2. Bleeding from nostril, nasal cavity or nasopharynx.
Most often self limited, but can often be serious and
life threatening.
5-10% of the population experience an episode of
epistaxis each year, 10% of those will seek a physician
and 1% of those will need a specialist.
Can occur in all age groups i.e children, adults and old
people.
It’s a sign not a disease but presents commonly as an
emergency.
INTRODUCTION
3. Rich vascularity
Supplied by both internal and external carotid system
Various anastomoses between arteries and veins
Blood vessels run under the mucosa unprotected
Larger vessels on the turbinate run in bony canals –
cannot contract
REASON FOR EXCESSIVE BLEEDING
4. Branches of internal
carotid system :
. Anterior Ethmoidal
artery
. Posterior ethmoidal
artery
Branches of external
carotid system :
. Sphenopalatine
artery- major branch
. Greater palatine
artery
. Superior labial branch
of facial artery
. Infraorbital branch of
maxillary artery
VASCULATURE OF NOSE
5. KIESSELBACH’S PLEXUS (Little’s area)
In anterior inferior part of
nasal septum
Most common site for
epistaxis
Mainly anterior epistaxis
1. septal br. Of
sphenopalatine
2. Anterior ethmoidal
3. Septal br. Of superior labial
4. greater palatine arteries
anastomose here.
6. WOODRUFF’S PLEXUS
Posterior end of middle
turbinate
Sphenopalatine artery
anastomoses with
posterior pharyngeal
artery
Most common site for
posterior epistaxis
7. SITES OF EPISTAXIS :
1) Little’s area. In 90% cases.
2) Above the level of middle turbinate.
3) Below the level of middle turbinate.
4) Posterior part of nasal cavity.
5) Diffuse. Both from septum and lateral nasal wall.
6) Nasopharynx.
8. CLASSIFICATION
Anterior
Epistaxis
. More common
. Occurs in
children and
young adults
. Usually due to
nasal mucosal
dryness
. Alarming as
bleeding seen
readily but
generally less
severe
Posterior
Epistaxis
. Usually older
population
. HTN and ASVD
are the most
common
causes
.Significant
bleeding in
posterior
pharynx
. More severe
and treatment
more
challenging
9. A. Congenital – Hereditary telengiectasia
B. Trauma
. Nose picking
. Facial and skull bone fractures
. Foreign body {living and non living}
. Iatrogenic trauma
. Hard blowing, violent sneeze.
C. Infections: Rhinitis,nasal dipththeria,Sinusitis,Tuberculosis
syphilis septal perforations.
CAUSES OF EPISTAXIS
Local causes:
10. D. Non Specific
. Viral – Common cold, Influenza
. Bacterial – Secondary bacterial rhinitis sinusitis
. Fungal rhinosinusitis
. Atrophic rhinitis
E. Physiological
. High altitude
. Extreme cold or hot climate
11. F. Neoplastic
. Benign – Juvenile angiofibroma, angioma of septum,
capillary and cavernous hemangioma
. Malignant – SCC, Olfactory neuroblastoma,
Nasopharyngeal carcinoma
G. Miscellaneous
. Deviated septum & spur
. Rhinitis sicca
. Spontaneous rupture of vessels
. Rhinolith
14. MANAGEMENT
HISTORY,EXAMINATION,INVESTIGATIONS
AND TREATMENT
Previous bleeding episodes
Onset, duration, frequency, amount of blood loss
h/o trauma
Family history of bleeding
Hypertension
Hepatic diseases
Drug history{analgesics or anticoagulants'}
Any other medical ailment
Side of the nose where bleeding occurs.
Bleeding ant or post.
PATIENT HISTORY
15. EXAMINATION: examination of nasal cavity
To locate the bleeding site.
Anterior and posterior rhinoscopy.
Diagnostic nasal endoscopy.
Examination of skin for bruises or petechiae.
Assess vital signs: B.p. pulse , temperature.
