HEAD AND NECK

Epistaxis

does occur more commonly in childhood with a peak incidence

between the ages of 3 and 8 years. The peak incidence of
epistaxis in adults is in 45e65 year olds in whom the incidence of
severe posterior bleeding is greater.2 The annual admission rate
of adult epistaxis to otolaryngology wards in the UK is around 30
per 100,000 per year, however less than 10% of admitted patients go on to require a surgical procedure under general
anaesthetic.3

Claire M McLarnon
Sean Carrie

Abstract
Epistaxis is extremely common and usually managed with simple first aid
measures in the community. However it can also present with life-threatening haemorrhage which requires appropriate resuscitation and arrest of
the bleeding. Of those patients presenting to local emergency services,
knowledge of the assessment and management of epistaxis are essential.
Epistaxis is classified as primary epistaxis, where no cause can be found
or secondary epistaxis where there is a defined cause. It is also described
in terms of the site of bleeding. Anterior bleeding from the nasal septum
is found in 90% of cases and can be controlled with simple first aid measures or nasal packing and/or cautery. Posterior bleeding is more dramatic
and may require a surgical procedure or radiological guided embolization.
Many patients, particularly the elderly have associated co-morbidities and
medications that need to be addressed along with the standard treatment. This article discusses the assessment and appropriate management
of patients with epistaxis and their associated morbidities.

Anatomy
Terminal branches of the external and internal carotid arteries
supply the nasal cavity with frequent anastomosis between them
on the nasal septum, lateral wall and midline. The anterior nasal
septum is a particularly well-described site of anastomosis between the external and internal carotid arterial systems where an
abundant plexus of vessels called Littles or Kiesselbachs area
are found (Figure 1). This is the site at which up to 90% of
epistaxis originates.
The branches of the external carotid artery supplying Littles
area include terminal branches of the internal maxillary artery
which are the sphenopalatine artery and the greater palatine
artery. The other external carotid branch is the facial artery,
which supplies the superior labial artery. The sphenopalatine
artery enters the nose via the sphenopalatine foramen in the
lateral nasal wall at the posterior end of the middle turbinate. It
then branches to supply most of the nasal septum and much of
the lateral nasal wall. The superior labial artery can be found
entering the nose from below just lateral to the anterior nasal
spine to supply the anterior nasal septum. This artery and the
greater palatine are often overlooked as they need to be identified
on or nearer the floor of the nose.
The internal carotid artery supplies the superior part of the
nasal cavity by way of the ophthalmic artery which gives off the
anterior and posterior ethmoidal arteries. These arteries run into
the roof of the nose from the orbit via their respective anterior
and posterior foramina. The posterior ethmoidal artery is smaller
than the anterior ethmoidal artery. It is absent in approximately
20% of individuals and can be found only a few millimetres (2e5
mm) anterior to the optic nerve as it exits the optic canal, and
about 10e12 mm posterior to the anterior ethmoidal artery.
Knowledge of the course and branching patterns of these arteries
is essential in the surgical management of epistaxis involving
these vessels.

Keywords Anterior ethmoidal artery; endoscope; epistaxis; hereditary

haemorrhagic telangiectasia; nasal cautery; nasal packing; sphenopalatine
artery

Introduction
Epistaxis is defined as acute haemorrhage from within the nasal
cavity including the nasopharynx. It is a common condition
ranging in severity from a single short-lived episode to a less
common life-threatening haemorrhage. The majority of cases are
self-limiting and do not require medical intervention. Of those
patients who do attend Accident and Emergency with an
epistaxis, the vast majority can be managed in the A&E department. Referral to ENT is reserved for the minority of cases where
the epistaxis is severe and/or there are other associated patient
factors or co-morbidities requiring admission. Epistaxis is classified as primary epistaxis, where no cause can be found or
secondary epistaxis where there is a defined cause for example
nasal trauma.

