Central Annals of Otolaryngology and Rhinology

Review Article *Corresponding author

Epistaxis Diagnosis and

Jose Luis Treviño González, Department of
Otolaryngology and Head and Neck Surgery, University
of Nuevo Leon, Medicine School and University Hospital,

Treatment Update: A Review

Mexico, USA, Tel: +83334846; Email:

Submitted: 15 May 2017

German A. Soto-Galindo and José Luis Treviño González* Accepted: 27 June 2017
Published: 28 June 2017
Department of Otolaryngology and Head and Neck Surgery, University of Nuevo Leon,
Medicine School and University Hospital, USA ISSN: 2379-948X
Copyright
© 2017 González et al.
Abstract
Epistaxis is a nose hemorrhage of a very variable severity. This entity is the most frequent chief OPEN ACCESS
complaint in the emergency room involving the Otolaryngology Department. It is categorized into
anterior and posterior epistaxis depending on the affected area. Anterior bleedings are easier Keywords
to treat and luckily they account to the 80% of cases. The correct identification of the bleeding site • Epistaxis
and its etiology is vitally important for a successful treatment. Visualization of the bleeding site is • Endoscopic surgery
usually achieved by rhinoscopy, but in some cases nasal endoscopy is needed. The first measure • Artery ligation
that needs to be taken is local pressure. If the bleeding persists, the correct identification of the • Cauterization
site and chemical cauterization with silver nitrate should be performed. Electrical cauterization
is indicated if the previous treatment fails. Surgical intervention is recommended if bleedings
are refractory to conservative treatment. There is a variety of surgical approaches with specific
indications and different success rates described in the manuscript.

INTRODUCTION Relevant Anatomy

Epistaxis or nasal bleeding may be manifested as an isolated
emergency, as a chronic disorder by recurrent bleeding events,
or as a symptom of a generalized pathology. Nose bleedings
are the most common chief complaint in the emergency room
referred to otolaryngologists. They account to 1 in 200 visits to
the emergency department.
Literature states that 60% of the population will suffer from
epistaxis at least one time in their lifetime, and only 6% of them
will require medical attention to stop the bleeding. The incidence
of the event increases from age 20 and its highest rates peaks in
the elderly [1].
The nasal bleedings are more common in winter than in other
seasons. Meteorological variations such as barometric pressure,
humidity and temperature changes affect the nasal vessels and
may explain the seasonal fluctuations [2].
When epistaxis presents as severe, recurrent bleedings, the
physician must suspect an underlying cause, such as Hereditary
Haemorragic Telangiectasia or Juvenile Nasal Angiofibroma, in
teenage boys [3].
The whole entity is divided into two main groups: anterior
and posterior epistaxis, depending on its anatomical site of origin.
Anterior epistaxis commonly develops from the Kiesselbach´s
plexus on the lower anterior portion of the nasal septum, also
known as little area. Anterior epistaxis is the most common
presentation with a frequency of 80%. Posterior epistaxis arises
from the posterior nasal septal artery, which is a branch of the
sphenopalatine artery [4].
Septum is irrigated by two mayor artery compounds:
the internal and external carotid arteries. Both compounds
communicate with each other forming an artery plexus. Internal
carotid artery is implicated in the septum irrigation by arising the
posterior and anterior ethmoidal arteries. The external carotid
artery is involved in this anatomical site by giving the maxillary
and facial arteries.
External Carotid compound
Facial Artery. It arises from the anterior surface of the
external carotid, it gives rise to eight branches, and ends in the
angular artery which is the terminal artery. One of the vessels
that arises from the facial artery is the lateral nasal branch which
runs by the nasogenian fold and irrigates the nasal ala and nasal
lobe. Also, the subseptal artery arises from the anastomosis of
the left and right superior labial arteries, and it is involved in the
irrigation of the anteroinferior septal wall [5].
Maxillary Artery. This vessel runs from the infratemporal
region to the sphenopalatine foramen and it gives rise to four
groups of arteries in a total of 16 branches. The fourth group
is the one implicated in epistaxis. One of the branches of this
group is the palatine artery, which irrigates the soft palate and
the palatine vault, runs through the greater palatine foramen
becoming the greater palatine artery. The terminal branch of the
maxillary artery is the sphenopalatine artery. It goes through
the sphenopalatine foramen and divides into the posterolateral
nasal artery and the posterior septal artery. The first one gives
rise to three branches which irrigate the turbinate region and

Cite this article: Soto-Galindo GA, Treviño González JL (2017) Epistaxis Diagnosis and Treatment Update: A Review. Ann Otolaryngol Rhinol 4(4): 1176.

