The patient in this vignette suffers from a case of intractable epistaxis. It is most likely an anterior bleed; posterior bleeds are mainly seen in patients with hypertension, history of cocaine abuse, recent nasal surgery, or nasal tumors. After nostril pinching and topical vasoconstrictor, the next step is the treatment of this patient is electrocautery of Kiesselbach's plexus.
Epistaxis (or nose-bleeding) can have a anterior or posterior bleeding source. Most often, it originates in the anterior nasal cavity. Diagnosis involves a directed history and physical examination. Patients often have a history of activity in high heat and low humidity or minor nasal trauma such as nose picking. Because packing does not always stop the source of bleeding, methods of direct vessel coagulation or constriction are superior.
Kucik et al. report that epistaxis usually responds to first-line treatments such as compression. When epistaxis does not respond to compression, the source of the bleeding should be located and treated by topical vasoconstriction, chemical cautery, electrocautery, nasal packing, and arterial ligation or embolization.
Qureishi et al. reviewed the current literature on recurrent idiopathic epistaxis and found that the optimal management is unknown. However, if silver nitrate nasal cautery is used, 75% silver nitrate preparation is preferable to 95% as it is more effective in the short term and causes less pain. There are no high-quality randomised controlled trials.
Illustration A details the organization of the blood supply to the anterior nose. Note the circled Kiesselbach's plexus.
Illustration B illustrates the primary difference between posterior and anterior epistaxis based on the anatomy of the vasculature. Note the confluence of several vessels in the nose.
Answer 1: Observation is never appropriate in a patient who is actively bleeding.
Answer 2: Anterior nasal packing would be tried if electrocautery of Kiesselbach's plexus fails.
Answer 3: Posterior nasal packing is only used if the bleed is of posterior origin.
Answer 5: Electrocautery of Woodruff's plexus is only used if the bleed is of posterior origin.
Kucik CJ, Clenney T. Management of epistaxis. Am Fam Physician. 2005 Jan 15;71(2):305-11.
PMID:15686301 (Link to Abstract)
Qureishi A, Burton MJ. Interventions for recurrent idiopathic epistaxis (nosebleeds) in children. Cochrane Database Syst Rev. 2012 Sep 12;9:CD004461.
PMID:22972071 (Link to Abstract)