Incidence
The reported incidence of an episode of epistaxis occurring
during a lifetime is approximately 60%, with less than 10%
requiring medical attention.1 There is a bimodal distribution of
epistaxis incidence with peaks in children and the older adult.
Epistaxis is rare in children under the age of 2 years; however it

Aetiology
Most causes of epistaxis can be identified through a directed
history and physical examination. The patient history should
include details of the initial presentation of bleeding, previous
bleeding episodes and their treatment, comorbid conditions, and
current medications. Risk factors and causes of secondary
epistaxis can be divided into local and systemic aetiologies
(Table 1). Despite no obvious cause in primary epistaxis, it is
well recognized that there is an increased frequency of epistaxis
in the autumn and winter months.4 This correlates with changes
in temperature and humidity, which may be the causative factors. It has also been found that there is a circadian rhythm, with
peaks in incidence of epistaxis in the morning and late evening.5

Claire M McLarnon MB ChB MSc FRCS (ORL-H&N) is a Consultant ENT

Surgeon at the Freeman Hospital, Newcastle upon Tyne, UK. Conflict
of interests: none declared.
Sean Carrie MB ChB FRCS (ORL) is a Consultant ENT Surgeon at the
Freeman Hospital, Newcastle upon Tyne, UK. Conflict of interests: none
declared.

SURGERY 33:12

587

2015 Elsevier Ltd. All rights reserved.

HEAD AND NECK

trauma may indicate a post-traumatic aneurysm. In elderly

adults, particularly those with dementia repeated digital trauma
is a recognized cause and keeping fingernails short can be a
simple preventative measure. Chronic crusting and inflammation
from repeated digital trauma can lead on to a septal perforation.
Here troublesome recurrent bleeding is seen from both nasal
cavities. Patients using regular intra-nasal steroid sprays, typically used in the treatment of rhinosinusitis; also have an
increased risk of recurrent epistaxis.7 Epistaxis that is unilateral
and recurrent should be referred on to an ENT specialist for
endoscopic rhinoscopy and further investigation to exclude a
tumour within the nasal cavity or nasopharynx.

History and initial assessment

The initial assessment of any patient presenting with bleeding
should always start with checking their airway, breathing and
circulation. A patient with persistent bleeding and a reduced
conscious level as seen in alcohol/drug intoxication or head
injury is at risk of aspirating and will require prompt action to
protect the airway. A quick assessment of the vital signs and any
available laboratory results should be done. Any haemodynamic
compromise should be addressed urgently with intravenous access and fluid resuscitation. Most patients with epistaxis will not
have any significant compromise; however special attention
should be paid to the elderly and those patients with significant
underlying cardiopulmonary disease. After ensuring the patient
is stable a more in-depth history should then be taken. This
should include: side of bleeding, duration, amount and frequency
of bleeding, a judgment on amount of blood swallowed or spat
up, any preceding trauma or precipitating causes. Any previous
history of epistaxis and any previous treatments for it should be
asked. The past medical history and current medications are also
important especially with respect to the systemic causes given in
Table 1.

Figure 1 Anatomical sites for epistaxis.

Epistaxis in children
Epistaxis in children is common and often related to repeated
digital trauma (nose picking) in combination with mucosal
changes due to reduced humidification seen in the winter
months. However some children get repeated nose bleeds with
no specific cause (recurrent idiopathic epistaxis). Other common
causes include nasal injury, recurrent upper respiratory tract
infections, rhinitis and nasal foreign bodies. Epistaxis from more
serious systemic conditions such as leukaemia or tumours within
the nasal cavity is rare.
Clinical history and careful examination will direct the use of
any further investigations to look for the less common and more
serious causes. Common treatments in children include silver
nitrate cautery and/or a topical antiseptic cream application. A
Cochrane review in 2012 recommended using the weaker
strength of silver nitrate (75% vs 95%) to cauterize bleeding
vessels in recurrent idiopathic epistaxis.6

Examination
Before going to examine a patient it is important to remember to
put on a disposable apron and gloves, and if available a surgical
face mask and eye protection. Patients will be extremely anxious
and it is always worth having an assistant with you to help
support the patient and help with passing and holding equipment. Good lighting is essential and ideally a head light should be
worn but if one is not available a bright torch, lamp or the
auroscope can be used. Suction is a must and you should
remember to provide a bowl and tissues for the patient who
should be sat up preferably in a proper examination chair. If the
bleeding has been controlled with first aid measures or stopped
spontaneously then routine examination of the oropharynx to
check for any on-going posterior bleeding or clots is done followed by anterior rhinoscopy. In patients that continue to bleed
the examination is often combined with the management so as to
stop or reduce bleeding to allow for a better assessment. Therefore it is important to make sure you have equipment and topical
agents to hand before starting. Equipment should include nasal
dressing forceps, nares dilators and a tongue depressor. In the
scenario of a patient continuing to bleed, getting the patient to
blow their nose and removing the clots with the sucker may
enable you to see where the bleeding is coming from. If you

