Epistaxis cpt code

This clinical practice guideline CPG is intended for all clinicians who evaluate and treat patients with nosebleed. The target population for the guideline is any individual aged three years or older with a nosebleed or history of nosebleed who needs medical treatment or seeks medical advice. The purpose of this multidisciplinary CPG is to identify quality improvement opportunities in managing patients with nosebleeds and to create explicit and actionable recommendations to implement these opportunities in clinical practice.

Abramson, MD; Jacqueline D. Feldstein, MD; Jesse M. Hackell, MD; Eric H. Holbrook, MD; Sarah M. Riley, MD; John S. Valdez, MD; Lorraine C. American Geriatrics Society AGS Affirmation of value means that AGS supports the general principles in this document and believes it is of general benefit to its membership.

Get Involved. Search form. Clinical Practice Guideline. This is more content. Additional Information Title:. Click here for instructions on how to customize these handouts. Related Files External Link:.

Nosebleed FAQs. External Link:. Nasal Packing FAQs. Guidelines Link:.A majority of the population will experience epistaxis at some time in their life. Most cases will be from an anterior source and can be treated with pressure, anterior nasal packing, or cautery. Intractable epistaxis is generally posterior in origin and may require endoscopic cautery, posterior packing, surgical ligation, or embolization.

These excellent results require thorough knowledge of the regional anatomy, familiarity with the equipment and various agents used to achieve this type of embolization, as well as attention to detail and meticulous technique.

There remains debate on several aspects of embolization, including the agent of choice, preferred size of the embolic, and the number of vessels to embolize. Advances in endoscopic surgery have evolved to the point that similar success rates for embolization and modern surgical techniques in treating epistaxis may be expected.

This detailed review of pertinent vascular anatomy, embolization technique, and surgical alternatives should allow practitioners to formulate treatment algorithms that result in optimal outcomes at their institutions. Objectives: Upon completion of this article, the reader will be able to identify the etiology and overall management of patients presenting with epistaxis.

In particular, the reader will be able to demonstrate a thorough knowledge of the pertinent anatomy, angiographic appearances, transcatheter techniques, and complications associated with transcatheter embolotherapy in the setting of epistaxis. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Epistaxis is a Greek word meaning nosebleed. Some of the earliest accounts of epistaxis date to Egyptian times and describe the use of the ashes of papyrus mixed with vinegar to treat nasal bleeds.

InPilz was the first person to treat epistaxis by surgically ligating the external carotid artery. Seiffert described ligation of the internal maxillary artery IMAX through the maxillary antrum via the Caldwell-Luc approach to control epistaxis in Since that time a variety of embolic agents have been used including GF, autologous clot, fat, marrow, polyvinyl alcohol PVAcalibrated microspheres, N -butyl cyanoacrylate, coils, Onyx, and other agents.

The proximity to the brain and eyes makes the endovascular treatment of epistaxis somewhat more challenging and risky than embolization in other locations of the body. Interventional radiologists IRs who wish to work in this region must have a thorough knowledge of the regional anatomy, dangerous collaterals, pathophysiology, and available alternative treatments.

Armed with this knowledge, the IR, most often in concert with the otolaryngologist, can provide optimal care to epistaxis patients. Most large studies show a mild peak in epistaxis cases in the first to second decade of life, and a subsequent increase with age above 40 years.

Rarely, other more unusual causes such as tumor e. The typical patient presenting for evaluation and treatment at an emergency room is an elderly hypertensive patient.

Epistaxis is more common in the winter months. This seasonal variation is believed to be related to reduced humidity, temperature, and increased prevalence of upper respiratory tract infections.

How to Code CPT® Surgery Anatomically

Since the vast majority of epistaxis will be anterior in location, it is relatively easily accessible to local therapy. Less common posterior bleeding is more difficult to access and often more difficult to control. The blood supply of the nasal cavity is rich and varied.

Several authors also describe a small contribution to the posterior nasal cavity from the ascending pharyngeal artery APhAwhich arises from the IMAX just beyond the facial artery FA origin.

The SPA provides the dominant supply to the nasal cavity walls via both medial septal and lateral branch; the lateral branch supplies the superior, middle, and inferior turbinates, while the medial branch supplies the nasal septum. The richly vascularized posterior aspect of the nasal cavity, sometimes referred to as Woodruff plexus, is primarily supplied by the SPA.

The GPA courses via the incisive foramen to supply the inferior portion floor of the nasal septum and anastomoses with septal branches of the SPA. The FA generally supplies the more anteroinferior portion of the nasal cavity via the terminal alar branches of the superior labial artery SLA as well as the lateral nasal artery LNA.A nosebleedalso known as epistaxisis the common occurrence of bleeding from the nose. It is usually noticed when blood drains out through the nostrils.

