Basic anatomy of nose and epistaxis

1. D R . M O H A M E D T A R I G A L H A K E E M
R 2
M R . O S M A N S U N I T
EPISTAXIS

2. DEVELOPMENT
 nasal placodes which develop into nasal pits. These are
bounded by medial and lateral nasal prominences that
unite to encircle the nostril
 Floor of the nasal cavity is formed by fusion of the medial
nasal process (nasal septum) with the
palatine processes of the maxilla.
 Roof of the nose is formed from the lateral nasal processes.
 Paranasal sinuses develop as diverticula of the lateral nasal
wall and extend into the maxilla, ethmoid, frontal, and
sphenoid bones.

3. 1- BONY PART two nasal bones which meet in the
midline and rest on the upper part of the nasal
process of the frontal bones
EXTERNAL NOSE

4. 2- CARTILAGINOUS PART
1. Upper lateral cartilages.
2. Lower lateral cartilages (alar cartilages
3. Lesser alar (or sesamoid) cartilages.
4. Septal cartilage.

6. INTERNAL NOSE
Nasal cavity
function
 Its function is to warm, clean, humidify, filter the
inhaled air for respiration, and help smell and taste.

7.  A. Roof
■ Is formed by the nasal, frontal, ethmoid
(cribriform plate), and sphenoid (body) bones.
The cribriform plate transmits the olfactory nerves.

8.  Floor
■ Is formed by the palatine process of the maxilla
and the horizontal plate of the palatine bone.
■ Contains the incisive foramen, which transmits
the nasopalatine nerve and terminal branches of the
sphenopalatine artery.

9.  C. Medial Wall (Nasal Septum)
■ Is formed primarily by the perpendicular plate of
the ethmoid bone, vomer, and septal cartilage.
■ Is also formed by processes of the palatine,
maxillary, frontal, sphenoid, and nasal bones.

10.  D. Lateral Wall
■ Is formed by the superior and middle conchae of
the ethmoid bone and the inferior concha.

12.  superior turbinate.
Part of the ethmoid and situated in the posterior superior to
middle turbinate
 middle Turbinate
It is an ethmoturbinal , attachment with basal lamella, Lateral
edge of cribriform plate , lamina papyracea and the medial wall of
maxillary sinus.
Inferior Turbinate.
separate bone

13.  superior meatus.
It is a space below the superior turbinate. Posterior
ethmoid cells open into it.
 middle meatus
maxillary sinus ,frontal sinus , anterior and middle
ethmoid sinus
-Uncinate process hook like structre , inferiorly attached
to the inf. turbinate
 inferior meatus, opens the nasolacrimal duct
 sphenoethmoidal recess. It is situated above the
superior turbinate. Sphenoid sinus opens into it

14. -bulla Ethmoidalis behind the uncinate process ,
bulla may be a pneumatized cell or a solid bony
prominence
anterior surface of the bulla form the posterior boundry of
hiatus semilunaris - ( gap between the UP and the BE)
-agger Nasi. It is an elevation just anterior to the
attachment of middle turbinate.

16.  LINING MEMBRANE OF INTERNAL NOSE
1. Vestibule.
2. olFactory Region
3. respiratory Region.

17. Nerve supply
 1. Anterior ethmoidal nerve.
2. Branches of sphenopalatine ganglion.
3. Branches of infraorbital nerve. They supply
vestibule of nose both on its medial and lateral side.
 Most of the posterior two-thirds of nasal cavity (both
septum and lateral wall) are supplied by branches of
sphenopalatine ganglion

18.  3. Autonomic nerves. Parasympathetic nerve
fibres supply the nasal glands and control nasal
secretion. They come from greater superficial
petrosal nerve

21. Blood supply
1. The lateral nasal branches of the anterior and
posterior ethmoidal arteries of the ophthalmic artery.
2. The posterior lateral nasal and posterior septal branches
of the sphenopalatine artery of the
maxillary artery.
3. The greater palatine branch (its terminal branch
reaches the lower part of the nasal septum
through the incisive canal) of the descending palatine
artery of the maxillary artery.
4. The septal branch of the superior labial artery of the
facial artery and the lateral nasal branch of the facial
artery.
Kiesselbach plexus little’s area

23.  Veins accompany the arteries and drain in various
directions to the pterygoid plexus, facial vein and
ophthalmic veins

24. LYMPHATIC DRAINAGE
Lymphatics from the external nose and anterior part of
nasal cavity drain into submandibular L.N
while those from the rest of nasal cavity drain into
upper jugular nodes.