Epistaxis in adults
The systemic causes of epistaxis are more relevant in adults with
particular attention to the use of anti-coagulants. Hypertension is
seen in many adults presenting with epistaxis however there is
no good evidence of a direct role, and in most patients a raised
blood pressure is due to anxiety of having a nose bleed. Trauma
to the nose usually results in an associated epistaxis which in
many cases stops spontaneously. Persistent heavy bleeding after
trauma indicates an arterial cause most often from the anterior
ethmoidal artery and sphenopalatine artery. Early reduction of a
displaced nasal fracture can help, however the patient will most
likely require a surgical intervention to stop the bleeding.
Delayed bleeding of around 7 weeks following major facial

SURGERY 33:12

588

2015 Elsevier Ltd. All rights reserved.

HEAD AND NECK

inspecting the nose it is also important to note any abnormal

findings such as septal deviations and perforations, and any
masses or polyps. The ultimate goal of your examination is to
determine the side and site of bleeding and any relevant pathology to the cause of bleeding.

Causes of epistaxis
Local causes of epistaxis

Systemic causes of epistaxis

Traumatic
Nasal fracture
Surgical procedures
Nasal intubation
Nose picking e digital trauma
Topical medications
(including intra-nasal steroids)
Cocaine snuffing
Nasal oxygen
Nasal foreign bodies
Structural
Nasal septum deviation
Septal perforation
Inflammatory disease
Common colds and flu
Nasal vestibulitis
Rhinosinusitis
Pyogenic granuloma
Granulomatous disease
(Wegners, TB, sarcoidosis, syphilis)
Environmental irritants
(smoking, chemicals, pollution)
Tumours and vascular malformations
Inverting papilloma, squamous cell
carcinoma, adenocarcinoma,
melanoma of nasal cavity
and paranasal sinuses
Angiofibroma
Haemangioma
Olfactory neuroblastoma

Coagulation disorders
Anticoagulant drugs
(aspirin, clopidogrel, nonsteroidal anti-inflammatory
drugs, warfarin, heparin)
Thrombocytopenia
Acquired coagulopathies
Congenital coagulopathies
Vitamin deficiencies
(A, D, C, E, K)
Liver disease including
chronic alcohol abuse
Renal failure
Malnutrition
Polycythaemia vera
Multiple myeloma
Leukaemia
Vascular disease
Atherosclerosis
Collagen abnormalities
Hereditary haemorrhagic
telangiectasia
Cardiovascular conditions
Cardiac failure, mitral valve
stenosis
Hypertension

Management
Thankfully most patients presenting to A&E will not present in
severe haemodynamic shock, although many may display varying degrees of shock in relation to their blood loss, age and underlying cardiovascular status. All patients who continue to bleed
should have intravenous access and have a blood sample
collected for full blood count and group and save. Other laboratory tests may include coagulation studies, urea and electrolytes, liver function and international normalized ratio for those
patients on warfarin. It is useful to divide epistaxis into anterior
and posterior when discussing their management.8
First aid
Position the patient sitting, with their head over a bowl. Their
nostrils should be pinched together firmly for at least 5e10 minutes, alongside cooling with an icepack on the nose or sucking
an ice lolly if available. Squeezing the top part of the nose over
the bony dorsum never works. Persistent bleeding after 20 minutes requires further intervention.
Anterior epistaxis
This is bleeding from Littles area in most cases (90%). First aid
measures to control bleeding should be attempted initially. If this
fails then the nose should be decongested and the clots cleared as
described above in examination. Any prominent vessel which
bleeds easily on touch or area with a fresh clot is the likely site of
bleeding. Nasal cautery provides an effective treatment for
bleeding here. The area should be anesthetized with a topical
local anaesthetic agent if some has not already been applied.
Silver nitrate on a special applicator is commonly used. Electrocautery is very effective however should only be used by
appropriately trained ENT medical personnel. Application of
silver nitrate is done by rolling the applicator stick between your
thumb and first finger whilst gently applying the tip to the area
you wish to cauterize for 10e20 seconds. Care should be taken to
not accidently burn the nasal skin, when you introduce the
applicator stick into the nose. It is worth starting in an area
immediately adjacent to the vessel making an orbit around the
vessel before rolling the tip in to the centre, directly on the vessel.
Going straight for the vessel usually culminates in making it
bleed again. The danger here is continuing and ending up with a
large area of septal mucosa cauterized and the patient still
bleeding. Occasionally anterior bleeding occurs from the margins
of a septal perforation where cautery can similarly be effective. If
cautery cannot control the bleeding then a nasal pack will be
required. There are numerous types ranging from impregnated
ribbon with Vaseline or bismuth iodoform paraffin paste (BIPP),
nasal tampons and anterior nasal balloons (Figure 2). Availability and familiarity tend to dictate choice as all are similarly
effective.9 Nasal packs should be introduced into the nose
directly front to back following the floor of the nose which is the
same as the roof of the mouth (Figure 3). Never try to place a
pack in an upwards direction as this will not work and will be

