Endoscopic Management of Epistaxis in Lumbini 
Medical College

Anup Acharya,a,d Madan Mohan Singh,b,d Arati Shresthac,d

—–—————————————————————————————————————————————
ABSTRACT:
Introduction: Epistaxis is one of the commonest Ear Nose Throat (ENT) emergency. Proper guidelines for its 
management are lacking; on the other hand, the management is mostly done by the junior health service providers 
which has invited non-standardized practice of epistaxis management. Thereby this study was much inclined towards 
assessment of the effectiveness of endoscopic management of epistaxis. Methods: This prospective study included 
patients above 16 years who were diagnosed with idiopathic epistaxis visiting Out Patient of ENT Department or in 
the Emergency Department of Lumbini Medical College from 1st of July 2014 to 30th of June 2015. ENT examination 
was done to find the cause and site of bleeding. Thereafter different epistaxis management interventions were done 
depending on the bleeding condition. The data were collected, entered and then analyzed using SPSS version 21. 
The descriptive statistics were applied. Results: Of the total 116 patients, 53 (45.69%) were male and 63 (54.31%) 
were female showing no gender preponderance with epistaxis in our study. Majority (49%) of the patients were 
managed with cauterization with silver nitrate or electrocautery in out-patient clinic. Second most common (18%) 
procedure was endoscopic sphenopalatine artery cauterization. Nasal packing was done only in three cases with 
zero posterior pack. Conclusion: Endoscopic intervention of epistaxis seems to be safe, simple, fast, and effective 
for the management of epistaxis with low rates of morbidity and complications. Thereby it can be preferred over the 
conservative nasal packing and considered as immediate second-line management. 

Keywords: electrocoagulation • epistaxis • ligation • packing • sphenopalatine
———————————————————————————————————————————————

___________________________________________________________________________________

a - Assistant Professor,
b - Associate Professor and Head
c - Medical Officer
d - Department of ENT Head and Neck Surgery
     Lumbini Medical College, Palpa, Nepal

Corresponding Author:
Dr. Anup Acharya
e-mail: anupent@gmail.com

How to cite this article:
Acharya A, Singh MM, Shrestha A. Endoscopic management of 
epistaxis in Lumbini Medical College. Journal of Lumbini Medical 
College. 2015;3(2):38-40. doi: 10.22502/jlmc.v3i2.70
___________________________________________________________________________________

J. Lumbini. Med. Coll. Vol 3, No 2, July-Dec 2015

Original Research Article

jlmc.edu.np

https://doi.org/10.22502/jlmc.v3i2.70

INTRODUCTION:
Epistaxis	 is	 defined	 as	 bleeding	 from	 the	

nasal	cavities.	Dry	weather,	use	of	alcohol,	and	use	
of	NSAIDs	have	a	proven	association	with	epistaxis	
whereas	hypertension	and	septal	deviation	do	not.	
Epistaxis,	most	commonly,	occurs	from	the	Little’s	
area	 in	 the	 septum.	 There	 are	 various	 modalities	
of	 management	 of	 epistaxis	 namely	 medical,	
cauterization,	 nasal	 packing,	 hot	 water	 irrigation,	
septal	 surgery,	 endoscopic	 sphenopalatine	 artery	

ligation	(ESPAL)	or	cauterization,	and	embolization.1
Epistaxis	is	the	second	most	common	cause	

of	emergency	admission	to	ENT	services.	Despite	of	
such	an	important	condition,	there	are	no	guidelines	
for	management,	and	the	most	junior	members	are	
often	the	main	caregiver	resulting	in	several	areas	of	
controversy	and	non-standardised	practices.2

