Surgical Management of Epistaxis (Nosebleeds)

Introduction

Epistaxis, or nosebleed, is one of the most common emergencies in otolaryngology. While most cases are self-limiting or managed conservatively, a subset of patients may require surgical intervention, especially in cases of recurrent, posterior, or life-threatening bleeding.

Surgical options are considered when medical and non-invasive treatments such as nasal packing or cautery fail.

Classification of Epistaxis

• Anterior Epistaxis
  Originates from Kiesselbach’s plexus (Little’s area). Common in children and usually manageable with conservative therapy.

• Posterior Epistaxis
  Arises from branches of the sphenopalatine artery, typically more severe and common in elderly or hypertensive patients. Often requires surgical management.

Causes of Severe/Recurrent Epistaxis

• Hypertension

• Trauma (facial injury, nasal fracture)

• Nasal tumors (benign or malignant)

• Coagulopathies or anticoagulant use

• Hereditary hemorrhagic telangiectasia (HHT)

• Chronic inflammation or infections

• Postoperative complications

Initial Management Before Surgery

1. Patient stabilization: airway, breathing, circulation (ABC)

2. Nasal compression

3. Topical vasoconstrictors (e.g., oxymetazoline)

4. Cauterization (silver nitrate for anterior bleeds)

5. Nasal packing (anterior and/or posterior)

Indications for Surgical Treatment

Surgical intervention is indicated in the following cases:

• Failure of nasal packing

• Recurrent posterior bleeding

• Severe bleeding in patients with coagulopathies

• Vascular malformations or tumors

• Refractory bleeding after trauma or surgery

Surgical Options for Epistaxis

1. Endoscopic Sphenopalatine Artery Ligation (ESPAL)

• Gold standard for posterior epistaxis

• Performed endonasally under general anesthesia

• Involves clipping or cauterizing the sphenopalatine artery

• High success rate (>90%) and minimal morbidity

2. Anterior Ethmoidal Artery Ligation

• Reserved for persistent anterior or superior bleeding

• Requires external approach or transorbital endoscopy

3. Maxillary Artery Ligation (via transantral approach)

• Used less commonly today due to invasiveness

• Accessed through a Caldwell-Luc approach

4. Endovascular Embolization

• Performed by interventional radiologists

• Used for uncontrolled bleeding when surgical access is difficult

• Risk of stroke, blindness, or tissue necrosis

Postoperative Care

• Nasal irrigation with saline

• Avoiding nose blowing or strenuous activity

• Blood pressure control

• Monitoring for re-bleeding or infection

• Follow-up endoscopy if necessary

Complications of Surgery

• Recurrent bleeding

• Infection

• Crusting or nasal obstruction

• Orbital injury (very rare)

• Anosmia (loss of smell)

Conclusion

While most nosebleeds can be managed conservatively, surgical treatment plays a critical role in managing severe or refractory epistaxis. Advances in endoscopic techniques have made surgical ligation highly effective and less invasive. Prompt evaluation and proper patient selection ensure optimal outcomes with minimal complications.