Table 1

cannot, then the nose will need to be gently packed with plain
gauze ribbon soaked in a topical decongestant and local anaesthetic agent. Examples of agents used include 2% lidocaine with
1 in 80,000 adrenaline or 1 in 100,000 plain adrenaline with 1%
lidocaine. These should be left in the nasal cavity for 5e10 minutes. During this time you can continue your head and neck
examination including examination of the external nose and face,
ears, neck, oral cavity and oropharynx. It is important to do this
as you may find other physical signs such as telangiectasia seen
in hereditary haemorrhagic telangiectasia (HHT), or petechiae as
a result of thrombocytopenia, or a neck mass secondary to a
sinonasal malignancy. The application of topical vasoconstrictors
in many cases temporarily stops the bleeding. So once you have
removed the impregnated gauze dressing this is the best opportunity to inspect the nasal cavity. Anterior rhinoscopy is ideally
performed with a nares dilator (e.g. a Thudicum nasal speculum), looking for any obvious vessel especially in Littles area.
Again the auroscope can also be used to look at the anterior nasal
septum. Any obvious bleeding source can be cauterized at this
point. If no obvious cause is seen anteriorly then a look posteriorly is required especially looking at the lateral wall in the area
of the sphenopalatine artery. It is difficult to do this with a
headlight and a rigid nasal endoscope is recommended. While

SURGERY 33:12

589

2015 Elsevier Ltd. All rights reserved.

HEAD AND NECK

painful. Dry packs such as the Merocel nasal tampon need to

moistened with saline after insertion so they expand. The Rapid
Rhino consists of an air-inflatable balloon and a self-lubricating
hydrocolloid fabric covering that provides for ease of insertion
and removal. This pack has to be soaked in water for 30 seconds
prior to insertion. Once in place the balloon is inflated with air
using a 20-ml syringe until the pilot cuff is tense. Most of these
manufactured nasal tampons have either a string or tubing which
should be taped to the patients cheek to secure it. Any dressing
or pack placed within the nasal cavity has the potential risk of
being aspirated; this risk alongside the potential for further
bleeding and haemodynamic instability makes it standard UK
practice to always admit any patient with a pack in-situ. Typically packs will be left in place for 24e48 hours, and the patient
instructed to refrain from exertion and straining. Any co-existing
medical problems (e.g. coagulopathy) needs to be addressed and
the patients medications reviewed. Antibiotics are not routinely
indicated, but should be considered in any patient who requires
prolonged nasal packing or has an underlying medical condition
requiring antibiotic prophylaxis such as an artificial heart valve.
Toxic shock syndrome is a rare condition seen where by colonized Staphylococcus aureus on the pack releases an enterotoxin
in to the circulation. Although a rare complication it can lead to
multiple organ failure, shock and death.

Figure 3 Correct position for insertion of a nasal tampon pack.

