhagic telangiectasia), and idiopathic (unknown) causes. Local trauma is the most common cause; followed by facial trauma, foreign bodies, nasal or sinus infections, and prolonged inhalation of dry air. Tumors and vascular malformations are also important causes of nose bleeds. Epistaxis is also associated with septal perforations (holes in the nasal septum).

Local Factors
Trauma or injury to the turbinate mucosa and septum is a frequent cause of epistaxis. Nose picking and repeated irritation caused by the tips of nasal spray bottles commonly give rise to many anterior bleeds. Certainly, traumatic deformation and fractures of the nose and surrounding structures can cause bleeding. Another common cause of nosebleeds is due to infection and mucosal inflammation. Sinusitis, upper respiratory tract infections, and allergies can damage the respiratory lining to the point that it becomes irritated. Additionally, septal deviations (bends in the wall that divides the nose between two sides), nasal fractures, and septal perforations (holes through the septum) can be a cause of irregular nasal airflow causing dryness and bleeding in some cases. Causes due to medical treatment such as after endoscopic sinus surgery, skull base surgery, and orbital surgery can also be a cause of severe epistaxis.

Tumors of the nasal cavity, sinuses, and nasopharynx can also give rise to recurrent bleeding. In general, recurrent one sided nosebleeds should be evaluated by endoscopy (scoping) with or without imaging studies to screen for a tumor.

Systemic Factors
Hypertension, hereditary hemorrhagic telangiectasia, use of anticoagulants such as aspirin, clopidogrel, warfarin, and a variety of conditions causing vasculitis such as Wegener’s granulomatosis are common systemic factors associated with epistaxis. Epistaxis is also associated with blood disorders, patients with lymphoproliforative disorders, immunodeficiency, and liver failure. Thrombocytopenia (low platelet levels) is associated with nasal bleeding. There can be spontaneous mucous membrane bleeding at platelet levels of 10-20,000. Platelet deficiency can also result from use of chemotherapy, antibiotics, malignancies, hypersplenism, and some drugs. Platelet dysfunction can occur in patients with liver failure, kidney failure, vitamin C deficiency and in patients taking aspirin and NSAIDs.

Clotting factor abnormalities can result in frequent, recurring epistaxis. Bleeding disorders such as Von Willabrand’s disease (most common), Factor VIII deficiency (Hemophilia A), Factor IX deficiency (Hemophilia B), and Factor XI deficiency are all common primary coagulopathies. Additionally, patients with recurrent nosebleeds should be questioned about the use of complementary and alternative medicines such as Ginkgo Biloba and Vitamin E, which may increase their risk of bleeding.

Treatment
Direct pressure is usually effective for stopping epistaxis by applying pressure to the front of the nose. Nasal decongestants such as oxymetazoline or neosynephrine may also be used. Gently applying Vaseline or other ointment to the front of the nose with a Q-tip on a daily basis helps to moisturize the nose and prevent nose bleeds due to dryness. It is also very important to avoid any trauma to the nose after a nose bleed by picking healing scabs or blowing the nose too aggressively.

Chemical cauterization with silver nitrate is also used for control of epistaxis not controlled by local application of pressure. When these methods are not effective, anterior or posterior packing might be necessary. Packing can be absorbable or non-absorbable.

For complicated nose bleeds, another method of treatment is angiographic embolization of the internal maxillary artery. It has a success rate of 71% to 95%, but the procedure carries risk of stroke, ophthalmoplegia (limitation of eye movement), facial nerve palsy (not being able to move half the face), and hematomas (blood clots) at the catheterization site. Also revascularization (reopening of the blood vessel) after embolization is not uncommon.

Direct surgical ligation or clipping is an increasing popular alternative to embolization. The traditional approach for ligation of the anterior and posterior ethmoids artery is via an external facial incision, but other approaches have been described, including an approach through the corner of the eye. Endoscopic sphenopalatine artery (SPA) ligation (Figure 3) throught the nose, has been proposed as an ideal treatment for certain nosebleeds as it takes the major arterial supply to the nasal cavity at a point closest to the bleeding, and therefore minimizes the risk of persistent bleeding from other circulation and spares the patient from a transoral incision. A review found a 92% to 100% success rate with endoscopic SPA ligation. Failures of this technique are attributed to the failure to identify all branches of the SPA, or the significant dissection that may be required in a patient with suboptimal coagulation properties.



Figure 3: Endoscopic view of a left sphenopalatine artery (arrow) that is being ligated with a surgical clip. Image courtesy of Dr. Kevin C. Welch.

Conclusion
In general, non-surgical treatments are effective for control of most cases of nosebleeds. Holding pressure, nasal packing, chemical cautery, and use of nasal decongest sprays represent the first line of treatment for a majority of nasal bleeding. For persistent epistaxis, embolization and surgical ligation is sometimes required. More recently, endoscopic approaches to the sphenopalatine artery and ethmoid arteries have been utilized with promising results.

Revised 2/17/2015
©American Rhinologic Society