Residency · Residency · Otolaryngology

Epistaxis: Systematic Management

Overview

Epistaxis is one of the most common ENT emergencies, with a lifetime prevalence of approximately 60%. Most episodes are minor and anterior, managed with simple measures. However, posterior epistaxis and refractory bleeding require systematic escalation including nasal packing, endoscopic cautery, and arterial ligation or embolization. A structured approach is essential.

Nasal Vascular Anatomy

Arterial Supply (Dual Supply)

External carotid artery system: Internal maxillary artery (terminal branch of ECA) gives rise to: Sphenopalatine artery (SPA): most important artery in posterior epistaxis; enters the nasal cavity through the sphenopalatine foramen (posterior to the middle turbinate attachment); branches into posterior lateral nasal artery and posterior septal artery. Descending palatine artery -> greater palatine artery (enters nasal floor via incisive foramen). Facial artery -> superior labial artery (anterior septum). Internal carotid artery system: Ophthalmic artery gives rise to: Anterior ethmoidal artery: crosses the ethmoid roof; supplies the anterior-superior septum and lateral wall. Posterior ethmoidal artery: supplies the posterior-superior septum.

Kiesselbach Plexus (Little Area)

Anterior-inferior nasal septum. Anastomosis of: anterior ethmoidal artery, sphenopalatine artery (posterior septal branch), superior labial artery, greater palatine artery. Site of ~90% of epistaxis episodes (anterior epistaxis).

Woodruff Plexus

Posterior nasal cavity, near the posterior end of the inferior turbinate. Venous plexus (not true arterial anastomosis), Associated with posterior epistaxis.

Etiology

Local Causes

Digital trauma (nose picking) -- most common cause, Mucosal dryness (dry climate, heated environments), Nasal septal deviation with exposed spurs, Nasal surgery or trauma, Nasal foreign body. Sinonasal tumors (juvenile nasopharyngeal angiofibroma, inverted papilloma, SCC). Rhinosinusitis and allergic rhinitis, Nasal oxygen or CPAP use, Intranasal drug use (cocaine), Topical nasal steroids (minor mucosal irritation).

Systemic Causes

Anticoagulant/antiplatelet therapy (warfarin, DOACs, aspirin, clopidogrel). Coagulopathy (liver disease, renal failure, DIC). Hereditary hemorrhagic telangiectasia (HHT / Osler-Weber-Rendu). Von Willebrand disease and other platelet disorders. Hypertension (does not cause epistaxis but may prolong bleeding). Hematologic malignancies.

Initial Assessment

ABCs and Resuscitation

Assess hemodynamic stability; IV access, fluid resuscitation if significant bleeding. CBC, coagulation studies (PT/INR, PTT), type and screen for severe cases. Reverse anticoagulation if life-threatening hemorrhage.

History

Side of bleeding, duration, frequency, volume, Anticoagulant/antiplatelet use, Prior epistaxis episodes and treatments, Family history of bleeding disorders (HHT), Nasal surgery history.

Examination

Patient upright, leaning forward (reduces swallowing blood). Suction and headlight, Anterior rhinoscopy with nasal speculum. Topical decongestion (oxymetazoline or 1:1000 epinephrine on cotton pledgets) + topical anesthetic (4% lidocaine). Nasal endoscopy if anterior source not identified.

Management Algorithm

Step 1: First Aid Measures

Firm, continuous pressure on the nasal ala (pinching the soft nose) for 15-20 minutes without releasing. Upright, forward-leaning position, Topical oxymetazoline spray.

Step 2: Anterior Cautery

If a discrete anterior bleeding point is identified: Silver nitrate cautery: apply to the bleeding point for 5-10 seconds after drying the area; cauterize around the vessel, then directly on it. Cauterize ONE side of the septum only (bilateral cautery risks septal perforation). Electrocautery: bipolar or monopolar suction cautery for more active bleeding.

Step 3: Anterior Nasal Packing

If cautery fails or bleeding point not identified: Absorbable packing: Surgicel, Gelfoam, FloSeal (thrombin-gelatin matrix) -- do not require removal. Non-absorbable packing: Merocel (expandable PVA sponge), Rapid Rhino (inflatable balloon with carboxymethylcellulose coating). Ribbon gauze packing (Vaseline gauze or antibiotic-impregnated): layered from floor to roof, front to back. Coat with antibiotic ointment; leave in place 24-72 hours. Prophylactic antibiotics controversial but commonly prescribed to prevent toxic shock syndrome (rare).

Step 4: Posterior Nasal Packing

Indicated when anterior packing fails or posterior source identified. Posterior balloon: Foley catheter (10-14 Fr) placed through the nose, balloon inflated in nasopharynx with 7-15 mL saline, traction applied anteriorly; anterior packing placed in front. Dual-balloon devices: Rapid Rhino posterior (epistaxis catheter) with both anterior and posterior balloons. Posterior packing requires hospital admission: risk of respiratory compromise, vasovagal response, and cardiac arrhythmia (nasopulmonary reflex). Monitor oxygen saturation; consider ICU or monitored bed.

Step 5: Surgical / Interventional Management

Endoscopic Sphenopalatine Artery Ligation (ESPAL)

Gold standard surgical treatment for refractory posterior epistaxis. Performed endoscopically; sphenopalatine foramen identified at the posterior attachment of the middle turbinate (crista ethmoidalis). Mucosal flap elevated; artery identified and clipped or cauterized. Success rate: 90-98%. Advantages: targeted, low morbidity, shorter hospital stay than packing.