ENT and gastroenterology may be needed. After decongestion

and topical anaesthetic the nasal cavity should ideally be
inspected with a zero degree rigid nasal endoscope in one hand
and a small nasal sucker in the other hand. With experience and
the use of the endoscope the point of bleeding can be identified in
the majority of patients (approximately 80%). Once identified
cauterization with either silver nitrate or electrocautery can be
done under endoscopic visualization. With this approach unnecessary nasal packing and admission can be avoided. However
if bleeding persists then nasal packing will be required. Options
here include BIPP gauze dressing, posterior Rapid Rhino packs,
Foley catheter posterior packing. Posterior packing is usually
done in conjunction with anterior nasal packing. Occasionally
bilateral nasal packs may be required to control a heavy bleed.
Undoubtedly pre-manufactured posterior packs such as the
Rapid Rhino are easier to insert and use, however they may not
always be available so knowledge of how to perform traditional
anterior/posterior nasal packing is essential. Typically a 12
French Foley catheter is used in conjunction with BIPP-impregnated inch ribbon gauze dressing. The Foley catheter balloon
should be tested with saline prior to use and all equipment as
discussed earlier should be set up ready. Nasal decongestion and
a topical local anaesthetic solution should be applied to the nasal
cavity on ribbon gauze dressing as before. The procedure is
explained to the patient and analgesia with paracetamol and
codeine can be offered. It is essential to have an assistant when
placing this type of packing. The Foley catheter is lubricated and
advanced into the nose until the tip can just be seen passing the
soft palate in the mouth. At this point the catheter needs to be
pulled back 1 cm as the balloon should be inflated in the nasopharynx. About 5e10 ml saline is used to inflate the balloon and
once inflated the catheter is pulled taught so that the balloon is
effectively occluding the posterior choanae at the back of the
nasal cavity. While your assistant maintains tension on the
catheter an anterior BIPP pack is placed tightly into the nasal
cavity by way of folding layers of ribbon on top of each other.
The catheter can then be secured at the front of the nose with an
umbilical clamp. Great care must be taken that the clamp is not
in direct contact with the skin of the nose as pressure necrosis
can occur early on and results in a lasting nasal deformity. BIPP
dressing at the front of the nose can be used to provide a barrier
between skin and the clamp. After insertion inspection of the

Posterior epistaxis
This tends to present with much heavier bleeding and many
patients will have signs of haemodynamic shock. Bleeding is
from larger arterial vessels, namely the sphenopalatine artery at
the back of the nasal cavity. There is usually a pattern of rapid
profuse bleeding over 10e20 minutes. It can be difficult to assess
which side the bleeding is from as blood tends to pour down into
the throat and out of both sides of the nose. As the vessel goes
into a reactionary vasospasm the bleeding subsides, however it
will most certainly start again as the vessel relaxes and opens up.
Therefore if you suspect this type of bleeding, even if it has
stopped it is unwise to send the patient home. Because much of
the bleeding goes down the back of the throat, it is then swallowed and some patients present with a clinical picture more like
an upper gastrointestinal bleed with haematemesis. This can be
an even more confusing picture in a patient with a background of
alcoholic liver disease, and a multidisciplinary approach with

Figure 2 From left to right: a) Rapid Rhino nasal pack b) Netcell tampon c)
Co-phenylcaine nasal spray d) Nasal dressing forceps e) Ribbon gauze f )
Silver nitrate cautery stick.

SURGERY 33:12

590

2015 Elsevier Ltd. All rights reserved.

HEAD AND NECK

pterygopalatine fossa. Here the neurovascular bundles are

encountered, the internal maxillary artery and any branches
identified and ligated or cauterized.

oropharynx is vital to make sure no packing or blood clots have

come into the throat and to check that the bleeding has stopped.
These packs are typically left in situ for not more than 24e48
hours with antibiotic prophylaxis and can provide effective
bleeding control before definitive intervention. This type of
packing is extremely uncomfortable and makes swallowing very
difficult, so regular analgesia should be prescribed. An interesting alternative treatment is hot water irrigation which has
shown efficacy in approximately 80% of patients treated; however this technique is not standard practice in the UK.10

External carotid artery ligation

Rarely performed, this procedure still has a role in refractory
bleeding not controlled by other means. The artery is approached
via a neck incision, the carotid vessels are found medial to the
sternocleidomastoid muscle which is retracted laterally. The
external artery must be differentiated from the internal carotid
artery by identification of at least two branches, before ligation.

Surgical intervention

Septal surgery
Septoplasty and submucous resection (SMR) have a role in epistaxis
management. Elevating the mucoperiosteum from the septum interrupts the blood supply here and provides effective bleeding
control.11 Straightening of the nasal septum is a useful adjunct for
other procedures where a deviated septum makes access difficult to
assess where the bleeding is coming from and to manage it.

Previously this was reserved for patients in whom nasal packing

has been ineffective, or where the patient has required repeated
re-packing to control bleeding. A falling blood count despite
apparent anterior control should also be taken into account.
However it is becoming more common practice to operate much
earlier in a patient with significant arterial bleeding reducing
prolonged nasal packing and admission. The type of surgical
intervention is tailored to the cause and site of bleeding.
Currently endoscopic sphenopalatine artery ligation is the commonest procedure performed.

