Surgical management
Any bleeding that fails to stop, despite an escalation of management, requires surgical intervention. This includes cases in which the bleeding continues after pack removal.4 Options include4:
- Diathermy, with bipolar or radiofrequency laser, can be used to localize the bleeding site.
- Septoplasty allows for better access to the nasal cavity, reduction of blood flow to the nasal mucosa by raising a mucoperichondrial flap, correction of a deviated septum, and removal of a septal spur that may be responsible for the epistaxis.
- Arterial ligation involves identification of the bleeding vessel that is clipped or coagulated with bipolar diathermy.
- Endoscopic SPA ligation is an excellent, well-tolerated, and cost-effective method of treating recurrent epistaxis.6,14 It controls 98% of posterior epistaxis, and is superior to posterior nasal packing and embolization.2,3,10 It results in a shorter hospital stay, reduction in repeated hemorrhage and painful packing procedures, and a cost saving of >$7,000 per patient if performed early.7 Concomitant ligation of the anterior ethmoidal artery may be performed in traumatic epistaxis or when severe bleeding is from the ethmoidal region.4,6
- Ligation of the IMAX and external carotid arteries is performed rarely due to potential complications and high failure rates.
Arterial embolization
When arterial ligation fails, or is not possible due to anesthetic concerns, selective embolization of the maxillary or facial arteries by specialist radiologists can be considered.6 Access to the vascular system through a femoral punch leads to identification of the bleeding point. A catheter is then placed in the artery and the bleeding vessel is embolized. Possible candidates include patients with HHT, bleeding tumors, poor surgical candidates, or patient preference.3
Other management considerations
Once bleeding is controlled, factors that contributed to the epistaxis should be addressed.3 Hypertension needs to be managed. Antiplatelet or anticoagulant therapy may need to be temporarily halted in consultation with specialist physicians. Local treatments such as cautery are unlikely to be effective in patients who are anticoagulated. Nasal packing with a ‘procoagulant’ dressing, such as Kaltostat or Rapid Rhino, is often required.
Patient education and follow-up
Patients should be started on saline sprays or irrigation to maintain nasal hygiene after acute epistaxis. It’s a good idea to teach patients about proper first aid for recurrence (eg, sitting upright with digital pressure applied to the cartilaginous part of the nose, ice packs around the neck and ice to suck) and to encourage them to refrain from activities that may stimulate bleeding (blowing or picking the nose, heavy lifting, strenuous exercise). Also advise patients to abstain from alcohol and hot drinks that cause vasodilatation of nasal vessels as much as possible.4 Advise patients that topical gels, lotions, and ointments such as kenacomb, nasalate, or paraffin can be used to moisturise the mucosa and promote healing.1
All patients with a history of severe or recurrent epistaxis require formal examination of the nasal cavity to rule out a neoplastic lesion.
CORRESPONDENCE
Amy Wong, BMBS, Department ENT/Head and Neck Surgery, Monash ENT Building, PO Box 72, Rear 867 Centre Road, Bentleigh East 3165 Australia, amy.wong@monashhealth.org.au.