Goroll_Primary Care Medicine, 8e

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Chapter 213 Approach to Epistaxis

anterior septal mucosal atrophy and may be followed by frank ulcer formation or, in rare cases, septal perforation. Bleeding Diatheses (see also Chapter 81) Patients taking oral anticoagulants, high-dose aspirin, and other antiplatelet agents may present with complex epistaxis, sometimes with multiple sites of bleeding, unresponsive to standard conservative measures. Spontaneous and often severe nosebleeds are the most common initial presentation of heredi tary hemorrhagic telangiectasia ( Osler-Weber-Rendu syndrome ). The bleeding can be severe enough to be life-threatening and commonly causes anemias severe enough to require transfu sion. Its pathogenesis is the result of a genetically determined imbalance between angiogenesis and antiangiogenetic factors. Characteristic features include telangiectasias on the nasal mucosa, lips, and tongue; a positive family history; visceral arteriovenous malformations; and onset of repeated bleeding episodes by the third or fourth decade. Adolescent boys with a nasopharyngeal angiofibroma experience repeated bouts of brisk posterior epistaxis. Sinus x-rays or computed tomographic scan imaging with contrast demonstrate a nasopharyngeal mass. Inflammatory and Neoplastic Conditions Wegener granulomatosis , midline granuloma , and nasal malignancy share a presentation of epistaxis, unremitting sinus infection, and opacified sinuses on three-dimensional imaging. Posterior epistaxis, most commonly due to bleeding from the sphenopala tine plexus deep in the nose, is commonly attributed to hyper tension, but epidemiologic studies show that few hypertensive individuals experience nosebleeds. Site of Bleeding Regardless of the etiology, the site of bleeding has distinguish ing clinical characteristics. Anterior Epistaxis Active anterior epistaxis usually presents as unilateral, continuous, moderate bleeding from the anterior septum called the Kiesselbach plexus. Recurrent episodes of bleeding, lasting from a few minutes to half an hour over the preceding few days and controlled by pinching the anterior nose, are characteristic. Most adult cases and almost all spontaneous nasal hemorrhage in children occur on the anterior aspect of the nasal septum. Most are venous, but an arte rial source becomes more common with advancing age because of mucosal and vascular atrophy. Anterior epistaxis remains the most common site for patients taking antiplatelet agents. Anterior nose bleeds account for roughly 90% of all epistaxis episodes. Posterior Epistaxis Posterior epistaxis is associated with intermittent, very brisk arterial bleeding, with blood flowing posteriorly into the phar ynx unless the patient is leaning forward. When the patient is leaning forward, the blood may run from one or both sides of the nose. Spontaneous posterior hemorrhage is more common in the older age groups and after severe facial trauma with mul tiple facial fractures. The vessel rupture is usually just superior or inferior to the posterior tip of the inferior turbinate on the lateral nasal wall from the sphenopalatine artery. DIFFERENTIAL DIAGNOSIS (1–4) The differential diagnosis of nosebleeds can be divided into local and systemic disorders (Table 213-1). The local causes are most commonly inflammatory or traumatic. More than 90% of bleeds are related to local irritation; most occur in the absence of a specific underlying anatomic lesion.

Table 213-1 Major Causes of Epistaxis Local Disease

Systemic Disease

Dry indoor environment Upper respiratory infection Chronic sinusitis Trauma (nose picking, forceful blowing) Occupational exposure to irritants Cocaine abuse Angiomas Allergies Lack of humidification Malignancy Nasal steroid sprays Pyogenic granuloma (pregnancy)

Granulomatous disease (Wegener, sarcoidosis) Hereditary hemorrhagic telangiectasia Infection (chickenpox, influenza) Bleeding diathesis Malignant hypertension

WORKUP (1–5) History

History should begin with inquiry into the amount of bleeding, duration, and frequency. After the bleeding is under control, the patient can be questioned about easy bruising, hematuria, melena, heavy menstrual periods, family history of bleeding disorders, the use of oral anticoagulants or drugs with anti platelet effects (e.g., aspirin, NSAIDs), occupational exposure to irritating chemicals or dust, dry home, chronic cocaine use, and repeated nose blowing or picking. Patients should be que ried about any previous nasal surgery (cosmetic or otherwise) because this may affect suitability for subsequent procedures. Physical Examination Physical examination should be performed with the patient sit ting and leaning forward so that the blood flows from the nose. This allows the physician to assess the rate and site of bleeding and to prevent the swallowing of blood, which will quickly lead to emesis. The pulse and blood pressure should be taken, and the skin, mucous membranes, and conjunctiva should be checked for rash, pallor, purpura, petechiae, and telangiectasias. Lymph nodes should be examined for enlargement, suggesting sar coidosis, tuberculosis, or malignancy. The sinuses are percussed for evidence of sinusitis, which would raise considerations of Wegener granulomatosis, midline granuloma, and nasal tumor. Laboratory Studies Laboratory studies are best ordered on the basis of findings from the history and physical examination. Patients suspected of a bleeding diathesis should have a prothrombin time test, par tial thromboplastin time test, bleeding time, blood smear, and platelet count obtained (see Chapter 81). Blood work is essential for patients whose epistaxis recurs after simple cautery or nasal packing. Sinus films are appropriate for evaluating the patient with recurrent bouts of sinus pain, tenderness, and bleeding or in whom sinonasal polyposis or malignancy is suspected. Patients of southern Chinese descent with recurrent epistaxis must be studied for potential nasopharyngeal carcinoma. PRINCIPLES OF MANAGEMENT (1–7) The first objective is to stop the bleeding. The approach depends on whether the source is anterior or posterior.

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