Arterial embolization
Selective angiography and embolization of external carotid arterial
branches is an effective and comparatively successful (80e90%)
alternative to surgical arterial ligation. It is performed by an experienced interventional radiologist under local anaesthetic. Contraindications include severe atherosclerotic disease, untreated coagulopathies and allergy to contrast material. The risk of serious
cerebrovascular injury is around 4%.12 The choice of surgical
ligation or embolization depends on numerous factors including
patient status, availability of personnel and local resources.

Endoscopic sphenopalatine artery ligation

This is usually performed under general anaesthetic, but can be
done under local anaesthetic. The nasal cavity is inspected with a
zero degree endoscope to confirm the site of bleeding. Once
confirmed topical decongestion is administered. Using the
endoscope a small flap of lateral wall nasal mucosa is elevated
about a centimeter anterior to the posterior end of the middle
turbinate. A crest of bone (crista ethmoidalis) is found projecting
medially and the sphenopalatine foramen is encountered just
behind this. The sphenopalatine artery exits here and needs to be
closely inspected as it has variable branching patterns. The artery
and any associated branches are ligated with clips as near to the
foramen as possible, and are either divided or electro-cauterized
(Figure 4).

Medical therapies
There are numerous individual studies published looking at
various haemostatic products available and their efficacy in
epistaxis but as yet no overall consensus on their use. A review
of locally applied haemostatic agents in epistaxis had been proposed by a Cochrane collaborative group in 2011, however a final
report was never issued recommending any particular agents.13
Products include fibrin-based agents which are typically

Anterior ethmoidal artery ligation

Bleeding from the anterior ethmoidal artery is more common
following nasal trauma or iatrogenic following endo-nasal surgery. Traditionally it is ligated via an open approach, using a
Lynch incision in the medial canthus. However an experienced
surgeon may attempt endoscopic ligation. A sub-periosteal flap is
raised along the medial wall of the orbit until the vessel is
visualized approximately 24 mm posterior to the anterior
lacrimal crest. The posterior ethmoidal artery can be found about
a further 12 mm posteriorly. The artery is then clipped and
divided and/or cauterized. Care must be taken to avoid damage
to the optic nerve which lies in very close proximity to the posterior ethmoidal artery. The wound is irrigated, a small drain
inserted and closed.
Internal maxillary artery ligation
This has been mostly superseded by endoscopic sphenopalatine
artery ligation. Traditionally the artery is approached by an
incision in the buccal mucosa to gain entry into the maxillary
sinus via the canine fossa (CaldwelleLuc approach). The back
wall of the maxillary sinus is opened to reveal the

SURGERY 33:12

Figure 4 Picture demonstrating clips on the sphenopalatine artery. (Kindly

supplied by G. McGarry, Glasgow).

591

2015 Elsevier Ltd. All rights reserved.

HEAD AND NECK

packaged as a two-vial system containing fibrinogen, thrombin,

factor XIII and calcium. Other agents include gelatin, collagen,
and cellulose. Floseal is a gelatin and thrombin combination
which can be used for anterior and posterior epistaxis. However
a recent study looking at using Floseal in epistaxis has demonstrated only limited success.14 It is also a costly alternative to
traditional methods of cautery and nasal packing but may have a
limited role as second-line treatment particularly in frail patients
for whom a general anaesthetic is risky.15
Other agents tried have included topical IV tranexamic acid
soaked onto the nasal dressing or pack. There has also been more
recent interest in a natural product e microporous polysaccharide hemospheres (MPH). MPH is a bio-degradable substance derived from potato starch and is produced in spheres
ranging from 10 to 200 mm with tiny pores acting like a biological
sieve. The powerful osmotic action dehydrates and gels the blood
on contact to accelerate the natural clotting process.16