Sometimes in more severe cases, the blood can come up the nasolacrimal duct and out from the eye. Fresh blood and clotted blood can also flow down into the stomach and cause nausea and vomiting. There are two types: anterior more commonand posterior less common, more likely to require medical attention.

Initially treatment is generally with applying pressure for at least five minutes over the lower half of the nose. Nosebleeds can occur due to a variety of reasons. Some of the most common causes include trauma from nose pickingblunt trauma such as a motor vehicle accidentor insertion of a foreign object more likely in children.

Most causes of nose bleeding are self-limiting and do not require medical attention. However, if nosebleeds are recurrent or do not respond to home therapies, an underlying cause may need to be investigated.

Some rarer causes are listed below: [5] [6] [7]. The nasal mucosa contains a rich blood supply that can be easily ruptured and cause bleeding. Rupture may be spontaneous or initiated by trauma. Spontaneous epistaxis is more common in the elderly as the nasal mucosa lining becomes dry and thin and blood pressure tends to be higher.

The elderly are also more prone to prolonged nosebleeds as their blood vessels are less able to constrict and control the bleeding.

The vast majority of nosebleeds occur in the anterior front part of the nose from the nasal septum. This area is richly endowed with blood vessels Kiesselbach's plexus. This region is also known as Little's area. Bleeding farther back in the nose is known as a posterior bleed and is usually due to bleeding from Woodruff's plexusa venous plexus situated in the posterior part of inferior meatus.

They can be associated with bleeding from both nostrils and with a greater flow of blood into the mouth. Sometimes blood flowing from other sources of bleeding passes through the nasal cavity and exits the nostrils. It is thus blood coming from the nose but is not a true nosebleed, that is, not truly originating from the nasal cavity. Examples include blood coughed up through the airway and ending up in the nasal cavity, then dripping out.

People with uncomplicated nosebleeds can use conservative methods to prevent future nosebleeds such as sleeping in a humidified environment or applying petroleum jelly to the nasal nares. Most anterior nosebleeds can be stopped by applying direct pressurewhich helps by promoting blood clots. Vasoconstrictive medications such as oxymetazoline Afrin or phenylephrine are widely available over the counter for treatment of allergic rhinitis and may also be used to control benign cases of epistaxis.

Epistaxis Management in the Emergency Department: A Helpful Mnemonic

This method involves applying a chemical such as silver nitrate to the nasal mucosa, which burns and seals off the bleeding. Silver nitrate can cause blackening of the skin due to silver sulfide deposit, though this will fade with time.

If pressure and chemical cauterization cannot stop bleeding, nasal packing is the mainstay of treatment. Traditional gauze packing has been replaced with products such as Merocel and the Rapid Rhino.

Posterior nasal packing can be achieved by using a Foley catheterblowing up the balloon when it is in the back of the throat, and applying traction.

epistaxis cpt code

As a result, many forms of nasal packing involve use of topical antistaphylococcal antibiotic ointment. Tranexamic acid helps promote blood clotting. For nosebleeds it can be applied to the site of bleeding, taken by mouth, or injected into a vein.

Ongoing bleeding despite good nasal packing is a surgical emergency and can be treated by endoscopic evaluation of the nasal cavity under general anesthesia to identify an elusive bleeding point or to directly ligate tie off the blood vessels supplying the nose. These blood vessels include the sphenopalatineanterior and posterior ethmoidal arteries.Epistaxis is a common presentation to the emergency department ED 1 that can be challenging and time consuming.

Knowledge of the pearls, pitfalls, and troubleshooting tips around managing nosebleeds often can be the difference between a frustrating versus straightforward ED stay for patients. Recurrent or intractable bleeding has led to the development of management algorithms in the urgent care setting. Attempt to visualize site of bleeding.

ICD-10 coding challenge: Epistaxis

Have patient gently blow nose to clear the clots. Obtain adequate lighting and use a nasal speculum, if available. As with any bleed, compression is key. Fatigue becomes an issue as patients tire of squeezing their nose. There are commercially available nasal compression clips, but in a pinch get it?

Irrigation of the nares can improve visibility. Warm-water irrigation has been demonstrated to facilitate hemostasis in posterior bleeds by causing mucosal edema that constricts vessels.

If a bleeding anterior vessel is identified, an attempt at chemical or electrical cautery can be made. Silver nitrate sticks offer an easily accessible and efficacious option. Nasal tampons, often made of Merocel, are used for nasal packing.

