Epistaxis

1. EPISTAXIS

2. INTRODUCTION
Bleeding from inside the nose is called
epistaxis
Fairly common and is seen in all age
groups.

3. BLOOD SUPPLY OF NOSE

4. Nasal septum
•Internal carotid system
Anterior ethmoidal artery
Posterior ethmoidal artery
•External carotid system
Sphenopalatine artery (branch of maxillary
artery) gives nasopalatine and posterior medial
nasal branches
Septal branch of greater palatine artery (branch
of maxillary artery)
Septal branch of superior labial artery (branch of
facial artery)

5. Lateral wall
•Internal carotid system
Anterior ethmoidal artery
Posterior ethmoidal artery
•External carotid system
Posterior lateral nasal branches- from
Sphenopalatine artery
Greater palatine artery- from maxillary artery
Nasal branch of anterior superior dental- from
infraorbital branch of maxillary artery
Branches of facial artery to nasal vestibule

6. Little’s area
It is situated in the anterior part of nasal septum, just
above the vestibule.
Four arteries- anterior ethmoidal, septal branch of
superior labial, septal branch of sphenopalatine and the
greater palatine, anastomose here to form a vascular
plexus called “Kiesselbach’s plexus”.
Usual site for epistaxis in children and young adults.
Retrocolumellar vein runs vertically downwards just
behind the columella, crosses the floor of nose and joins
venous plexus on the lateral nasal wall. This is a common
site of venous bleeding in young people.

8. Woodruff’s area
This vascular area is situated under the
posterior end of inferior turbinate where
sphenopalatine artery anastomoses with
posterior pharyngeal artery.
Posterior epistaxis may occur in this area.

9. CAUSES OF EPISTAXIS
Local, in the nose or nasopharynx
General
Idiopathic

10. Local causes
Nose
1. Trauma- Finger nail trauma, injuries of nose, intranasal
surgery, fractures of middle third of face and base of
skull, hard-blowing of nose, violent sneeze.
2. Infections
Acute: viral rhinitis, nasal diphtheria, acute sinusitis.
Chronic: all crust-forming diseases, e.g. atrophic rhinitis,
rhinitis sicca, tuberculosis, syphilis septal perforation,
granulomatous lesion of the nose, e.g. rhinosporidosis.

11. Local causes…
3. Foreign bodies
Non-living: any neglected foreign body,
rhinolith.
Living: maggots, leeches.
4. Neoplasm of nose and paranasal sinuses.
Benign: haemangioma, papilloma.
Malignant: carcinoma or sarcoma.
5. Atmospheric changes. High altitudes, sudden
decompression (Caisson’s disease).
6. Deviated nasal septum.

12. Local causes…
Nasopharynx
2.Adenoiditis
3.Juvenile angiofibroma
4.Malignant tumours

13. General causes
1.Cardiovascular system- hypertension,
arteriosclerosis, mitral stenosis,
pregnancy (hypertension and hormonal).
2.Disorders of blood and blood vessels-
Aplastic anaemia, leukemia,
thrombocytopenic and vascular purpura,
haemophilia, Christmas disease, scurvy,
vitamin K deficiency, hereditary
haemorrhagic telangectasia.
3.Liver disease- hepatic cirrhosis
(deficiency of factor

14. General causes…
4. Kidney disease- chronic nephritis
5. Drugs- excessive use of salicylates and
other analgesics, anticoagulant therapy.
6. Mediastinal compression
7. Acute general infection- influenza,
measles, chickenpox, whooping cough,
rheumatic fever, infectious mononucleosis,
typhoid, pneumonia, malaria, dengue
fever.
8. Vicarious menstruation.

15. Sites of epistaxis
Little’s area
Above the level of middle turbinate
Below the level of middle turbinate
Posterior part of nasal cavity
Diffuse- both from septum and
lateral nasal wall.
Nasopharynx

16. Classification
Anterior epistaxis
More common
Mostly from Little’s area or
anterior part of lateral wall
Mostly occurs in children
or young adults
Mostly trauma
Usually mild, can be easily
controlled by local
pressure or anterior pack
Posterior epistaxis
Less common
Mostly from
posterosuperior part of
nasal cavity
After 40 years of age
Spontaneous; often due
to hypertension or
arteriosclerosis
Bleeding is severe,
requires hospitalization;
postnasal pack often
required

17. Management
In any case of epistaxis, it is important to know:
Mode of onset. Spontaneous or finger nail trauma.
Duration and frequency of bleeding.
Amount of blood loss.
Side of nose from where bleeding is occurring.
Whether bleeding is of anterior or posterior type.
Any known bleeding tendency in the patient or family.
History of known medical ailment (hypertension,
leukemias, mitral valve disease, cirrhosis, nephritis).
History of drug intake (analgesics, anticoagulants,
etc.).

18. First aid
Little’s area- pinching the nose with thumb
and index finger for about 5 minutes-
compression of vessels.
Trotter’s method- patient is made to sit,
leaning a little forward over a basin to spit
any blood, and breathe quietly from
mouth- cold compresses should be
applied to nose to cause reflex
vasoconstriction.

19. Cauterisation
Useful in anterior epistaxis.
The area is first anaesthetised and the
bleeding point cauterised with a bead of
silver nitrate or coagulated with
electrocautery.

20. Anterior nasal packing
If bleeding is profuse and/or the site of bleeding
is difficult to localise, anterior packing is done.
For this, a ribbon gauze soaked with liquid
paraffin is used.
About 1 metre gauze (2.5 cm wide in adults and
12 mm in children) is required for each nasal
cavity.
Pack can be removed after 24 hours if bleeding
has stopped.

21. Posterior nasal packing
It is required for patients bleeding
posteriorly into the throat.
A postnasal pack is first prepared by tying
three silk ties to a piece of gauze rolled
into the shape of a cone.

22. Endoscopic cautery
Posterior bleeding point can sometimes be
better located with an endoscope.
It can be coagulated with suction cautery.
Local anaesthesia with sedation may be
required.

23. Elevation of Mucoperichondrial flap and
SMR operation
In case of persistent or recurrent bleeds
from the septum, just elevation of
mucoperichondrial flap and then
repositioning it back helps to cause
fibrosis and constrict blood vessels.
SMR operation can be done to achieve
the same result or remove any septal spur
which is sometimes the cause of epistaxis.

24. Ligation of vessels
a)External carotid- above the origin of
superior thyroid artery.
b)Maxillary artery- approach is via
Caldwell-Luc operation.
c)Ethmoidal arteries- in anterosuperior
bleeding above the middle turbinate.

25. General measures in epistaxis
Make the patient sit up with a back rest and record any
blood loss taking place through spitting or vomiting.
Reassure the patient. Mild sedation should be given.
Keep check on pulse, BP and respiration.
Antibiotics may be given to prevent sinusitis, if pack is to
be kept beyond 24 hours.
Intermittent oxygen may be required in patients with
bilateral packs because of increased pulmonary
resistance from nasopulmonary reflex.
Investigate and treat the patient for any underlying local
or general cause.

26. Hereditary Haemorrhagic Telangectasia
It occurs on the anterior part of nasal
septum and is the cause of recurrent
bleeding.
It can be treated by using Argon, KTP or
Nd: YAG laser.
Some cases require septodermoplasty
where anterior part of septal mucosa is
excised and replaced by a split skin graft.