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 Kesselbachs 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 but not popularized until the 1960s. 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 patients 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 practiti