SURGERY FOR EPISTAXIS (NOSEBLEED)

Epistaxis is defined as acute hemorrhage from the nostril, nasal cavity, or nasopharynx (region behind the nose). While over 60% of the population will experience a nosebleed in their lifetime, only about 6% will require medical intervention. Most nosebleeds are infrequent, short-lived, and can be managed with some direct pressure applied to both nostrils for about 10 minutes. It is only the most severe nosebleeds that will require a visit to the emergency room, or the assistance of an Ear, Nose, and Throat Specialist.

There are a multitude of causes of epistaxis, and the list below is not all-inclusive. Certainly, the most common cause of a nosebleed is local trauma, either by nose picking or blunt trauma to the face. Other causes are listed below:

Local trauma:

  • Nose picking
  • Facial trauma
  • Foreign bodies
  • Nasogastric tube insertion
  • Nasotracheal intubation

Environmental:

  • Dry cold conditions (presentations increase during winter)
  • Dryness due to continuous oxygen therapy

Medicinal:

  • Anticoagulants: Aspirin, warfarin, platelet inhibitors (very common)
  • Topical nasal steroid sprays and antihistamines
  • Illicit use of cocaine or solvent inhalation (huffing)

Coagulopathies (problems with blood clotting mechanism):

  • Von Willebrand disease, hemophilia A & B
  • Thrombocytopenia (low platelets) or platelet dysfunction
  • Liver disease (hepatitis, alcoholic cirrhosis)
  • Kidney failure

Vascular Abnormalities:

  • Hereditary haemorrhagic telangiectasia (Osler Weber Rendu Syndrome)
  • Ateriovenous malformation
  • Pyogenic granulomas
  • Neoplasm (tumors)
  • Septal perforation/deviation

Hypertension:

  • Hypertension is rarely a direct cause of epistaxis, though high blood pressure can make it more difficult to stop a nosebleed
  • Patients presenting to ED with epistaxis are anxious, and will usually have significantly higher blood pressure

One of the reasons that nosebleeds are so common is because of the tremendous blood supply to the nose (see figure 1), and that the vessels are quite superficial. About 90% of nosebleeds are anterior, that is, the bleeding comes out of the nostril. They usually arise from a region called Kieselbach’s Plexus, where may blood vessels converge. The other 10% are posterior, where the blood drains backwards into the throat. Most nosebleeds that present to the emergency room or ENT’s office can be handled non-surgically or with a minor procedure. The typical management of a serious nosebleed includes the following interventions:

  • Silver nitrate cauterization
  • Electrical cauterization
  • Merocel (expandable sponge) packing
  • Balloon packing (anterior or posterior)

When bleeding persists despite these maneuvers, the nosebleed requires a higher level of intervention. Sometimes, the bleeding actually stops with the packing, but as soon as it is removed, bleeding recurs. This is another scenario that might require additional treatment. This may be done by an Ear, Nose, and Throat Specialist, a Neurointerventional radiologist, or sometimes, by a combination of both physicians.

Your doctor at Suburban Ear, Nose, and Throat might recommend one of four procedures to manage the nosebleed. The first three procedures are performed by an ENT. The last one is done by a neurointerventional radiologist. All of these are done on an inpatient basis:

  1. Nasal cauterization under anesthesia. The patient is fully anesthetized and then any pre-existing nasal packing is removed. The surgeon then places a telescope in the nose and looks for the source of bleeding. If identified, an electrical cautery device that has a suction attached is used to cauterize and hopefully stop the bleeding.
  2. Endoscopic sphenopalatine artery ligation. This is another procedure done under general anesthesia. A telescope is placed in the nose and surgical instruments are used to dissect out the sphenopalatine artery, which is a common source of posterior bleeds. Once this artery is identified, it is clipped closed with a surgical clip to close the vessel and prevent further bleeding. This procedure may be performed in conjunction with packing or nasal cautery.
  3. Anterior ethmoid artery ligation. The patient is placed under general anesthesia. The anterior ethmoid artery is responsible for anterior bleeding. This blood vessel has to be accessed through an external incision, which is placed on the outside of the nose, just between the nasal sidewall and the eye. (SEE DIAGRAM) It is a small incision that heals with minimal scarring. Once, this is done, we trace back until we reach the artery, and a surgical clip is placed. Patients are admitted overnight after this procedure.
  4. Arterial embolization. This is a very common procedure utilized for severe epistaxis. It is performed by a neurointerventional radiologist. This is a specialty or radiology with extensive training in placing catheters through blood vessels to access difficult to reach areas in the head and neck. If you require this procedure, the details can be further explained by your interventional radiologist. However, the principal is that a large blood vessel in your groin will be accessed with a catheter. The catheter is then advanced up into the facial region and very selectively, vessel to the nose are mapped out. Then, material is injected into the appropriate vessel to clog it up and prevent bleeding.

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