What is the best imaging modality for chronic recurrent epistaxis (nosebleeds)?

Imaging for Chronic Recurrent Epistaxis

Nasal endoscopy is the best imaging modality for chronic recurrent epistaxis, allowing identification of the bleeding site in 87-93% of cases and detection of underlying pathology. 1, 2

Initial Assessment

Anterior Rhinoscopy

• First-line examination after removal of blood clots
• Can identify anterior bleeding sites (90-95% of cases)
• Limitations: Cannot visualize posterior nasal cavity or nasopharynx adequately 1

When to Progress to Nasal Endoscopy

Nasal endoscopy should be performed in patients with:

• Recurrent nasal bleeding despite prior treatment with packing or cautery
• Recurrent unilateral nasal bleeding
• Epistaxis that is difficult to control
• Concern for unrecognized pathology contributing to epistaxis 1, 2

Benefits of Nasal Endoscopy

1. Superior Visualization: Allows examination of the entire nasal cavity and nasopharynx
2. Precise Bleeding Site Identification: Localizes bleeding in 87-93% of cases
3. Detection of Underlying Pathology:
   • Nasal masses (benign or malignant)
   • Juvenile nasopharyngeal angiofibroma (in adolescent males)
   • Nasal foreign bodies
   • Septal deviations or perforations 1

Advanced Imaging Modalities

For cases where nasal endoscopy cannot identify the source or when vascular abnormalities are suspected:

CT Angiography

• Indicated for post-traumatic epistaxis with suspected internal carotid injury
• Evaluates cerebral and supra-aortic vessels 3
• Helps identify vascular malformations or aneurysms

Conventional Angiography

• Reserved for cases requiring embolization
• Complete bilateral selective external and internal carotid angiograms are essential
• Can detect rare causes such as traumatic or mycotic aneurysms 4
• Not recommended as initial imaging due to invasiveness

Special Considerations

Hereditary Hemorrhagic Telangiectasia (HHT)

• Assess for nasal and oral mucosal telangiectasias in patients with:
  • History of recurrent bilateral nosebleeds
  • Family history of recurrent nosebleeds
• Nasal endoscopy is essential for diagnosis and management 1

Anticoagulation and Antiplatelet Medications

• First-line treatments should be initiated prior to considering reversal of anticoagulation
• Nasal endoscopy helps guide targeted therapy in these high-risk patients 1

Clinical Pitfalls to Avoid

1. Delayed Diagnosis: Failure to perform nasal endoscopy can lead to missed diagnosis of serious underlying pathology, including malignancies
2. Incomplete Examination: The French Society of Otorhinolaryngology recommends nasal endoscopy even when ectasia of Kiesselbach's plexus is seen 1
3. Overreliance on Anterior Rhinoscopy: Posterior epistaxis (5-10% of cases) is often missed without endoscopy 5
4. Inadequate Follow-up: Patients with recurrent epistaxis despite treatment should be referred to otolaryngology for endoscopic evaluation 2

Nasal endoscopy not only serves as a diagnostic tool but also guides appropriate interventions, which may include topical vasoconstrictors, nasal cautery, or moisturizing agents based on the identified bleeding site 1, 2.