Current Treatment Strategies for Epistaxis
Epistaxis is a common clinical complaint with a spectrum of severity ranging from spontaneous cessation to unrelenting, life threatening hemorrhage requiring surgical treatment. Both otolaryngologic and neurointerventional techniques are discussed to provide a comprehensive paradigm to treat patients with epistaxis. An exhaustive review of the anatomic basis for the two main subtypes of epistaxis is provided as well as a graduated approach to appropriate clinical management.
Epistaxis is the most common otolaryngologic emergency, affecting up to 60% of the population in their lifetimes, with 6% requiring medical attention. The most common etiology is idiopathic, followed by primary neoplasms and traumatic or iatrogenic causes. Other causes include hypertension, coagulopathies, inflammatory conditions, infectious diseases, drug use and congenital nasal septal abnormalities. There are peaks in incidence for individuals less than 10 years old and more than 40 years old. For management purposes, epistaxis is loosely classified as either anterior or posterior, based on distinct anatomic boundaries and the blood supply to each region.
The maxillary sinus ostium can be used to determine the dividing line between anterior and posterior epistaxis. Anterior bleeds are most common (90–95%) and involve the anterior septum. The particular area of the septum is known as Little's area or Kiesselbach's plexus, which represents an anastomosis between terminal branches of the external and internal carotid arteries (figure 1A). This region is composed of a consistently arranged anastomotic triangle of large thin walled vessels, formed by the terminal septal branches of the sphenopalatine artery, the anterior ethmoidal artery and the superior labial branch of the facial artery. To some extent, the posterior ethmoidal and greater palatine arteries are also involved in Kiesselbach's plexus.
(Enlarge Image)
Figure 1.
(A) Endoscopic image demonstrating epistaxis from Kiesselbach's plexus. (B) Cadaveric dissection of the left lateral nasal wall depicting the left sphenopalatine artery.
Most cases of posterior epistaxis involve the sphenopalatine artery. This artery is the terminal branch of the maxillary artery and typically emerges from the sphenopalatine foramen in the posterior lateral nasal cavity. It enters and divides into a septal branch, which courses medially along the inferior portion of the sphenoid rostrum, and a conchal branch that supplies the lateral nasal wall below the middle turbinates. The sphenopalatine foramen is most frequently located at the transition between the middle and superior meatus about 6.6 cm from the anterior nasal spine. In approximately 12% of individuals the sphenopalatine artery emerges from a different foramen. Therefore, awareness of this potential anatomic variation is important when performing endoscopic ligation to control posterior epistaxis.
The anterior and posterior ethmoidal arteries are the branches of the internal carotid artery that supply part of the lateral wall of the nasal cavity. Bleeding due to the anterior ethmoidal artery is uncommon. It usually occurs in patients with facial trauma and skull base fractures. Another common mechanism of injury to these vessels is iatrogenic damage during endoscopic sinus surgery.
The basic approach to any case of epistaxis consists of three steps: identification of the bleeding site, stopping the bleeding and identification and treatment of the underlying cause, if any. Determination of amount of blood loss and volume status can be critical. Vital signs are important but hypotension is usually a late sign. In any patient with epistaxis, all potentially complicating factors, such as uncontrolled hypertension, medications, drug use, coagulopathy and platelet dysfunction, must be considered and addressed appropriately. First aid measures include firm constant pressure applied to the anterior cartilaginous portion of the nose with the patient leaning forward.
Abstract and Introduction
Abstract
Epistaxis is a common clinical complaint with a spectrum of severity ranging from spontaneous cessation to unrelenting, life threatening hemorrhage requiring surgical treatment. Both otolaryngologic and neurointerventional techniques are discussed to provide a comprehensive paradigm to treat patients with epistaxis. An exhaustive review of the anatomic basis for the two main subtypes of epistaxis is provided as well as a graduated approach to appropriate clinical management.
Introduction
Epistaxis is the most common otolaryngologic emergency, affecting up to 60% of the population in their lifetimes, with 6% requiring medical attention. The most common etiology is idiopathic, followed by primary neoplasms and traumatic or iatrogenic causes. Other causes include hypertension, coagulopathies, inflammatory conditions, infectious diseases, drug use and congenital nasal septal abnormalities. There are peaks in incidence for individuals less than 10 years old and more than 40 years old. For management purposes, epistaxis is loosely classified as either anterior or posterior, based on distinct anatomic boundaries and the blood supply to each region.
Anatomy
The maxillary sinus ostium can be used to determine the dividing line between anterior and posterior epistaxis. Anterior bleeds are most common (90–95%) and involve the anterior septum. The particular area of the septum is known as Little's area or Kiesselbach's plexus, which represents an anastomosis between terminal branches of the external and internal carotid arteries (figure 1A). This region is composed of a consistently arranged anastomotic triangle of large thin walled vessels, formed by the terminal septal branches of the sphenopalatine artery, the anterior ethmoidal artery and the superior labial branch of the facial artery. To some extent, the posterior ethmoidal and greater palatine arteries are also involved in Kiesselbach's plexus.
(Enlarge Image)
Figure 1.
(A) Endoscopic image demonstrating epistaxis from Kiesselbach's plexus. (B) Cadaveric dissection of the left lateral nasal wall depicting the left sphenopalatine artery.
Most cases of posterior epistaxis involve the sphenopalatine artery. This artery is the terminal branch of the maxillary artery and typically emerges from the sphenopalatine foramen in the posterior lateral nasal cavity. It enters and divides into a septal branch, which courses medially along the inferior portion of the sphenoid rostrum, and a conchal branch that supplies the lateral nasal wall below the middle turbinates. The sphenopalatine foramen is most frequently located at the transition between the middle and superior meatus about 6.6 cm from the anterior nasal spine. In approximately 12% of individuals the sphenopalatine artery emerges from a different foramen. Therefore, awareness of this potential anatomic variation is important when performing endoscopic ligation to control posterior epistaxis.
The anterior and posterior ethmoidal arteries are the branches of the internal carotid artery that supply part of the lateral wall of the nasal cavity. Bleeding due to the anterior ethmoidal artery is uncommon. It usually occurs in patients with facial trauma and skull base fractures. Another common mechanism of injury to these vessels is iatrogenic damage during endoscopic sinus surgery.
Graduated Approach to Treatment
The basic approach to any case of epistaxis consists of three steps: identification of the bleeding site, stopping the bleeding and identification and treatment of the underlying cause, if any. Determination of amount of blood loss and volume status can be critical. Vital signs are important but hypotension is usually a late sign. In any patient with epistaxis, all potentially complicating factors, such as uncontrolled hypertension, medications, drug use, coagulopathy and platelet dysfunction, must be considered and addressed appropriately. First aid measures include firm constant pressure applied to the anterior cartilaginous portion of the nose with the patient leaning forward.
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