The	 first	 step	 in	 general	 algorithm	 for	
the	 management	 of	 epistaxis	 is	 assessment	 and	
resuscitation.	If	the	site	of	the	bleeder	is	identified,	
it	is	cauterized	chemically	or	electrically.	If	site	is	
not	 found	and	 there	 is	no	active	bleeding,	patient	
is	 observed	 with	 medical	 treatment.	 With	 active	
bleeding	 and	 site	 not	 found,	 nasal	 packing	 is	
applied.	If	epistaxis	continues	despite	nasal	packing,	
further	management	has	to	be	done,	which	includes	
posterior	nasal	packing,	endoscopic	sphenopalatine	
artery	ligation,	embolization	etc.3

Nasal	 packing	 has	 been	 very	 commonly	
used	for	the	management	of	epistaxis	when	bleeder	
is	not	 identified	on	initial	clinical	examination.	In	

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J. Lumbini. Med. Coll. Vol 3, No 2, July-Dec 2015

Acharya A. et al. Endoscopic management of epistaxis in Lumbini Medical College.

jlmc.edu.np

a	 study,	 at	 a	 setup	 similar	 to	 ours,	 nasal	 packing	
was	done	in	about	60%	of	 the	cases	admitted	for	
epistaxis.4	Nasal	packing	has	been	associated	with	
many	complications	including	pain	and	discomfort,	
swallowing	 difficulty,	 trauma	 to	 the	 structures	
while	 packing,	 pressure	 necrosis	 of	 the	 palate,	
alar	or	 columellar	skin,	 displacement	with	 airway	
obstruction,	sinus	infection,	synechia,	otitis	media,	
hypoxia,	 and	 toxic	 shock	 syndrome.	 Packing	 also	
requires	antibiotics	to	prevent	development	of	sinus	
infection	or	toxic	shock	syndrome.2,5
	 Conventionally,	 endoscopic	 intervention	
like	 ESPAL	 was	 tried	 after	 failed	 or	 unsuccessful	
nasal	 packing.3,6	 With	 widespread	 popularization	
of	 endoscopic	 sinus	 surgery	 and	 a	 greater	
understanding	 of	 nasal	 anatomy,	 endoscopic	
control	 of	 the	 sphenopalatine	 artery	 has	 been	
advocated	 as	 a	 desirable	 and	 effective	 alternative	
for	 the	 control	 of	 posterior	 epistaxis.7,8	 ESPAL	
is	 technically	 straightforward	 to	 perform,	 allows	
direct,	secure	ligation	of	the	major	vessel	supplying	
the	posterior	nasal	cavity,	can	be	easily	done	under	
local	anaesthesia	in	cooperative	adults,	avoids	nasal	
packing,	has	an	excellent	patient	tolerance,	makes	
hospitalization	if	required	much	shorter,	and	has	few	
side	effects.
	 The	 aim	 of	 this	 prospective	 study	 was	 to	
assess	the	effectiveness	of	endoscopic	management	
in	patients	with	epistaxis	in	whom	bleeding	site	was	
not	localized	during	initial	clinical	examination.

METHODS:
	 Patients	 above	 16	 years	 of	 age	 coming	 to	
Out	Patient	of	ENT	Department	or	in	the	Emergency	
Department	 of	 Lumbini	 Medical	 College	 from	 1st 
of	July,	2014	to	30th	of	June,	2015	with	diagnosis	
of	idiopathic	epistaxis	were	included	in	the	study.	
On	 arrival,	 patients	 were	 assessed	 for	 Airway,	
Breathing,	 and	 Circulation	 (ABC).	 Patients	 were	
resuscitated,	 if	 seemed	 necessary,	 with	 IV	 fluids	
while	 waiting	 for	 the	 investigation	 reports.	 ENT	
examination	was	done	to	find	the	cause	of	bleeding.	
If	 nose	 was	 packed	 from	 the	 referral	 site,	 it	 was	
removed	 and	 examination	 done.	 Nose	 was	 gently	
packed	with	cotton	soaked	in	4%	lidocaine	and	0.5%	
oxymetazoline	for	20	minutes	before	examination	to	
improve	the	visualization	of	the	nasal	cavities.	
	 If	 the	 bleeder	 was	 identified	 on	 initial	
examination,	 it	 was	 cauterized	 chemically	 with	
silver	nitrate	or	with	electrocautery.	If	 the	bleeder	

