Updated: 12/17/2021

Epistaxis

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  • Snapshot
    • A 8-year-old boy presents to the pediatric emergency department for a nose bleed. His symptoms began after he was hit in the face with a basketball. He denies any shortness of breath, hemoptysis, or hematemesis. Family history is unremarkable. On physical examination, there is small volume bleeding. He is asked to bend at the waist and press on his nasal alae. Hemostasis is eventually achieved.
  • Introduction
    • Overview
      • acute bleeding from the nasopharynx or the nose
    • Associated conditions
      • nasal trauma
  • Epidemiology
    • Demographics
      • occurs in children or in the elderly (most common)
    • Risk factors
      • digital trauma to the nose (most common)
      • nasal mucosal drying (e.g., dry air)
      • rhinitis
      • septal deviation
      • coagulopathy
      • medications (e.g., antiplatelet and anticoagulant therapy)
      • foreign body
  • ETIOLOGY
    • Pathophysiology
      • anterior nose bleed
        • damage to Kiesselbach plexus which results in bleeding
      • posterior nose bleed
        • damage to the posterolateral branches of sphenopalatine artery
          • can be severe and life-threatening
  • Presentation
    • Symptoms
      • bleeding from the nose
        • anterior nose bleed
          • small volume bleed
        • posterior nose bleed
          • large volume bleed
  • Studies
    • Nasal endoscopy
    • Serum studies
      • in cases of severe bleeding
        • complete blood count
        • type and screen
        • PT/INR and aPTT
  • Differential
    • Hemoptysis
      • differentiating factors
        • blood with coughing
        • signs of respiratory distress
    • Hematemesis
      • differentiating factors
        • bloody emesis
        • history of gastrointestinal illness (e.g., peptic ulcer disease)
        • melena
    • Malignancy/mass
      • juvenile angiofibroma
        • assess with CT/MRI
  • Treatment
    • Conservative and lifestyle
      • squeeze alae and bend at the waist
        • indication
          • initial management in anterior nose bleeds
      • anterior nasal packing
        • indication
          • performed in patients with presumed anterior nose bleeds when cautery fails
      • posterior nasal packing
        • indication
          • performed when hemostasis is not achieved with anterior nose packing
            • increases the suspicion for posterior nose bleeds
    • Medical and pharmacologic
      • oxymetazoline
        • indication
          • initial management in anterior nose bleeds
    • Surgical and interventional
      • cautery
        • indication
          • performed when an anterior nose bleed is identified via rhinoscopy and conservative measures and oxymetazoline is unsuccessful
        • modality
          • chemical (e.g., silver nitrate)
          • electrical
      • endoscopic ligation or embolization
        • indication
          • performed after hemostasis is not achieved with posterior nasal packing
  • Complications
    • Hypovolemia
    • Angina and myocardial infarction
  • Prognosis
    • Most nosebleeds are benign and self-limiting
    • Most cases of anterior epistaxis are responsive to local treatment
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Questions (5)

(M2.ET.17.4828) A 16-year-old boy presents to the emergency department due to right-sided hearing loss, headache, and nasal bleeding. He reports that for the past few months, he has found it difficult to breathe through his nose and has had nasal drainage. He also states that he has not been able to stop his nose from bleeding for the last few hours. His right-sided hearing loss began around the same time as his difficulty with nasal breathing. He denies any history of trauma to the nose, uncontrollable bleeding, and easy bruising. His family history is unremarkable. His temperature is 99°F (37.2°C), blood pressure is 112/67 mmHg, pulse is 95/min, and respirations are 20/min with an oxygen saturation of 99%. On physical examination, the patient appears anxious. There is an amber fluid collection in the right ear appreciated on otoscopy. Physical exam is notable for the finding in Figure A which does not remove with irrigation or the patient blowing their nose. Which of the following is the most appropriate next step in management?

QID: 109461
FIGURES:

Biopsy

11%

(35/320)

CT head

21%

(68/320)

Intranasal phenylephrine

15%

(47/320)

Radiotherapy

1%

(4/320)

Surgical resection

51%

(163/320)

M 6 C

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(M3.ET.13.14) A 14-year-old boy presents to the emergency department with an intractable nosebleed. Pinching of the nose has failed to stop the bleed. The patient is otherwise healthy and has no history of trauma or hereditary bleeding disorders. His temperature is 98.9°F (37.2°C), blood pressure is 120/64 mmHg, pulse is 85/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam is notable for multiple clots in the nares which, when dislodged, are followed by bleeding. Which of the following location is the most likely etiology of this patient's symptoms?

QID: 102613

Carotid artery

0%

(0/11)

Ethmoidal artery

0%

(0/11)

Kiesselbach plexus

100%

(11/11)

Septal hematoma

0%

(0/11)

Sphenopalatine artery

0%

(0/11)

M 11 E

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Evidence (2)
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EXPERT COMMENTS (3)
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