growth factor (VEGF), thus inhibiting blood vessel growth. It can

be given systemically or injected locally following KTP laser
ablation in the nose.17
A
REFERENCES
1 Petruson B, Rudin R. The frequency of epistaxis in a male population
sample. Rhinol 1975; 13: 129e33.
2 Watkinson JC. Epistaxis. In: Mackay IS, Bull TR, eds. Scott Browns
otolaryngology, 18. London: Butterworths, 1997; 5e7.
3 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: 444e6.
4 Nunez DA, McClymont LG, Evans RA. Epistaxis: a study of the relationship with weather. Clin Otolaryngol 1990; 15: 49e51.
5 Manfredini R, Portaluppi F, Salmi R, Martini A, Gallerani M. Circadian
variation in onset of epistaxis: analysis of hospital admissions. Br
Med J 2000; 321: 1112.
6 Qureishi A, Burton MJ. Interventions for recurrent idiopathic
epistaxis (nosebleeds) in children. Cochrane Database Syst Rev
Sept 2012. Issue 9. Art. No.: CD004461. http://www.ncbi.nlm.nih.
gov/pubmed/22972071.
7 Benninger MS. Epistaxis and its relationship to handedness with
use of intranasal steroid spray. Ear Nose Throat J 2008; 87:
463e5.
8 Oneal RM, Beil Jr RJ, Schlesinger J. Surgical anatomy of the nose. Clin
Plast Surg 1999; 32: 145e81.
9 Corbridge RJ, Djazaeri B, Hellier WP, Hadley J. A prospective randomized controlled trial comparing the use of merocel nasal tampons
and BIPP in the control of acute epistaxis. Clin Otolaryngol Allied Sci
1995 Aug; 20: 305e7.
10 Schlegel-Wagner C, Siekmann U, Linder T. Non-invasive treatment of
intractable posterior epistaxis with hot-water irrigation. Rhinol 2006;
44: 90e3.
11 Cumberworth VL, Narula AA, Bradley PJ. Prospective study of two
management strategies for epistaxis. J R Coll Surg Edinb 1991; 36:
259e60.
12 Cullen MM, Tami TA. Comparison of internal maxillary artery ligation
versus embolization for refractory posterior epistaxis. Otolaryngol
Head Neck Surg 1998; 118: 636e42.
13 Kullar P, Weerakkody R, Cathcart R, Yates P. Locally applied haemostatic agents in the management of acute epistaxis (nosebleeds).
Cochrane Database Syst Rev 2011. Issue 10. Art. No.: CD009373.
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009373/
abstract.
14 Khan MK, Reda El Badawey M, Powell J, Idris M. The utility of FloSeal
haemostatic agent in the management of epistaxis. J Laryngol Otol
2015; 129: 353e7.
15 Cote D, Barber B, Diamond C, Wright E. FloSeal hemostatic matrix in
persistent epistaxis: prospective clinical trial. J Otolaryngol Head
Neck Surg 2010; 39: 304e8.
16 Humphreys MR, Castle EP, Andrews PE, Gettmann MT, Ereth MH.
Microporous polysaccharide hemispheres for management of
laparoscopic trocar injuries to the spleen. Am J Surg 2008; 195:
99e103.
17 Simonds J, Miller F, Mandel J, Davidson TM. The effect of bevacizumab (Avastin) treatment on epistaxis in hereditary hemorrhagic
telangiectasia. Laryngoscope 2009; 119: 988e92.

Hereditary haemorrhagic telangiectasia (HHT)

HHT, also known as OslereRendueWeber disease is an autosomal dominant genetic disease characterized by the presence of
malformed, ectatic vessels in the skin, mucosa and viscera
(Figure 5). The small telangiectasias in the nasal cavity rupture
very easily causing recurrent epistaxis. Chronic respiratory and
gastrointestinal bleeding leads to serious health problems which
can be life threatening so many of these patients are frail and
extra care is needed in managing their epistaxis. As well as
traditional cautery and nasal packing, other treatments include
laser ablation of the telangiectasias, septodermoplasty (split skin
grafting), and closure of the nasal cavity e Youngs procedure.
Permanent surgical closure of the nasal cavity prevents bleeding
by removing desiccating airflow which is thought to lead to
rupture of the fragile telangiectasias.
These patients need a multidisciplinary approach and more
recently in collaboration with haematologists and oncologists
there has been success using bevacizumab e an anti-cancer
therapy. This agent works by blocking vascular endothelial

Figure 5 Intra-oral mucosal telangiectasia on hard palate in a patient with

hereditary haemorrhagic telangiectasia. (Reproduced care of: Herbert L.
Fred, MD and Hendrik A. van Dijk).

SURGERY 33:12

592

2015 Elsevier Ltd. All rights reserved.