was	not	identified,	patient	was	taken	to	Operation	
Theatre	(OT)	for	rigid	nasal	endoscopy	under	local	
anaesthesia	to	identify	the	bleeder.	Severely	deviated	
nasal	 septum	 (DNS)	 hampering	 the	 visualization	
of	posterior	nasal	cavity	was	corrected	in	the	same	
setting	under	local	anaesthesia.	If	 the	bleeder	was	
identified,	it	was	cauterized	with	electrocautery.	If	
bleeder	was	still	not	identified	even	after	thorough	
endoscopic	 nasal	 examination,	 endoscopic	
sphenopalatine	artery	cauterization	was	done	on	the	
side	of	epistaxis.	We	preferred	local	anaesthesia	as	it	
decreases	the	cost,	does	not	require	nil	per	oral	status,	
reduces	hospital	stay,	and	avoids	general	anaesthesia	
related	 complications.	 General	 anaesthesia	 was	
reserved	 for	 uncooperative	 patients.	 Three	 ml	
(3ml)	 of	 2%	 lidocaine	 with	 1:200,000	 adrenaline	
was	injected	into	the	pterygopalatine	fossa	through	
greater	palatine	foramen	to	anesthetize	the	posterior	
part	of	nasal	cavities.	Additional	three	ml	of	same	
solution	 was	 injected	 in	 the	 inferior	 and	 middle	
turbinates.	Then	the	ESPA	cauterization	was	done.	
Nasal	packing	was	not	done	in	these	patients.	The	
patients	whose	houses	were	nearby	and	could	come	
anytime	within	30	minutes	in	case	of	any	problem	
occurred,	 were	 discharged	 after	 two	 hours	 of	
observation.	Patients	undergoing	general	anaesthesia	
or	septoplasty	with	postoperative	nasal	pack,	were	
admitted	for	48	hours.	If	patient	developed	bleeding	
from	 the	 same	 side	 in	 this	 period,	 anterior	 nasal	
packing	was	done.	If	epistaxis	persisted	posteriorly,	
posterior	and	anterior	nasal	packing	was	done	and	
patient	admitted	in	ICU	for	continuous	monitoring	
for	72	hours	before	packs	were	removed.
 
RESULTS:
	 There	were	a	total	of	116	patients	included	in	
the	study.	Of	those,	53	(45.69%)	were	male	and	63	
(54.31%)	were	female.	Chi-square	goodness	of	fit	
test	did	not	show	a	significant	difference,	X2(N=116,	
df=1)	=	0.86,	p	=	0.35.	Thus,	there	was	no	gender	
preponderance	with	epistaxis	in	our	study.	The	mean	
age	of	all	the	patients	was	38.67	year	(SD=11.29).	
Management	 modality	 of	 the	 cases	 is	 shown	 in	
Table	1.	Majority	of	the	patients	were	managed	with	
cauterization	with	silver	nitrate	or	electrocautery	in	
out-patient	clinic.	Second	most	common	procedure	
was	endoscopic	sphenopalatine	artery	cauterization.	
Nasal	 packing	 was	 done	 only	 in	 three	 cases	 with	
zero	posterior	pack.

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Acharya A. et al. Endoscopic management of epistaxis in Lumbini Medical College.