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the middle and inferior meatus. The second one gives a branch
that irrigates the superior turbinate and then runs through the
nasal septum until it anastomoses with the terminal branch of the
major palatine artery [5–7].
Internal Carotid compound
Ethmoidal Arteries. The ophthalmic artery, branch of the
internal carotid, gives rise to the anterior and posterior ethmoidal
arteries. The first one rises from the anterior ethmoidal foramen
and irrigates the frontal and anterior ethmoidal sinuses. Then it
gives rise to branches which irrigate the superior portion of the
septum and the lateral nasal wall. The second one is implicated
in the irrigation of the posterior region of the lamina cribosa [7].
Kiesselbach Area
This area is also called Little´s area and it is irrigated by
branches of the sphenopalatine artery, grater palatine artery and
facial artery. This area is composed of potentially vulnerable thin
large vessels. It’s a site of great relevance, being the most affected
portion in anterior Epistaxis [8].
SIGNS AND SYMPTOMS
The clinical appearance of a patient with an epistaxis event
will depend on the etiology of the underlying pathology. However,
patients may be emotionally altered due to the evident blood loss
they are observing. This anxiety may cause an increase in blood
pressure and tachycardia.
DIAGNOSIS
Clinical diagnosis is commonly evident and presents no
challenge for physicians to identify. Usually, a headlight and a
rhinoscope may be enough to identify the bleeding area. However,
the etiological diagnosis may be complicated in some cases due
to the wide variety of pathological entities that predisposes
epistaxis events.
The etiological diagnoses in nose bleedings are classified into
two major factors: local and systemic. However, in more than half
of the events the specific etiology is not found [9].
Local Factors
These factors commonly produce nose bleeding by altering
the normal physiology of the nasal mucosa and its vessels. Facial
trauma including nose picking is most relevant during infancy.
Foreign bodies and insertion of medical materials such as
nasogastric tube or nasotraqueal intubation are also a cause of
epistaxis. Infectious and inflammatory entities such as sinusitis,
rhinitis and allergies; and topical decongestants and drugs like
cocaine are also local factors contributing to nose bleeding events
[9].
Systemic Factors
These causes are associated with epistaxis, and the most
common systemic factors include pathologies that increase
the blood pressure, cardiovascular disease, factors that alter
the coagulation processes, and inherited or acquired blood
dyscrasias [10].
The theory that states that hypertension is the cause of
Ann Otolaryngol Rhinol 4(4): 1176 (2017)
González et al. (2017)
Email:
epistaxis is still in debate. There is plenty of evidence that supports
the association of high blood pressure in Epistaxis [11,12]. Some
authors, as Moriyuki, have found that systolic blood pressure is
significantly higher in patients with Epistaxis [13]. However, in
one study, the author measured the blood pressure of patients
during the bleeding event and it showed no difference to the one
measured on routine situations [14].
Cardiovascular factors are associated with the risk of epistaxis
events due to the volume overload and increased pressure in
venous vessels, triggering rupture of the thin arteries in the
Kiesselbach area. This factors include congenital heart failure,
mitral stenosis, coarctation of the aorta, and superior vena cava
obstruction.
Coagulation dysfunctions are usually developed by
medication such as non-steroidal anti-inflammatory drugs,
clopidogrel and warfarin. Lymphoproliferative diseases, chronic
alcohol intake, renal and liver dysfunction are also related to
platelet/coagulation dysfunction [15].
One third of patients with recurrent epistaxis have and
underlying hemostatic disorder, such as coagulation factor
deficiencies, Von Willebrand disease, and several rare inherited
platelet function disorders. [16]]
TREATMENT
[Anterior epistaxis are simpler and easier to treat. Since the
80% of nasal bleedings are anterior, the most part of this events
are solved with conservative treatment.
Medical therapy
Usually, non-severe epistaxes are stopped by applying local
pressure in the affected area. However, if this approach does
not solve the hemorrhage, the first line of treatment is chemical
cauterization with silver nitrate. As stated by the Guidelines of
the French Society of Otolaryngology, this initial treatment is less
aggressive for the mucosa. In case of failure, electric cauterization
should be performed [17].
There is controversy when it comes to decide whether to
use chemical/electrical cauterization or nasal packing with
vasoconstrictor agents. Some authors claim that when a single
