Epistaxis is a very common complaint seen by many types of physicians including otolaryngologists, family physicians, and others. Management of epistaxis is often challenging and requires many types of intervention. The following review describes the different types of past and current treatment modalities including cautery, nasal packing, maxillary artery ligation, anterior artery ligation, and sphenopalatine artery ligation. The paper also proposes an algorithm for managing such cases.
Epistaxis is one of the commonest presenting symptoms to ENT physicians as well as to family and emergency physicians. It is thought to affect 10–12% of the population, of which 10% require medical attention [
Topical decongestants are widely available, and their limited side effect profile makes them a convenient first-line therapy for the treatment of epistaxis. Chart reviews revealed that the use of topical oxymetazoline can be successful in treating posterior epistaxis in the emergency setting in up to 65–75% of cases [
Recently, a randomized control trial published by Zahed et al. compared the application of topical tranexamic acid (a drug used for patients with hereditary hemorrhagic telangiectasia) with the use of anterior packing for cases of anterior epistaxis presenting to the emergency department [
When nasal packing products came into the market, along with the advent of nasal endoscopy and endoscopic procedures, the technique of warm water irrigation fell out of favor [
Initial evaluation of a patient with epistaxis with anterior rhinoscopy might often reveal the source of the bleed if indeed this bleed is anterior.
Cautery options include chemical (with silver nitrate) and electric bipolar cautery. Since chemical cautery is less costly, easier to perform, and more readily available, it is more commonly used, especially by the non-ENT physician. The main risk of this procedure is septal perforation, which increases with bilateral cautery on opposing sides [
A recent chart review performed by Shargorodsky et al. reported that 77.1% of anterior epistaxis cases in their case review were treated with silver nitrate cautery with a 79% success rate on the first trial [
Nasal packing is often an effective and simple means of stopping nasal bleeds. The wide availability of packs, ease of use by nonspecialists, and low cost make this option a valid one as a first-line treatment.
However, nasal packing can be quite uncomfortable and may be responsible for a plethora of complications and adverse effects. Some of these can fortunately be mild and self-limited such as eustachian tube dysfunction, epiphora, and vasovagal reactions during insertion of the pack [
The failure rate of nasal packing has been reported to be up to 52% [
In an attempt to avoid complications during surgery, angiographic embolization for treating posterior epistaxis has first been described in 1974 [
The complications of this procedure have been extensively reported in the literature and include hemiplegia, ophthalmoplegia, facial paralysis/paresthesia, blindness, or other neurological deficits caused by accidental embolization of cerebral arteries [
Interestingly, some authors advocate embolization of the internal maxillary artery instead of the sphenopalatine artery in children under the age of 10 [
In 1965, Chandler and Serrins described the transantral ligation of the maxillary artery under local anesthesia [
It has been associated with persistent pain in the upper teeth, infraorbital neuralgia, oroantral fistula, sinusitis, potential damage to sphenopalatine ganglion and vidian nerve, and, rarely, blindness [
Chandler and Serrins reported no failures in all 21 patients [
Due to this somewhat invasive approach and potential complications, the transantral ligation of the maxillary artery technique has lost popularity, especially with the advent of the endoscopic procedures.
Ligation of the external carotid artery has also been described for refractory epistaxis; however, its failure was found to be quite high (45%) in a retrospective study conducted in 1992 [
The ligation of the anterior ethmoid artery has first been described through a Lynch incision in 1946 [
A study conducted in 2006 suggested the use of endoscopic anterior ethmoid artery ligation only when the artery is in a mesentery and is clearly visible (present in 20% of cases according to the study). Otherwise, the authors rather suggested an external approach [
The surgeon should be familiar with the anatomy of the anterior ethmoid artery and should recognize its intraorbital and ethmoid components in order to properly identify it intraoperatively and to avoid complications, such as bleeding and CSF leak [
Cautery under endoscopic vision is another option for the control of epistaxis that may avoid the uncomfortable insertion of nasal packs in the case of an unidentified bleeder. While this can be performed in the operating room, a well-equipped clinic or emergency department can also be adequate settings for this procedure. While some authors report a very high success rate [
Additionally, nasal cautery for epistaxis has been associated with palatal numbness [
Cautery of the bleeding nasal mucosa seems to be simple and effective means of epistaxis control; however, the restricted availability of endoscopes and endoscopic surgeons in small centers limits the use of this technique.
