2. Introduction
• A very common health problem
• 60% of patients have at least one episode of epistaxis in their life time
• Most are self limited and treated conservatively
• Requires meticulous and individualized approach
• Incidence increases during dry, cold winter months
3. Anatomy
• Efficient management of patients with epistaxis requires thorough
knowledge of the anatomy of
the interior aspect of the nose . This includes :
- Blood supply, and
- Mucosal morphology and configuration
4. Blood Supply
• The nasal mucosa receives its blood supply from branches of both the
internal and external carotid arteries
A. Internal carotid artery
↓
Ophthalmic artery
↓
Anterior and posterior ethmoidal arteries -supplies superior anterior
nasal cavity
5. B. External Carotid Artery
↓
1.Internal maxillary artery
↓
Greater palatine and sphenopalatine arteries
2. Facial artery(superior labial branch)–supplies inferior anterior nasal
septum
.The posterior and superior nasal septum is supplied by branches of
sphenopalatine, anterior and posterior ethmoidal arteries
( kiesselbach’s plexus -”Little area”)
6.
7. Mucosa morphology and configuration
• Respiratory Epithelium
- Pseudo-stratified columnar ciliated
- interspaced goblet cells
- protective mucus blanket assured by ciliary activity
- abundant network of blood vessels in lamina propria
• Any interference that may disrupt this structural configuration is apt to
end up in bleeding
8. Types
A. Anterior Epistaxis
B. Posterior Epistaxis
• Appropriate control of epistaxis calls for identification of
the bleeding site
• Bleeding may, however, occur from any other sites
9. Anterior Epistaxis
• Almost invariably associated with Kiesselbach’s Plexus “Little’s Area”
• Results from any process that causes mucosal hyperemia
• Most commonly occurs in children
• Represents 85-90% of all nosebleeds
10. Posterior Epistaxis
• Majority of it is associated with the sphenopalatine artery ”Woodruff’s
Plexus”
• The sphenopalatine artery is sometimes referred to as the “artery of the
laryngologist”
• Accounts for 10-15% of nose bleeds
• Mostly involves those older than 50
11. Incidence
• Epistaxis has a bimodal age distribution, most cases occurring before
age 10 and between 45 and 65 years of age
• Serious cases encountered with advancing ages, showing a male
preponderance prior to age 49, the gender ratio equalizing thereafter
12. Causes
A. Local
- trauma - nasal picking, rhinitis,
nasal fracture
- foreign body in the nose - rhinoliths
- tumors: benign - polyp
malignant - nasal , paranasal sinuses
B. Systemic
- Infection: AFI, typhus, influenza
- Blood Diseases, coagulopathies
13. • Vascular and circulatory problem: hypertension and arteriosclerosis
• Hereditary: HHT (Osler Rendu Weber Disease)
Clinical features
• Unilateral nasal bleeding (anterior)
• Sensation of blood in posterior throat (posterior)
14. Evaluation
• Initial assessment
- Airway assessment and CV stability and management with
otolaryngologist consultation
• Hx
- Timing, severity, frequency of epistaxis
- Previous epistaxis, trauma, head /neck tumor and surgery, radiation
therapy, cirrhosis, HIV
- Personal and family for bleeding disorders
- Medications (warfarin, plavix, ASA, intranasal glucocorticoids)
• Coagulation profile ,CBC, Cross match
15. • P/E
- V/S, mental status, airway
- Examination of the nose
DDX
• Bleeding that is not from the nose but escaping from the nostril (s)
- Nasopharyngeal tumors
- Esophageal varices
- Skull base vascular Injury
16. Treatment
General Measures
• Get ready basic equipment
• Calm the patient, calm yourself
• Sit up the patient, head bent forward, mouth breathing, pinching alae
of the nose against the septum for 10 minutes
• Advice the patient to blow through the nose
• Cold application - nasal root
• Lower BP, D/C anticoagulant, anti platelates
• IV fluid, blood transfusion
17. Specific measures
Anterior bleeding
- minor bleeding usually resolves spontaneously prior to clinical evaluation
or making tamponade
• Cautery
- chemical - AgNo4 stick for 10 seconds
- electrical
• Nasal packing
- administer small dose of anxiolytics before insertion
- a synthetic open cell foamed polymer nasal tampon-”Merocel™” is
preferable than traditional gauze packing
18. • Gauze packing
- ribbon gauze impregnated with petrolatum
• Nasal balloon catheters (Rapid Rhino)
- parental narcotics and anxiolytics prior to insertion
- Soak the catheter for 30 seconds before insertion
Packing should be followed for 24-48 hrs for recurrence of bleeding
and has a success rate of
90-95%
• Prophylaxis antibiotics
-Amoxycyllin-cavulinate or cephalexin
19. Posterior Bleeding
• Balloon catheters (e.g Epistat,storz-3100)
- Pre treat with 2% lidocain and oxymetazoline
• Foley catheter-10-14 French size
• Cotton packing
• Vascular Ligation – last option
- Sphenopalatine artery
- Anterior & posterior ethmoid arteries
- External carotid artery
20. • Hospitalization
- Posterior source of bleed for cardiac monitoring
- Patient with anterior packing who can not be reasonably expected to
return for prompt follow up or who have serious co-morbidities or
concerning symptoms
22. Summary
• Nosebleed may at times turn out to be life threatening!! .Therefore,
effective handling requires:
- All round readiness
- Pre-consideration of potential complications associated with the
designed management
- patience to review therapeutic procedure and to be aware of any
corrective measures