site of anterior bleeding is identified, a phenylephrine or
oxymetazoline solution are effective examples of vasoconstrictor
drugs, and re inspection must be done after at least five minutes
of direct pressure to the nasal septum with cotton pledges soaked
in vasoconstrictor agents, previously placed in the anterior
portion of the septum [18].
On the other hand, a newer study work showed evidence
that suggest the effectiveness of electro cauterization. It showed
better results over the nasal packing, which presented more
bleeding recurrences. It stated that electrocautery must be the
first-choice treatment in all sites of bleeding, and nasal packing
should be inadvisable for posterior bleedings due to the pain [19].
If nasal packing is decided, topical antibiotic should be placed
in the pack. It should not be left more than five days to prevent
infections, and the most serious complication: toxic shock. Also,
oral antibiotics should be prescribed for as long as the packs
remain in the nose [20].
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Surgical
Conservative medical treatment should be the first choice,
surgical and interventional treatments are only indicated when
epistaxis could not be controlled by the first mentioned [21].
Endoscopic cauterization
A number of studies show that endoscopic cauterization for
posterior bleedings are a very effective non radical approach.
A recent study published in 2016, concludes that endoscopic
monopolar cauterization is a non-invasive, well-tolerated,
effective and reliable procedure to perform for control in
intractable Epistaxis [22]. Success rates of this approach round
from 80 to 90% [23].
Artery Embolization
When initial treatment fails, determine where the bleeding
by angiography is, identify potential anastomoses to the carotid
siphon and ophthalmic artery to avoid serious complications
such as stroke or blindness, control angiography, platinum coils
and gelfoam may be used to occlude the bleeding artery. Gelfoam
powder may embolize to distally and cause necrosis or nerve
plasy, failure is associated with bleeding from the ethmoidal
branches of the ophthalmic artery, but it is not indicated for the
risk of blindness [23,24].
Artery Ligation
Maxillary artery ligation is frequently performed by the
Caldwell-Luc approach. Complications: upper teeth pain,
intraorbital neuralgia, oroantral fistula, sinusitis, damage to the
sphenopalatine ganglion, and blindness is rare. Prevalence of
complications is 28% [25].
Anterior ethmoid artery ligation was first made by an
external approach, though a Lynch incision. With the advances in
endoscopic technology, the endoscopic anterior ethmoidal artery
ligation is a very effective surgical treatment. Authors researching
this technique suggest to perform this surgical approach only
when the anterior ethmoidal artery is clearly visible. If not, an
external approach should be offered. However, there this artery
was correctly identified in 98.5% of cases in a study published in
2011 [26].
The surgeon should be familiarized with the anatomy of
this artery to avoid complications such as Cerebro Spinal Fluid
leak. Other complications of this surgical approach are scarring,
edema, and facial ecchymosis [27].
Endoscopic sphenopalatine artery ligation is also another
approach for posterior epistaxis, with evidence that show good
results in its use. It is performed by an incision in the dorsally
to posterior portion of the attachment of the middle turbinate.
A mucosal flap is elevated and the sphenopalatine artery is
exposed, clipped, and ligated [28].
However, there is a study published in 2014 that compared
endoscopic techniques. Authors of this work conclude that both
techniques are very effective. The study also showed that anterior
ethoid artery ligation is more effective than sphenopalatine
artery ligation [29].
Ann Otolaryngol Rhinol 4(4): 1176 (2017)
González et al. (2017)
Email:
DISCUSSION & CONCLUSION
After extensive research, we conclude that epistaxis is a
pathological entity with countless implications, being the most
common otolaryngological emergency. There is no standard
classification for the severity of the hemorrhage and it may
vary from patient to patient. Specific treatment will depend of
the artery that its involved. The most fundamental action for an
effective treatment is the correct identification of the bleeding
artery. We suggest more and deeper studies to continue to
expand the knowledge of these hemorrhagic events.
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Cite this article
Soto-Galindo GA, Treviño González JL (2017) Epistaxis Diagnosis and Treatment Update: A Review. Ann Otolaryngol Rhinol 4(4): 1176.
Ann Otolaryngol Rhinol 4(4): 1176 (2017)
González et al. (2017)
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