Chapter 205: Epistaxis Management

INTRODUCTION

Epistaxis is an extremely common condition in the United States with an incidence estimated at 10 per 10,000 people per year and a lifetime incidence of approximately 60%.¹ It is a common reason for patient visits to the Emergency Department. Epistaxis has a bimodal age distribution with an early peak in those less than 10 years of age.² The frequency of epistaxis decreases in the teens followed by a progressive increase after 20 years of age with the highest frequency in the elderly.² Epistaxis is usually the result of intranasal trauma. It may be the initial sign of a more serious underlying systemic illness.³ Epistaxis is often self-limited and can be managed conservatively.⁴ Epistaxis can also manifest as a profuse spontaneous hemorrhage that is extremely difficult to control and can result in aspiration, hypotension, cardiovascular collapse, syncope, and airway compromise.

The proper management of epistaxis and the prevention of adverse consequences depend on a timely and thorough evaluation of the patient, appropriate intervention, and expeditious intervention. The Emergency Physician must be familiar with a variety of techniques to control intranasal hemorrhage (Figure 205-1).^5-8

ANATOMY AND PATHOPHYSIOLOGY

An understanding of the vascular anatomy supplying the nasal cavity is essential to the efficient and timely control of epistaxis. The blood supply to the sinonasal cavity arises from branches of the internal and external carotid arteries (Figure 205-2). The sphenopalatine artery is the primary blood supply to the sinonasal cavities. The sphenopalatine artery arises from the terminal branches of the internal maxillary artery which is a branch of the external carotid system. The anterior and posterior ethmoid arteries, the terminal branches of the internal carotid system, supply blood to the superior straits of the nose. The superior labial branch of the facial artery supplies the anterior nasal cavity and anastomoses with branches from the anterior ethmoid artery and the sphenopalatine artery in Little’s area of the anterior and inferior nasal septum known as Kiesselbach’s plexus (Figure 205-3). It has been estimated that 90% of all nasal bleeding occurs anteriorly in Kiesselbach’s plexus.⁹ This is particularly true for children and young adults. Older adults have a higher incidence of bleeding from the posterior nasal cavity which receives its blood supply from branches of the sphenopalatine and posterior ethmoidal arteries. It is in Woodruff’s area located at the posterior end of the inferior turbinate. Atherosclerosis and use of anticoagulants are often causes of epistaxis in the elderly.⁹