Epistaxis

Epistaxis is one of the commonest presentations at the accident and emergency (A&E) department and is the most common ENT emergency (1). Most cases of nose bleeds are minor or self limiting but rarely can be a life threatening emergency due to massive bleeding (1).

An estimated 60 % of the general population has had at least one episode of epistaxis throughout their life time (2).

• out of these only 6% sought medical assistance for it
• a bimodal distribution is seen in the population (2)
  • the incidence peaks at ages less than 10 years and above 50
  • in the young, the blood comes from Little's area, a highly vascular area at the anterior border of the nasal septum. With age the site of bleeding moves posteriorly
• rare in children under the age of 2 years and if present is often associated with injury or serious illness
• seasonal variation can also be seen with an increase during the winter months
• occurs frequently in males than in females

Epistaxis may be due to local causes or general causes.

Epistaxis is usually classified into two types:

• anterior bleeding
• posterior bleeding

Epistaxis summary (3)

• epistaxis is common
  • an estimated lifetime prevalence of 60%
  • approximately 6% of persons who have nosebleeds seek medical attention.
  • there are about 25,000 acute presentations to ENT services in the UK per year with increased prevalence in children and older adults (1)
• management of epistaxis is straightforward in most cases but can be challenging in patients with cardiovascular disease, impaired coagulation, or platelet dysfunction.
• epistaxis is appropriately controlled in a systematic and escalating fashion
  • initial management
    • patients in the medical setting are advised to apply digital compression to the lower third of the nose for 15 to 20 minutes, which is followed by anterior rhinoscopy
• anterior bleeding can usually be controlled with topical vasoconstrictors, tranexamic acid, cautery, or anterior nasal packing
  • intranasal tranexamic acid
    • study evidence found addition of intranasal tranexamic acid to controlled topical therapy of phenylephrine and lidocaine was linked to a lower rate of need for anterior nasal packing, stay in A+E for >2hrs, and re-bleeding in 24hrs (4)
• continued epistaxis despite these measures requires more aggressive treatment, with the involvement of specialists in otolaryngology and head and neck surgery and, generally, hospital admission

Reference

1. National ENT Trainee Research Network. The British Rhinological Society multidisciplinary consensus recommendations on the hospital management of epistaxis. J Laryngol Otol. 2017 Dec;131(12):1142-56.
2. Yau S. An update on epistaxis. Aust Fam Physician. 2015 Sep;44(9):653-6.
3. Seikaly H. Epistaxis. N Engl J Med 2021; 384:944-951
4. Hosseinialhashemi M et al. Intranasal Topical Application of Tranexamic Acid in Atraumatic Anterior Epistaxis: A Double-Blind Randomized Clinical Trial. Ann Emerg Med. 2022 Jun 22:S0196-0644(22)00247-5.