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Epistaxis (ReelDx + Lecture)

VIDEO-CASE-PRESENTATION-REEL-DX

9 Year Old with Nosebleeds

9-year-old with acute onset epistaxis and low platelet count

Patient will present as → a 14-year-old who is brought to your Emergency Department (ED) with an intractable nosebleed. Pinching of the nose has failed to stop the bleeding. In the ED, a topical vasoconstrictor is tried but also fails to stop the bleeding.

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Kiesselbach's Plexus or Little's Area is the most common site for anterior bleeds

  • Woodruff's Plexus is the most common site for posterior nosebleeds
    • The sphenopalatine artery is generally the source of severe posterior nosebleeds causing bleeding from both nares and posterior pharynx
  • Patients should always be asked about aspirin or ibuprofen use

Image by Osmosis

The majority of patients do not require testing other than direct visualization

  • Patients with symptoms or signs of a bleeding disorder and those with severe or recurrent epistaxis should have CBC, PT, and PTT.
  • CT may be done if a foreign body, a tumor, or sinusitis is suspected.

Most nosebleeds are anterior and stop with direct pressure

  • Apply direct pressure for at least 10-15 minutes, seated, leaning forward
  • Short-acting topical decongestants (two sprays of oxymetazoline (Afrin), phenylephrine, cocaine)
  • Anterior nasal packing 
    • Patients with nasal packing must be treated with antibiotics (cephalosporin) to prevent toxic shock syndrome, and the patient has to return to take the packing out
  • If there is no packing in the nose, place a small amount of petroleum jelly or antibiotic ointment inside the nostril 2 times a day for 4–5 days
  • Posterior balloon packing is used to treat posterior epistaxis. These patients must be admitted to the hospital, and prompt consultation with an otolaryngologist is indicated
  • Recurrent epistaxis: Must rule out hypertension or coagulation disorder (like vWD)

Question 1
A 66-year-old male with hypertension and cardiovascular disease presents with persistent epistaxis of two hours' duration. Initial pressure application fails to control the bleeding, and a bilateral anterior nasal pack is placed. However, continued bleeding is visualized in the posterior oropharynx. Of the following, the most appropriate next step is to:
A
Remove the packing and insert a posterior balloon pack
B
Remove the packing and cauterize Kiesselbach's plexus
Hint:
This plexus is a common source of anterior bleeds. Since the bleeding is from a posterior source, cauterization here would be ineffective.
C
Replace the existing packing with Gelfoam packing
Hint:
While Gelfoam may be helpful, it won't achieve the tamponade pressure needed for a posterior bleed.
D
Apply a topical solution of lidocaine and epinephrine
Hint:
This topical solution can help with vasoconstriction but isn't sufficient for a significant posterior bleed.
E
Administer intranasal tranexamic acid (TXA)
Hint:
While TXA can be useful for epistaxis, a posterior bleed requires mechanical tamponade like a balloon pack.
Question 1 Explanation: 
Persistent bleeding despite anterior packing, especially with visualization in the posterior oropharynx, indicates a posterior source. A posterior balloon pack is designed to tamponade a posterior bleed and is the most appropriate next step. These patients must be admitted to the hospital and prompt consultation with an otolaryngologist is indicated.
Question 2
What is the most common location of anterior nasal epistaxis?
A
Middle turbinate
Hint:
See D for explanation.
B
Posterior ethmoid artery
Hint:
See D for explanation.
C
Kiesselbach's triangle
D
Inferior turbinate
Hint:
The inferior turbinate is the most common location for posterior epistaxis.
Question 2 Explanation: 
90% of all cases of anterior epistaxis originate from Kiesselbach's triangle.
Question 3

A 7-year-old boy is brought to the clinic by his mother for recurrent nosebleeds over the past month. They usually occur spontaneously in the mornings but recently started happening 2-3 times per week. There is no history of trauma or recent illness. He's not on any medications. Which of the following is the most likely underlying cause of his recurrent epistaxis?

A
Nasal trauma from digital manipulation
B
Coagulation disorder (e.g., hemophilia)
Hint:
Bleeding disorders can manifest with nosebleeds but usually also with bleeding episodes elsewhere (bruising, post-dental bleeding, etc.).
C
Nasal foreign body
Hint:
Presence of foreign body may lead to a more isolated/unilateral type of bleeding and often has discharge symptoms as well.
D
Hypertension
Hint:
While rarely an initial presentation of hypertension in children, epistaxis can occur alongside a hypertensive crisis with extremely elevated blood pressure.
E
Juvenile nasopharyngeal angiofibroma
Hint:
This benign vascular tumor occurs uncommonly, most notably in adolescent males, and characteristically bleeds on contact or with significant nasal obstruction symptoms.
Question 3 Explanation: 
Digital manipulation is the most common cause of epistaxis in children. Repeated minor trauma to the anterior nasal septum (Kiesselbach's plexus), especially with dry nasal mucosa (cold seasons, allergies), leads to frequent bleeds.
Question 4

A 65-year-old woman presents to the emergency department with a nosebleed that she has been unable to control for the past 45 minutes. She applied pressure and ice packs without success. Her medical history includes hypertension and chronic use of warfarin for atrial fibrillation. Following an initial attempt at anterior nasal pressure, the next step in managing this patient should be:

A
Topical oxymetazoline application
Hint:
A vasoconstrictor like oxymetazoline can help some milder bleeds but likely won't suffice alone with continued anticoagulation.
B
Cauterization with silver nitrate
Hint:
While potentially used for localized vessel sealing, it wouldn't fully address the impaired coagulation.
C
Anterior nasal packing
Hint:
Might be appropriate if bleeding primarily from anterior source and normal INR, but anticoagulation makes packing riskier (without reversal due to increased re-bleed potential).
D
Posterior nasal packing
Hint:
Used occasionally for significant epistaxis but in an anticoagulated patient (potential unknown INR elevation level), this carries extra risks for airway/bleeding.
E
Laboratory studies including International Normalized Ratio (INR)
Question 4 Explanation: 
Since the patient is on warfarin, which interferes with coagulation, checking her INR is critical. Significantly elevated INR indicates a need for reversal to manage the bleed appropriately and prevent serious complications from hemorrhage.
There are 4 questions to complete.
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References: Merck Manual · UpToDate

Lesson Intro Video

Brian Wallace PA-C Podcast: Nose, Sinus, Mouth and Throat Disorders (Prev Lesson)
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