Vincent Cumberworth BSc FRCS Consultant Ear, Nose and Throat Surgeon
Clementine Churchill Hospital Sudbury Hill Harrow Middlesex HA1 3RX
Private Secretary: Tel: 020 8872 3866 Fax: 0208872 3861

Information is supplied only upon the condition that the viewer will make their own determination as to the suitability of the information for its purposes prior to use.  There will be no responsibility for information that is misused or misinterpreted and the information should not be used as a substitute for consultation with a health care professional.  It is not possible to answer questions regarding individual cases or to enter into individual correspondence.

Epistaxis

Epistaxis is a medical term to describe bleeding from the nose.

Epistaxes are slightly more common in men than women and are very common in both children and those in more advanced years.  Up to half of children between the age of 6 and 15 may have occasional nose bleeds.

The cause is typically a rupture of a vessel and, typically a very small artery.  An esteemed ENT Surgeon, Omar Shaheen (now retired) wrote a very interesting PhD. thesis which suggested that the pathological process involved micro-aneurysm formation, with a localised area of weakening of the arterial wall leading to rupture.

Hypertension does not necessarily increase the incidence of bleeds, but does increase their duration.  Similarly, more troublesome bleeding may be associated with higher alcohol intake and certain anti-coagulant medications, especially Aspirin or Warfarin.  In the case of children, localised inflammation of the nose – “vestibulitis” – due to Staphylococcus aureus bacteria can be associated with epistaxes and may also respond very successfully to local treatment with anti-staphylococcal cream such as Naseptin or Bactroban, after preliminary ENT examination.  Sometimes regular use of Vaseline can also be of help, to reduce any dryness and crusting which may exacerbate the problem.

Minor nose bleeds will typically respond very well to pressure – local pinching over the distal part of the nose, for around 10 – 15 minutes.  In the event of persistent bleeding which does not respond to this, Accident & Emergency attendance may be required with possible onward transfer to a hospital unit with a 24 hour ENT team.

As mentioned above, a tendency for intermittent minor bleeds may respond very well to application of topical anti-staphylococcal creams or ointments and regular Vaseline can sometimes be very useful.  In the case of intermittent recurrent minor bleeds which do not respond to a local medical treatment, treatment with silver nitrate cautery under local anaesthesia can be very successful.  This may be performed in a general practitioner’s surgery, or – more likely – at consultation with an ENT Specialist.  This procedure is associated with only a mild discomfort but can produce a small area of grey staining on the skin.  This is relevant because the discolouration will not wash away, as it is due to oxidation of surface layers of the skin and typically disappears in 2 – 3 days.

As mentioned above, in the case of a severe and persistent epistaxis attendance at an out of hours ENT unit may be required.  There, treatment may be performed by direct silver nitrate, or even electrical cautery under local anaesthesia.  Frequently nasal packing may be required, along with admission for observation.

A traditional nasal pack relies on local pressure and can involve posterior packing, sometimes a balloon catheter, and an anterior pack of ribbon gauze or a nasal tampon.  These are inserted under local anaesthesia and it is most common to remain an inpatient whilst these dressings are in place.  Sometimes other medical conditions need to be addressed and blood tests may be helpful.  In the case of recurrent minor nose bleeds it is also often useful to obtain a full blood count, and sometimes clotting studies, to exclude any other potential medical problems.

Very rarely, nose bleeds may not be fully settled by nasal packing and surgical intervention may be required.  This can occur as either intermittent troublesome nose bleeds or a single severe episode, not responding to either cautery or packing during admission.

Treatment under anaesthesia can entail a more specific nasal cautery or diathermy, sometimes combined with – or managed instead by – septoplasty.  This procedure will correct any significant deviation of the internal nasal architecture; sometimes bleeding may occur on the convex part of a deviated nasal septum and limited access can also preclude accurate and effective nasal cautery to the troublesome vessel.

Surgical intervention may ultimately require arterial ligation.  This can range from a quite specific procedure such as sphenopalatine artery ligation, typically performed through the nose, to clip or diathermise the end-artery supplying most of the nasal cavity (the sphenopalatine artery).  This is actually a branch, indirectly, of the external carotid artery; this is relevant because very high recurrent or persistent bleeds in the nasal cavity can require an external approach to ligate, or diathermise, the internal carotid artery supply to the nose, via the anterior (and also posterior) ethmoidal arteries.  Typically, only the anterior ethmoidal artery would be approached surgically; this usually deals with the problem and the posterior ethmoidal artery is a little further behind and closer to the optic nerve!

An alternative surgical approach to the external carotid artery supply involves transantral maxillary artery ligation and is typically performed via a Caldwell-Luc approach, which is performed via the canine fossa, operating through the hard palate in the mouth.  This can be associated with numbness of the cheek.

Occasionally an approach to the external carotid artery, via the neck, can be required.  It must be said that surgical intervention is unlikely, very unlikely indeed in the case of the latter two procedures discussed.

Sometimes effective treatment may be provided via a radiological approach, performed under arteriorgraphy and involving embolisation of the troublesome supplying artery, to occlude that area of supply.