25. Epistaxis
LITTLE’S AREA
 just above the vestibule.
WOODRUFF’S PLEXUS
 inferior to posterior end
of inferior turbinate.

26. CAUSES OF EPISTAXIS
1. Local, in the nose or nasopharynx.
2. General.
3. Idiopathic.

27. A.LOCAL CAUSES
 Nasal
1. Trauma
2. Infections
3. Foreign bodies
4. Neoplasms of nose and paranasal sinuses.
5. Atmospheric changes.
6. Deviated nasal septum.

28.  Nasopharynx
1. Adenoiditis.
2. Juvenile angiofibroma.
3. Malignant tumours.

29. B. GENERAL CAUSES
1. Cardiovascular system. Hypertension, arteriosclerosis,
mitral stenosis, pregnancy (hypertension and hormonal).
2. Disorders of blood and blood vessels. Aplastic
anaemia, leukaemia, thrombocytopenic and vascular
purpura, haemophilia, Christmas disease, scurvy, vitamin K
deficiency and hereditary haemorrhagic telangectasia.
3. Liver disease. Hepatic cirrhosis
4. Kidney disease.
5. Drugs.
6. Mediastinal compression. (raised venous pressure in the
nose).
7. Acute general infection.
8. Vicarious menstruation (epistaxis occurring at the
time of menstruation).

30.  C. IDIOPATHIC

31. SITES OF EPISTAXIS
1. Little’s area. In 90% cases
2. Above the level of middle turbinate anterior and
posterior ethmoidal vessels (internal carotid system).
3. Below the level of middle turbinate. Here bleeding
is from the branches of sphenopalatine artery.
4. Posterior part of nasal cavity. Here blood flows directly
into the pharynx.
5. Diffuse. Both from septum and lateral nasal wall. This
is often seen in general systemic disorders
6. Nasopharynx.

32. CLASSIFICATION OF EPISTAXIS
Anterior Epistaxis
When blood flows out from the front of nose with the
patient in sitting position.
Posterior Epistaxis
Mainly the blood flows back into the throat. Patient
may
swallow it and later have a “coffee-coloured” vomitus.
This may erroneously be diagnosed as haematemesis.

34. MANAGEMENT
Hx & Ex
1. Mode of onset.
2. Duration and frequency of bleeding.
3. Amount of blood loss.
4. Side of nose from where bleeding is occurring (nasal
speculum and clott removal).
5. Whether bleeding is of anterior or posterior type.
6. Any known bleeding tendency in the patient or family.
7. History of known medical ailment (hypertension,
leukaemia, mitral valve disease, cirrhosis and nephritis).
8. History of drug intake (analgesics, anticoagulants,
etc.)

35.  FIRST AID
 CAUTERIZATION
 ANTERIOR NASAL PACKING
 POSTERIOR NASAL PACKING

39.  ENDOSCOPIC CAUTERIZATION
 ELEVATION OF MUCOPERICHONDRIAL FLAP
AND SUBMUCOUS RESECTION (SMR)
OPERATION
 LIGATION OF VESSELS
 TRANSNASAL ENDOSCOPIC SPHENOPALATINE
ARTERY LIGATION (TESPAL)
 EMBOLIZATION

40. GENERAL MEASURES IN EPISTAXIS
1. Make the patient sit up with a back rest and record
any blood loss taking place through spitting or vomiting.
2. Reassure the patient. Mild sedation should be given.
3. Keep check on pulse, BP and respiration.
4. Maintain haemodynamics. Blood transfusion may be
required.
5. Antibiotics may be given to prevent sinusitis, if pack is
to be kept beyond 24 h.
6. Intermittent oxygen may be required in patients with
bilateral packs because of increased pulmonary resistance
from nasopulmonary reflex.
7. Investigate and treat the patient for any underlying local
or general cause.