Modality n (%)
Cauterization 57	(49.1)
SPA	cauterization 21	(18.1)
Endoscopic	cauterization 11	(9.5)
Anterior	nasal	pack 3	(2.6)
Posterior	nasal	pack 0
No	bleeder	was	identified	and	
patient	refused	further	treatment 24	(116)

Table 1: Management modality of Epistaxis (N = 116)

DISCUSSION:
	 In	 our	 study,	 there	 was	 no	 gender	
preponderance	 to	 epistaxis.	 Studies	 in	 different	
places	 of	 our	 country,	 however,	 showed	 male	
preponderance	to	this	condition.4,9	We	are	unable	to	
explain	the	cause	of	this	difference.	Half	(49.14%)	
of	 the	 patients	 with	 epistaxis	 could	 be	 managed	
in	 OPD	 by	 cauterization	 of	 visible	 bleeder.	 This	
emphasize	 the	 fact	 that	 a	 careful	 and	 meticulous	
clinical	examination	of	the	nose,	of	a	patient	with	
epistaxis,	is	necessary	to	reduce	further	unnecessary	
investigation	 and	 procedures.	 In	 our	 experience,	
preparation	of	the	nose	with	4%	lidocaine	solution	
mixed	 with	 0.5%	 Oxymetazoline	 for	 20	 minutes	
improves	the	visualization	of	the	nasal	cavities.	
	 Traditionally,	for	the	treatment	of	epistaxis,	
if	 the	 bleeder	 is	 not	 identified	 during	 clinical	
examination,	and	there	is	active	bleeding	from	the	
nose,	nasal	packing	is	done.	This	makes	nasal	packing	
one	 of	 a	 common	 treatment	 option	 of	 epistaxis	
despite	its	several	complications.	In	a	study,	10	years	
back,	in	one	of	the	biggest	hospital	of	our	country,	
60%	of	epistaxis	were	managed	by	nasal	pack	and	
only	2%	were	managed	by	arterial	ligation.4	Even	
in	 Ninewells	 Hospital	 in	 United	 Kingdom,	 nasal	
packing	is	done	before	endoscopic	intervention.10	In	
our	study	we	prevented	nasal	packing	as	a	procedure	
for	treatment	of	epistaxis	to	an	absolute	minimum	
i.e.	three	(2.6%),	thus	reducing	all	the	complications	
and	 discomfort	 related	 to	 nasal	 packing.	 These	
three	 cases	 had	 to	 be	 packed	 as	 there	 was	 active	
bleeding	 and	 operation	 room	 was	 not	 available	
for	next	few	hours.	There	was	no	case	of	rebleed	
after	 SPA	 cauterization.	 Three	 out	 of	 21	 cases	 of	
shpenopalatine	artery	cauterization	had	to	be	done	
under	general	anaesthesia	due	to	poor	cooperation	of	
the	patients.
	 Two	 of	 the	 24	 patients	 who	 did	 not	 have	
active	bleeding	at	the	time	of	initial	evaluation	and	
refused	 further	 procedure	 returned	 with	 rebleed.	

One	 was	 managed	 with	 endoscopic	 cauterization	
of	a	bleeding	vessel	in	the	posterior	part	of	septum,	
the	other	underwent	SPA	cauterization	under	local	
anaesthesia.	Both	were	discharged	the	same	day.	
	 The	current	study	emphasizes	on	the	early	
assessment	 of	 nasal	 cavities	 with	 endoscopes	
to	 localize	 bleeders	 and	 cauterize	 them.	 In	 case	
the	 bleeder	 is	 not	 found,	 sphenopalatine	 artery	
can	 be	 cauterized	 or	 ligated	 at	 the	 same	 setting.	
Widespread	popularization	and	easy	availability	of	
nasal	 endoscopes,	 greater	 understanding	 of	 nasal	
anatomy,	 relative	 ease	 of	 endoscopic	 control	 of	
the	 sphenopalatine	 artery	 etc.	 has	 brought	 up	 this	
procedure	in	the	hierarchy	of	treatment	of	epistaxis.7 

CONCLUSION:
	 Endoscopic	management	of	 epistaxis	 is	 an	
effective	method	of	treatment	of	epistaxis.	It	should	
be	preferred	to	nasal	packing	due	to	its	effectiveness,	
less	adverse	effects,	less	hospital	stay,	and	direct	and	
secure	ligation	of	the	major	vessels.

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