What imaging modalities are recommended for evaluating nose bleeds (epistaxis)?

Imaging Modalities for Epistaxis Evaluation

For most patients with epistaxis (nosebleeds), imaging studies are not routinely indicated as part of the initial evaluation and management. 1, 2

Initial Evaluation Without Imaging

The American Academy of Otolaryngology-Head and Neck Surgery guidelines recommend a stepwise approach to epistaxis evaluation:

1. First-line assessment:

   • Anterior rhinoscopy after removing blood clots to identify bleeding site 1, 2
   • Nasal endoscopy if bleeding site cannot be identified with anterior rhinoscopy or posterior bleeding is suspected 2

2. Clinical history factors to document:

   • Personal or family history of bleeding disorders
   • Use of anticoagulant/antiplatelet medications
   • Intranasal drug use
   • Hypertension
   • Chronic alcohol use 2

Indications for Imaging

Imaging should be considered in specific clinical scenarios:

• Recurrent or severe epistaxis despite appropriate treatment
• Unilateral epistaxis (especially with unilateral nasal obstruction)
• Suspected vascular malformations or tumors
• History of facial trauma with suspected structural abnormalities
• Hereditary hemorrhagic telangiectasia (HHT) 1, 2

Recommended Imaging Modalities When Indicated

When imaging is warranted, the following modalities may be used:

1. Computed Tomography (CT):

   • CT with contrast: First-line imaging modality for suspected tumors, vascular malformations, or anatomical abnormalities
   • CT angiography (CTA): For suspected vascular lesions or to map vascular anatomy before surgical intervention

2. Magnetic Resonance Imaging (MRI):

   • MRI with contrast: For better soft tissue characterization when tumors are suspected
   • MR angiography (MRA): Alternative to CTA for vascular mapping, especially in patients with contrast allergy or renal insufficiency

3. Conventional Angiography:

   • Reserved for cases requiring embolization
   • Provides detailed vascular mapping before endovascular treatment
   • Used when other imaging is inconclusive and vascular pathology is strongly suspected

Clinical Pathway for Epistaxis Evaluation

1. Initial management:

   • Firm sustained compression to the lower third of the nose for 5+ minutes 1, 2
   • Anterior rhinoscopy to identify bleeding site 1

2. If bleeding persists:

   • Nasal endoscopy to identify bleeding site 1, 2
   • Nasal packing or cautery as appropriate 1

3. Consider imaging if:

   • Recurrent/persistent bleeding despite treatment
   • Unilateral epistaxis with suspicious features
   • Mass visualized on endoscopy
   • Suspected vascular abnormality

Common Pitfalls to Avoid

• Overutilization of imaging for routine epistaxis cases
• Delaying endoscopic evaluation in favor of immediate imaging
• Failure to perform adequate anterior rhinoscopy and endoscopy before ordering imaging
• Not considering underlying systemic conditions (coagulopathies, hypertension) that may contribute to epistaxis

Special Considerations

• For patients with HHT, screening imaging may be appropriate to identify pulmonary or cerebral arteriovenous malformations 2
• In cases requiring surgical intervention (arterial ligation) or embolization, pre-procedure imaging is essential to map vascular anatomy 2, 3

Remember that most epistaxis cases can be effectively managed without imaging studies, using proper examination techniques and standard treatment approaches.