Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Epistaxis Approximately 5-10% of the population experiences an episode of active nasal bleeding each year. Fortunately, fewer than 10% of these patients visit a physician for this problem and only one of those ten will require hospitalization. The incidence increases with advancing age, during the winter months, and epistaxis is more common in males. As otolaryngologists, we are required to have a clear understanding of the etiology of this condition and the available treatment options. Functionally, nasal bleeding is subdivided into "anterior" and "posterior" categories based on the site of mucosal abnormality. Arbitrarily, anterior sites are those anterior to the maxillary sinus ostium and posterior sites lie behind the ostium. "Anterior" sites include those areas supplied by the anterior ethmoid artery - especially Kesselbach's plexus on the anterior nasal septum. Posterior sites involve areas of the middle and interior turbinates and lateral nasal wall - those sites supplied predominantly by branches of the maxillary artery. The etiology of this process is, to say the least, multifactorial. Anatomic lesions can lead to anterior (e.g. septal perforation) or posterior bleeding (e.g. nasopharyngeal carcinoma). Systemic illnesses also have a marked effect on the nasal mucosa. Any nasal bleeding that is not anatomic or lesion-oriented should be considered the result of a coagulopathy until proven otherwise. Upon presentation, all patients should be worked up with a thorough history including any indication of a clotting disorder in the patient himself or other family members. A careful physical examination with topical decongestion and anesthesia is necessary to locate the actual site of bleeding. Endoscopic examination of the nose has become increasingly important in this regard. Obviously, some patients will present with such massive bleeding that localization is not possible and measures must be taken immediately to stop the hemorrhage. The first line of management involves the use of some form of cautery and/or nasal packing. Cautery is only useful for clearly visible nasal sites that are not bleeding briskly. Many patients will be best managed by placing packing material into the nose to either keep the mucosa moist or tamponade the mucosal hemorrhage. These measures are effective 80 to 90% of the time. The placement of anterior and posterior nasal packing should be precise and one must be aware of the potential complications of nasal tamponade including injury, infection, dehydration, and altered ventilation from obstructive and physiologic derangements in pulmonary mechanics. Second-line measures include operations or non-operative ligation of the feeding arteries of the nasal mucosa. These options are usually considered after failed first-line management for technical reasons or because of patient morbidity. More recently, however, authors have been considering the benefits of early vascular intervention for reasons of patient comfort, length of hospitalization, and overall effectiveness. Cost considerations are also being more closely scrutinized in this day of medical cost-consciousness. One of the earliest surgical procedures described was that of external carotid artery ligation (1910 - 1920). This approach decreases the pressure within the ipsilateral maxillary artery, an end-artery of the external carotid systemic. Unfortunately, because the ligation is quite proximal related to the site of bleeding, collateral circulations into the maxillary artery leads to a significant rate of failure. Additionally, several serious complications of this procedure have been described including stroke and vascular injury. A direct approach to the maxillary artery via the maxillary sinus was first described by Seiffert in 1929, but not popularized until the 1960's. This involves the direct visualization of the artery within the pterygomaxillary fossa and placement of metal chips on the end branches, especially the sphenopalatine and descending palatine arteries. It is more effective than external carotid artery ligation but has a slightly higher complication rate that is amplified by the technical skill required in the accurate identification and clipping of the arterial branches (an estimated 10-15% technical failure rate, overall complication rate 25-30%). The second major vascular contribution to the nose, that is the anterior and posterior ethmoid arteries, must be approached separately and is often performed in conjunction with maxillary artery ligation. There is some debate over the advisability of ligating both the anterior and posterior ethmoid arteries because of the relatively minor contribution from the posterior ethmoid artery and its close proximity to the optic nerve. In general, the usefulness of this maneuver depends upon the location of the bleeding, which cannot always be known with certainty. Reported complications include stroke, blindness, ophthalmoplegia, epiphora; and the complication rate is similar to that of maxillary artery ligation. Most recently, techniques for direct vascular access including angiographic visualization and embolization of the terminal branches of the maxillary artery have been described and are still being perfected. Arteriography has the advantage of being diagnostic and therapeutic, with an ever-decreasing complication rate as experience with the method continues to increase rapidly. Of particular benefit is the use of this technique in the face of failed vascular ligation when the clips have become dislodged or were misplaced. The most effective overall approach to epistaxis is a careful evaluation of the patient's condition with accurate identification of the site of bleeding. Treatment options must be carefully considered in light of these facts. The risks and benefits of each should be carefully understood by both the practitioner and the patient. Case Presentation A 57-year-old black male was seen at the Veterans Affairs Medical Center (VAMC) in July 1989. At that time, he had been treated for epistaxis at an outlying hospital in Louisiana and referred to the VAMC for continued care. He had undergone multiple nasal cauterizations, nasal pack placements, and blood transfusions. On examination Gelfoam was found in his nasal cavity bilaterally, and a plastic clamp was in place on the nasal alae. The Gelfoam was removed and a significant amount of clot was suctioned from the nose and nasopharynx. Multiple excoriated areas of nasal mucosa were seen and there was some active bleeding on the left side of the nose. A formal anterior/posterior nasal pack was placed for four days. His blood pressure control was adequate at all times and his hemoglobin and hematocrit remained stable. His prothrombin time and partial thromboplastin time were normal. After pack removal, the patient was observed for 24 hours and discharged without incident. Two weeks later, he returned with recurrent left-sided nasal bleeding which appeared to be originating from the area of the nasal roof anteriorly. His hematocrit was 30.8 and a bleeding time was obtained and found to be normal. He was taken to the operating room at which time his left anterior ethmoid artery was ligated. He remained dry for approximately 24 hours after surgery but again rebled from the left side of the nose. He was then returned to the operating room for left posterior ethmoid and transantral maxillary artery ligation. During the postoperative period, two units of red blood cells were transfused. Following these procedures, his nasal pack was removed five days after surgery and he eventually did well. 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