Apply saline to expand the tampon. Tampons can also be inserted into the contralateral nostril for further compression. They contain an internal balloon that is inflated for extra pressure.

epistaxis cpt code

Such products have been shown to be easier to use and better tolerated; however, the efficacy is similar to Merocel tampons. If such balloon catheter tampons are not readily available for difficult cases of posterior bleeding, Foley catheters can be used.

If bleeding persists anteriorly or into the oropharynx, the balloon can be incrementally inflated up to 30 mL. Avoid inflation with air as the pressure can be lost over time. Oxymetazoline Afrina selective alpha-1 adrenergic receptor agonist and partial alpha-2 receptor agonist, has been shown to be an effective vasoconstrictor even for posterior bleeding.

The use of tranexamic acid TXA in epistaxis and mucosal bleeding has been a topic of interest. ENT consultation should be obtained in a timely manner for severe, refractory bleeding that may require intravascular embolization or surgical ligation. Patients with posterior epistaxis and packing should be admitted to the hospital for observation and ENT consultation. The routine use of antibiotics to prevent toxic shock syndrome and sinus infections remains debated.A nosebleedalso known as epistaxisis bleeding from the nose.

Risk factors include trauma including putting the finger in the nose, blood thinnershigh blood pressurealcoholismseasonal allergiesdry weather, and inhaled corticosteroids. Prevention may include the use of petroleum jelly in the nose. Nosebleeds can occur due to a variety of reasons. Some of the most common causes include trauma from nose pickingblunt trauma such as a motor vehicle accidentor insertion of a foreign object more likely in children.

Most causes of nose bleeding are self-limiting and do not require medical attention. However, if nosebleeds are recurrent or do not respond to home therapies, an underlying cause may need to be investigated.

Some rarer causes are listed below: [2] [4] [12]. The nasal mucosa contains a rich blood supply that can be easily ruptured and cause bleeding. Rupture may be spontaneous or initiated by trauma. Spontaneous epistaxis is more common in the elderly as the nasal mucosa lining becomes dry and thin and blood pressure tends to be higher.

Epistaxis: the common and not-so-common nosebleed

The elderly are also more prone to prolonged nosebleeds as their blood vessels are less able to constrict and control the bleeding. The vast majority of nosebleeds occur in the anterior front part of the nose from the nasal septum. This area is richly endowed with blood vessels Kiesselbach's plexus. This region is also known as Little's area. Bleeding farther back in the nose is known as a posterior bleed and is usually due to bleeding from Woodruff's plexusa venous plexus situated in the posterior part of inferior meatus.

They can be associated with bleeding from both nostrils and with a greater flow of blood into the mouth. Sometimes blood flowing from other sources of bleeding passes through the nasal cavity and exits the nostrils. It is thus blood coming from the nose but is not a true nosebleed, that is, not truly originating from the nasal cavity. Examples include blood coughed up through the airway and ending up in the nasal cavity, then dripping out.

People with uncomplicated nosebleeds can use conservative methods to prevent future nosebleeds such as sleeping in a humidified environment or applying petroleum jelly to the nasal nares. Most anterior nosebleeds can be stopped by applying direct pressurewhich helps by promoting blood clots.

Vasoconstrictive medications such as oxymetazoline Afrin or phenylephrine are widely available over the counter for treatment of allergic rhinitis and may also be used to control benign cases of epistaxis.

If pressure and chemical cauterization cannot stop bleeding, nasal packing is the mainstay of treatment. Traditional gauze packing has been replaced with products such as Merocel and the Rapid Rhino. Posterior nasal packing can be achieved by using a Foley catheterblowing up the balloon when it is in the back of the throat, and applying traction.

As a result, many forms of nasal packing involve use of topical antistaphylococcal antibiotic ointment. Tranexamic acid helps promote blood clotting. This method involves applying a chemical such as silver nitrate to the nasal mucosa, which burns and seals off the bleeding. Silver nitrate can cause blackening of the skin due to silver sulfide deposit, though this will fade with time.

Ongoing bleeding despite good nasal packing is a surgical emergency and can be treated by endoscopic evaluation of the nasal cavity under general anesthesia to identify an elusive bleeding point or to directly ligate tie off the blood vessels supplying the nose. These blood vessels include the sphenopalatineanterior and posterior ethmoidal arteries. More rarely the maxillary or a branch of the external carotid artery can be ligated. The bleeding can also be stopped by intra-arterial embolization using a catheter placed in the groin and threaded up the aorta to the bleeding vessel by an interventional radiologist.

