Epistaxis

Epistaxis has a bimodal age distribution, peaking in children (<10 years) and the elderly (45-65 years). Approximately 90% of bleeds are 'Anterior', originating from Little's Area on the anterior septum, where four arteries anastomose to form Kiesselbach's Plexus (anterior ethmoidal, sphenopalatine, greater palatine, and superior labial arteries). 'Posterior' bleeds, usually from the sphenopalatine artery, are more severe, often bilateral, and can result in significant blood loss into the pharynx. Predisposing factors include local trauma (nose picking), anticoagulants/antiplatelets, hypertension (although not a direct cause of the bleed, it makes control difficult), and Hereditary Haemorrhagic Telangiectasia (HHT/Osler-Weber-Rendu syndrome). Management in the UK follows a clear hierarchy starting with first aid and moving to cautery or packing. Uncontrolled or bilateral epistaxis requires hospital admission to monitor for hypovolemia and to provide definitive ENT intervention.

The nasal mucosa is highly vascular to facilitate warming and humidifying inspired air. The septum receives its blood supply from both the internal and external carotid systems. Little's area is prone to bleeding because of its superficial vascular plexus and its exposure to drying and trauma. Chronic drying leads to mucosal friability. In older patients, atherosclerotic changes in vessels like the sphenopalatine artery prevent them from constricting, leading to the more severe 'posterior' bleeds. Underlying coagulopathies (e.g., Von Willebrand disease) or medications (aspirin, clopidogrel, warfarin) impair the normal haemostatic plug formation.

Clinical assessment must first address haemodynamic stability (A-E approach). Patients usually present with active bleeding from one or both nostrils. In anterior bleeds, blood usually flows forward. In posterior bleeds, the patient may complain of 'tasting' blood or may vomit blood (haematemesis). Examination involves 'clearing the clots' (asking the patient to blow their nose) followed by inspection with a Thudichum speculum or otoscope. Red flags include unilateral symptoms, facial pain, or cranial nerve signs, which suggest a sinonasal malignancy or juvenile nasopharyngeal angiofibroma (in adolescent males).

- Bedside: Examination with Thudichum speculum/headlight. Rigid or flexible nasendoscopy once bleeding is controlled to search for a source.
- Bloods: FBC (assess blood loss), Coagulation screen (if on warfarin or liver disease), Group and Save (if bleeding is heavy).
- Imaging: Generally not indicated for acute bleeds unless a tumour is suspected (CT/MRI).
- Blood pressure monitoring is essential.

Acute (First Aid): 'Trotter's Manoeuvre'—sit forward, pinch the soft part of the nose for 15-20 minutes, ice pack. Medical: If first aid fails, identify the bleeding point. Apply topical anaesthetic/vasoconstrictor (e.g., Co-phenylcaine spray). If point visible: Silver nitrate cautery. If not visible or cautery fails: Nasal packing (e.g., RapidRhino or Merocel). Following cautery, prescribe Naseptin cream (contains Neomycin/Chlorhexidine, avoid if peanut/soya allergy) for 10 days. Surgical: For refractory bleeds, refer for Sphenopalatine Artery (SPA) ligation or Ethmoidal artery ligation. Embolisation is an alternative in some centres.