Epistaxis, or nosebleed, is bleeding from inside the nose. It is common and can occur in people of all ages. The nose has a rich blood supply from both the internal and external carotid arteries, making it susceptible to bleeding. The most common site of bleeding is Kiesselbach's plexus in the anterior nasal septum. Epistaxis can be classified as anterior or posterior depending on the location and direction of bleeding. Causes include local trauma, infections, vascular abnormalities, and medications. Management involves first aid measures, cauterization, nasal packing, surgery, or ligation of vessels supplying the nose.

1. ASIM ABDU
AAY96@HOTMAIL.COM
KING KHALED UNIVERSITY

2. Introduction

3. Introduction
Definition
Epistaxis : Bleeding from inside the nose
Origin
From a Greek term “epistazo” which means “to bleed from nose”.

4. Introduction
• It is fairly common.
• It is seen in all age groups : children,
adults and older people.
• It often presents as an emergency.
• Epistaxis is a sign and not a disease.

5. Introduction
Why Nose?
• Situated in a vulnerable position as
it protrudes on the face.
• Has a very rich blood supply.
• Supplied by both internal and
external carotid system.
• Various anastomoses between
arteries and veins.
• Vasculature runs just under the mucosa.
• Exposed to the drying effect of inspiratory current.

6. Introduction
Epidemiology
• Lifelong incidence of epistaxis in general population is about 60%.
• Fewer than 60% seek medical attention.
• Peaks in young children (2 – 10 y) and older individuals (50 – 80 y)
• occur in males more than females.

7. The Blood Supply
of Nose

8. • Nose is richly supplied by both the external and internal carotid systems.
Superior part of the nose (Internal carotid artery):
• Ophthalmic artery
- Anterior ethmoidal artery
- Posterior ethmoidal artery
Inferior part of the nose (External carotid artery):
• Maxillary artery
- Greater palatine artery
- Sphenopalatine artery
• Facial artery
- Superior labial artery  vestibule of the nose

9. Kiesselbach’s plexus (Little’s area)
• In anterior inferior part of nasal septum.
• Most common site for epistaxis.
• Mainly anterior epistaxis.
• Four arteries:
1. Septal branch of sphenopalatine artery
2. Anterior ethmoidal artery
3. Septal branch of labial artery
4. Greater palatine artery

10. Woodruff’s Plexus
• Posterior end of middle turbinate.
• Most common site for posterior epistaxis.
• It is anastomoses of two arteries:
1. Sphenopalatine artery
2. posterior pharyngeal artery

11. Reterocolumellar Veins
• Runs vertically downwards just behind columella.
• Crosses the floor of nose and joints venus plexus on lateral nasal wall.
• Common site for venous bleed in young patient.

12. Pathophysiology

13. Bleeding typically occurs when the
mucosa is eroded
and vessels become exposed and
subsequently break.

14. Classification

15. Anterior Epistaxis
 Blood flow out from front nose with patient
in sitting position.
•Incidence: More common.
• Site: Mostly from Little’s area or anterior
part of lateral wall.
• Age: Mostly occurs in children or young adults.
• Cause: Mostly trauma.
• Bleeding: Usually mild, can be easily controlled
by local pressure or anterior pack.

16. Posterior Epistaxis
 Blood flow back into the throat.
• Incidence: Less common.
• Site: Mostly from posterosuperior part of nasal
cavity; often difficult to localize the bleeding point.
• Age: After 40 years of age.
• Cause: Spontaneous; often
due to hypertension or arteriosclerosis.
• Bleeding: severe,
requires hospitalization; postnasal pack
often required.

17. Site of Epistaxis

18. 1. Little’s area: 90% of cases.
2. Above level of middle turbinate: anterior and posterior ethmoidal artery.
3. Below level of middle turbinate: from branch of sphenopalatine artery.
4. Posterior part of nasal cavity: blood to pharynx.
5. Diffuse: from septum and lateral nasal wall.
6. Nasopharynx.

19. CAUSES OF EPISTAXIS

20. 1. Local (nose or nasopharynx).
2. General.
3. Idiopathic.