The utility of local cooling of the head and neck is controversial. In the visual language of Japanese manga and animea sudden, violent nosebleed indicates that the bleeding person is sexually aroused. In American and Canadian usage, " nosebleed section " or "nosebleed seats" are common slang for seating at sporting or other spectator events that are the highest up and farthest away from the event. The reference alludes to the propensity for nasal hemorrhage at high altitudes, usually owing to lower barometric pressure.

The oral history of the Native American Sioux tribe includes reference to women who experience nosebleeds as a result of a lover's playing of music, implying sexual arousal.While there is little evidence available directly regarding the use of topical tranexamic acid TXA for epistaxis or oral bleeds in the emergency department EDthe use of topical TXA has been used for epistaxis, hyphema, and dental extractions in a variety of settings.

Its use has been studied in patients both on and off oral anticoagulants and with or without bleeding disorders such as hemophilia. It can be extrapolated from the studies that topical TXA is effective in stopping or controlling bleeds, and has been shown to be safe for use in these cases. TXA is an antifibrinolytic drug which reversibly binds to plasminogen and prevents its interaction with fibrin, thus inhibiting the dissolution of fibrin clots.

The intravenous IV solution is FDA approved in patients with hemophilia for short-term use two to eight days to reduce or prevent hemorrhage and reduce the need for replacement therapy during and following tooth extraction while the oral PO formulation is FDA approval for the treatment of cyclic heavy menstrual bleeding. Despite the narrow indications for which TXA is approved in the United States, it has been studied in a wide variety of conditions in which systemic or local hyperfibrinolysis is involved including cardiac surgery, orthopedic surgery, spinal surgery, post-partum hemorrhage, gastrointestinal bleeding, trauma, epistaxis, hyphema, and dental extractions [1].

Topical TXA is an attractive option as it would inhibit local fibrinolysis at the site of bleeding with minimal systemic absorption [2]. This review will focus on the topical use of TXA in localized hyperfibrinolysis such as epistaxis, dental procedures, and hyphema.

In a randomized controlled trial conducted in an emergency department, patients presenting with ongoing epistaxis and known history of bleeding disorders thrombocytopenia, hemophilia, platelet disorders were randomized to receive either packing soaked in TXA mg in 5 mL or packing soaked in epinephrine plus lidocaine followed by packing covered in tetracycline for three days anterior nasal packing [3]. There was also a higher rate of rebleeding in the first 24 hours and within 1 week in the group treated with anterior nasal packing as compared to those treated with TXA.

There was no statistical significance between complications in the ED. Hosseini et al. Rate of rebleeding were evaluated at day 4, 8, and Only one patient 3. In both cases, the cohort receiving topical TXA was significantly older, and had a significantly lower intraocular pressure at baseline.

Treatment with topical TXA was well tolerated, and the authors concluded that topical TXA may be an option for treatment of hyphema gradesalthough the study design and small sample size limited them from making any decisive conclusions. The strict exclusion criterion limits the use of this study in a broad patient population. The largest body of evidence for use of topical TXA exists in the dental literature. The evidence applies to both peri-operative and post-operative uses, with varying results.

Use of 10 mL of 0. Anecdotally, one treatment site in South Africa has used crushed TXA tablets mg suspended in water for dental surgeries and tooth extractions post-operatively [6].Epistaxis has a bimodal age distribution, with most cases in children years old and adults years old. Certain high-risk groups, such as the elderly, require rapid intervention to stem bleeding and prevent further complications.

The treatment of epistaxis has undergone significant changes in recent years. Gone are the days when an uncomfortable nasal pack is inserted, with rebleeding upon removal several days later fairly common. New packing devices and ingenious hemostatic agents have been developed to provide a variety of effective and well-tolerated treatment options.

Treatment of any patient with epistaxis starts with ensuring a secure airway and hemodynamic stability. Ninety percent of nosebleeds are anterior and can be controlled by pinching the anterior aspect of the nose.

epistaxis cpt code

Good lighting, such as a headlight, is essential and keeps both hands free. The first step in identifying the source of bleeding is to clear the nose of blood either by the patient blowing the nose or by suctioning. Topical oxymetazoline Afrin spray alone often stops the hemorrhage. Pages: 1 2 3 4 5 6 Single Page. Topics: CME. Download PDF. Read More. Your email address will not be published. Learning Objectives After reading this article, the physician should be able to: Understand the treatment approach to epistaxis.

Utilize established techniques and new products available for nosebleeds. December 10, - 0 Comment. All Rights Reserved. ISSN Sorry, your blog cannot share posts by email. This site uses cookies: Find out more. Okay, thanks.


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