The ESPAL was first described over 20 years ago [
Despite being a relatively simple procedure, the endoscopic surgeon should have a good knowledge of the technique and the anatomy of the sphenopalatine artery (SPA) as well as the possible anatomical variations in order to achieve a successful surgery. The SPA is an end branch of the internal maxillary artery and enters the nasal cavity through the sphenopalatine foramen at the posterior lateral nasal wall (Figure
Endoscopic exposure of the left sphenopalatine artery.
The branching patterns of the SPA have been extensively studied. It may form two, three, or even four branches [
If performed correctly in the hands of an experienced endoscopic surgeon, the success rate of this procedure approaches 95–100% [
Endoscopic clipping of the left sphenopalatine artery.
The study by Nouraei et al., however, revealed a 90% efficacy rate at 5 years for SPA diathermy. It has also shown that the complication rate has not been associated with any predictive data, such as bilateral surgery, surgery for nasal polyps, or concomitant septoplasty.
A systematic review by Kumar et al. showed that ligation of the SPA and cautery were efficacious in 98% and 100%, respectively [
The traditional approach to manage patients with intractable epistaxis is to rely on surgery as a last-line treatment once all conservative and nonsurgical treatments (such as nasal packing) have failed. The ease of use of ESPAL technique, its high success rate, and low complication rates have led some authors to propose revision of this management strategy and an earlier deployment of ESPAL. During the past decade, there has been interest in the literature in comparing the cost-effectiveness of ESPAL with other treatment strategies.
A prospective randomized trial by Moshaver et al. in 2004 compared treatment costs of ESPAL with conventional packing. Their reported calculated costs were $5,133 and $12,213, respectively [
Additionally, Dedhia et al. conducted a review study in 2013 to determine event probabilities while comparing current practice algorithms (initial nasal pack insertion for 3 days) and first-line ESPAL [
Similarly, a study conducted by Rudmik and Leung in 2014 compared the cost-effectiveness of ESPAL and embolization for intractable epistaxis, defined as failure of posterior nasal packing after 3 days [
More recently, the same group published a modeling-based simulation of a 50-year-old male with intractable epistaxis [
When combining the results of this risk analysis with data on cost-effectiveness, the authors advocated a laddered approach to intractable epistaxis starting with ESPAL first.
In addition to that, there are other advantages of ESPAL over embolization, which include a reduced risk of major complications (such as stroke and blindness), direct endoscopic visualization of the bleeding site, potential diagnosis of rare causes of bleeding such as neoplasms with the possibility of biopsy, an opportunity to perform a concurrent anterior ethmoid artery ligation if required, and a reported lower health care cost [
On the other hand, many patients only experience one episode of epistaxis which may never recur, while others have only mild anterior epistaxis that may only require minimal definitive intervention. It would be difficult to justify the costs and the risks of surgery for these patients.
Therefore, we suggest in our algorithm (Figure
Algorithm for the management of epistaxis.
The management of posterior nasal bleeds will depend on the availability of experienced endoscopists and relevant equipment. The experienced endoscopist may be successful in treating these patients in an emergency setting, therefore avoiding the potential adverse effects of packs insertion and the potential complications and costs of surgery under general anesthesia. ESPAL can always be done after failure of this procedure.
When an endoscopist is not available, medical therapy or warm water irrigation can be attempted before posterior nasal packing. Recurrent cases, or failures of nasal packing, should be referred to an endoscopist for ESPAL. Endovascular embolization can be performed under local anesthesia and can be considered an alternative to ESPAL if patients are poor surgical candidates.
The management of epistaxis enjoys a wide range of strategies and treatment options. However, it is important to appreciate when to correctly employ the different individual interventions. It is also important to involve an experienced endoscopist when appropriate who can intervene either with endoscopic control in the emergency department or with ESPAL in the operating room. Recent literature advocates an earlier surgical intervention with ESPAL for such cases due to its simplicity, high success rate, low risks, and cost-effectiveness compared to other treatment modalities such as posterior nasal packing.
The authors declare that there is no conflict of interests regarding the publication of this paper.