21. Local Causes
Trauma:
• Finger nail trauma
• Injury of nose
• Intranasal surgery
• Fracture of middle third of face and base of skull
• Hard blowing of nose
• Violent sneeze
Infection:
• Acute: viral rhinitis, acute sinusitis, nasal diphtheria
• Chronic: Crust forming Disease(rhinitis sicca, tuberculosis); Granulamatous lesion of nose(rhinosporidosis)

22. Local Causes
Foreign bodies:
• Nonliving: any neglected foreign body
• Living: Maggots, leeches
Neoplasms:
• Benign: Hemangioma, papilloma
• Malignant: Carcinoma, sarcoma
Atmospheric changes:
high altitudes, sudden decompression, Casisson disease.
Deviation of nasal septum.

23. General Causes
Cardiovascular System:
• Hypertension
• Arteriosclerosis
• Mitral stenosis
• Pregnancy (hypertension and hormonal)
Disorders of blood and blood vessels:
• Aplastic anemia
• Leukemia
• Thrombocytopenia
• Vascular purpura

24. General Causes
Liver: Hepatic cirrhosis.
Kidney: Chronic nephritis.
Mediastinal compression: tumor causing raised venous pressure.
Acute general infection: influenza, measules, whooping cough.
Vicarious menstruation.
Drug:
• Excessive use of salicylates and other analgesics.
• Anticoagulant therapy

25. Management

26. First Aid
Bleeding from Little’s area can be stopped by pinching the nose for 5 min.
Trotter’s method:
1. Patient is made to sit
2. Leaning a little forward
3. Breath quietly from the mouth
4. Cold compression is applied(vasoconstriction)

27. Cauterization
• Useful in anterior epistaxis when bleeding point has been located
• Topically anaesthetized
• Bleeding point cauterization with bead of
silver nitrate or
coagulated with electrocautery

28. Anterior Nasal Packing
• Done if localized bleeding is profuse or bleeding point is not localize
• Use of a ribbon gauze soaked with liquid paraffin(1 m gauze; 2.5 cm
gauze in adult and 12 mm in children)
• Can be done with vertical layer and horizontal layer
• Can be removed with 24 hour and can be kept upto 2-3 days
• Systemic antibiotic should be given to prevent sinus infection
and toxic shock syndrome

29. Posterior Nasal Packing
• For posterior nasal bleed
• Can be carried through different instrument:
1. Gauze
2. Foley’s Catheterization
3. Nasal balloon
Nasal packing by Gauze
Nasal packing by Foley’s catheterNasal Balloon

30. Elevation of Mucoperichondrial Flap and Submucous Resection(SMR)
Operation:
• For persistant or recurrent bleeds from septum
• Elevation of mucoperichondrial flap
• Reposining flap back help to cause fibrosis and constrict blood vessel
Endoscopic Cauterization
• Topical or general anesthesia, bleeding point is localized
• with rigid endoscopy and cauterized
• Procedure is effective with less morbidity and decreased stay
• With profuse bleeding it is very difficult to localize so this
• procedure can’t be carried out

31. Ligation of Vessels
Ligation can be done to
• External Carotid (ligation on origin of superior thyroid artery)
• Maxillary artery
• Ethmoidal artery

32. Other process
• Transnasal Endoscpoic Sphenopalatine Artery
Ligation(TESPAL)
• Embolization of artery

33. General Measures in Epistaxis
• Making patient sit up with back rest and record any blood loss taking place through spitting or vomiting
• Mild sedation should be given
• Checking pulse, BP and respiration
• Maintenance of hemodynamics (Blood transfusion may required)
• Antibiotics can 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 nasopharynx reflex
• Investigation and treatment for any underlying local or general cause

34. References
• Disease of Ear, Nose and
Throat and head and neck
surgery. Dhingra PL,
Dhingra S. 6th ed.
Epistaxis.
• Disease of Ear, Nose and
Throat. Bhansal M. 1st ed.
Nose and Paranasal
Sinuses. =