Anterior Ethmoidal Artery Ligation

For superior/anterior bleeding not controlled by SPA ligation. External approach: Lynch incision (medial orbital); artery identified at the frontoethmoidal suture line, ~24 mm posterior to the anterior lacrimal crest. Clip or cauterize; do NOT transect (retraction into orbit causes retrobulbar hematoma). Endoscopic approach also described.

Endovascular Embolization

Performed by interventional radiology. Selective catheterization of the internal maxillary artery or its branches. Success rate: 80-90%. Risks: stroke (if ICA territory embolized), facial nerve injury, soft tissue necrosis. Cannot embolize anterior/posterior ethmoidal arteries (ICA branches -- risk of retinal artery embolization and blindness). Reserved for surgical failures or when surgery is not feasible.

Hereditary Hemorrhagic Telangiectasia (HHT / Osler-Weber-Rendu)

Genetics

Autosomal dominant; penetrance increases with age. HHT1: ENG gene (endoglin) -- more pulmonary AVMs. HHT2: ACVRL1 gene (ALK1) -- more hepatic AVMs. SMAD4 mutations: HHT + juvenile polyposis.

Curacao Diagnostic Criteria (3 of 4 = definite HHT)

Definite HHT: 3 or more criteria; Possible: 2 criteria; Unlikely: 0-1 criteria

Spontaneous, recurrent epistaxis. Mucocutaneous telangiectasias (lips, oral cavity, fingers). Visceral AVMs (pulmonary, hepatic, cerebral, GI). First-degree relative with HHT.

Management of HHT-Related Epistaxis

Nasal humidification and moisturizing (saline, emollients), Avoid digital trauma and nasal drying. Topical therapies: bevacizumab (anti-VEGF) nasal spray, tranexamic acid spray. Laser cauterization: KTP or Nd:YAG laser for telangiectasias (pulsed, low power to avoid septal perforation). Septodermoplasty (Young procedure): replacement of nasal mucosa with skin graft (reduces epistaxis but impairs smell). Nasal closure (Young procedure modified): complete closure of nostrils as last resort for severe, life-threatening epistaxis. Systemic bevacizumab: IV infusion for severe, transfusion-dependent HHT epistaxis. Screen for pulmonary AVMs (contrast echocardiography), cerebral AVMs (MRI brain).

<image>Anatomical diagram of the nasal septal blood supply showing the arterial contributions to Kiesselbach plexus (Little area). The anterior ethmoidal artery, posterior ethmoidal artery, sphenopalatine artery (posterior septal branch), superior labial artery (branch of facial artery), and greater palatine artery are shown converging at the anterior-inferior septum. The Woodruff plexus at the posterior nasal cavity is also indicated. The nasal septum is shown in sagittal view with each artery color-coded by parent vessel (internal carotid system in blue, external carotid system in red).</image>

<image>Step-by-step illustration of endoscopic sphenopalatine artery ligation. Panel A: endoscopic view of the left nasal cavity with the middle turbinate and posterior attachment visible. Panel B: mucosal incision and flap elevation at the sphenopalatine foramen, identified by the crista ethmoidalis landmark posterior to the middle turbinate. Panel C: the sphenopalatine artery and its branches identified exiting the foramen. Panel D: artery clipped with hemoclips. The posterior lateral nasal artery and posterior septal artery branches are labeled.</image>

<image>Management algorithm flowchart for epistaxis. Starting with initial assessment and first aid (pinch nose for 20 minutes), then anterior examination and cautery if source identified, followed by anterior packing if cautery fails, then posterior packing if anterior packing fails (with hospital admission indicated), then definitive surgical management (endoscopic SPA ligation or embolization). Decision points for checking coagulation status, anticoagulant reversal, and HHT screening are included at appropriate steps.</image>

Clinical Pearls

Most epistaxis is anterior (Kiesselbach plexus) and manageable with sustained pressure, topical decongestion, and silver nitrate cautery. Never cauterize both sides of the septum at the same location -- risk of septal perforation. Posterior packing mandates hospital admission and monitoring due to risk of respiratory compromise and cardiovascular events. Endoscopic sphenopalatine artery ligation has largely replaced posterior packing as definitive management for refractory posterior epistaxis at many centers. Always ask about anticoagulant use; reversal may be needed for life-threatening hemorrhage but involves multidisciplinary decision-making. The anterior ethmoidal artery is an ICA branch -- it cannot be safely embolized; ligation must be surgical. In young males with recurrent unilateral epistaxis and nasal mass, rule out juvenile nasopharyngeal angiofibroma (do NOT biopsy in clinic -- CT/MRI/MRA first). HHT should be suspected in any patient with recurrent, bilateral epistaxis and family history; screen for visceral AVMs.

References

• Tunkel DE, Anne S, Payne SC, et al. "Clinical Practice Guideline: Nosebleed (Epistaxis)." Otolaryngol Head Neck Surg. 2020;162(1_suppl):S1-S38.
• Kumar S, Sievert W, Ahmed S, et al. "Endoscopic sphenopalatine artery ligation for epistaxis." J Laryngol Otol. 2013;127(10):987-990.
• Faughnan ME, Mager JJ, Hetts SW, et al. "Second International Guidelines for the Diagnosis and Management of HHT." Ann Intern Med. 2020;173(12):989-1001.
• Christensen NP, Smith DS, Barnwell SL, Wax MK. "Arterial embolization in the management of posterior epistaxis." Otolaryngol Head Neck Surg. 2005;133(5):748-753.

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