INVESTIGATIONS :
. Hematological investigations – Hb%, TLC, DLC, BT, CT,
Platelet count, prothrombin time
. Blood urea, liver function tests
. Radiology:
x-ray and CT scan of nose, PNS and nasopharynx
. Other investigations :depending upon the possible
cause
16. TREATMENT OF EPISTAXIS
First aid
. Trotter’s method-
Make patient sit up,
pinch the nose for 5-10 minutes.
Head bent forward.
Open mouth and breathe
Vasoconstrictors:
oxymetazoline0.05%.
Anaesthetics: xylocaine.
Antibiotics: Mupirocin ointment 2%
Ansaids except aspirin.
Treatment of the cause.
17. CAUTERIZATION
. Chemical cautery with Silver nitrate sticks, Chromic
acid bead
. Electrocautery
Anterior nasal packing or anterior epistaxis balloons for
refractory epistaxis.
Posterior nasal packing.
Elevation of mucoepicondrial flap and SMR operation.
Ligation of vessels like:
External carotid artery.
Maxillary artery.{caldwell-luc operation and
transnasal endoscopic sphenopalatine artery light}
Ethmoidal artery.
Nasal sponge pack and tampon.
Foleys catheter and nasal balloons.
DEFINITIVE TREATMENT
18. Anterior nasal packing :
•If bleeding is profuse and/or the site of bleeding is difficult to
localise, anterior packing should be done.
•Ribbon gauze soaked with liquid paraffin.
•About 1 meter gauze (2.5 cm wide in adults and 12 mm in
children) is required for each nasal cavity. First, few centimeters
of gauze are folded upon itself and inserted along the floor, and
then the whole nasal cavity is packed tightly by layering the
gauze from floor to the root and layering the gauze from floor to
the roof and from before backwards.
•One or both cavities may need to be packed.
•Can be removed after 24 hours if bleeding has stopped.
•If it has to be kept for 2 to 3 days; systemic antibiotics should be
given to prevent sinus infection and toxic shock syndrome.
21. Posterior nasal packing :
•For patients bleeding posteriorly into the throat.
•A postnasal pack is prepared by tying three silk ties
to a piece of gauze rolled into the shape of a cone.
•Patients requiring postnasal pack should always be
hospitalized.
•Foleys' catheter can also be used.
•Nasal balloons are also available.
24. Best to place patient on antibiotics to decrease risk of
sinusitis and toxic shock syndrome
Advise patient to avoid straining, bending forward or
removing pack early
If other nostril is unpacked advise patient topical
saline spray or saline gel to moisturize nasal mucosa
Admitted and monitored in severe cases
PATIENTS ON NASAL PACK
26. Cauterization {septal perforation}
Anterior nasal packing{rhinosinusitis,
toxic shock syndrome, Eustachian tube
dysfunction and scarring of the nasal
ala}
Posterior nasal packing {as for ANP and
dysphagia, hypoventilation.}
Maxillary artery ligation {rhinitis,
sinusitis, cheek numbness and trismus}
Ethmoidal artery ligation{ lacrimal duct
injury and blindness }
Embolization {facial pain, trismus,
stroke, skin necrosis and blindness.}
COMPLICATIONS:
NECROSIS OF ALA
27. General Measures in Epistaxis :
1)Make the patient up with a back rest and record any blood loss through
spitting or vomiting.
2)Reassure the patient. Mild sedation.
3)Keep check on pulse, BP and respiration.
4)Maintain haemodynamics: Blood transfusion.
5)Antibiotics to prevent sinusitis, if pack is be kept beyond 24 hours.
6)Intermittent oxygen patients with bilateral packs.
7)Investigate and treat the patient for any underlying local or general cause.
28. Humidification and moisturization of room.
Dietary measure:
Avoid hot and spicy foods and drink plenty of water.
Avoid strenuous activities, hot showers.
Hot and dry environment.
Avoid digital trauma like nose picking.
Sneeze gently with mouth open.
Avoid drug abuse in adults.
Avoid inappropriate or careless use of drugs like aspirin
and warfarin.
Long term monitoring
PREVENTION OF EPISTAXIS
