This document discusses epistaxis (nosebleed), including its causes, risk factors, evaluation, and management. Epistaxis is common and usually arises from small blood vessels in the nose. Evaluation involves examining the nose to locate the source of bleeding. Treatment starts with first aid measures and may involve local therapies to constrict blood vessels or cauterize bleeding sites. For more severe bleeding, nasal packing or arterial ligation may be needed. Managing underlying risk factors can help prevent future epistaxis.

1. EPISTAXIS

2. EPISTAXIS
• Bleeding from inside the nose is called
epistaxis.
• Seen in all age groups.
• Presents as an emergency.
• Epistaxis is a sign and not a disease per se.

3. BLOOD SUPPLY OF NOSE
• 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

4. 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)
• Males 58%, females 42%

5. Blood Supply
• 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

6. Lateral wall :
• Internal carotid system :
a) Anterior ethmoidal Branches of ophthalmic
b) Posterior ethmoidal artery
• External carotid system :
a)Posterior lateral nasal
b)Greater palatine artery
c)Nasal branch of anterior superior dental
d)Branches of facial artery to nasal vestibule

7. KIESSELBACH’S PLEXUS (Little’s area)
• In anterior inferior part of
nasal septum
• Most common site for
epistaxis
• Mainly anterior epistaxis
• Anastomosis between
a) septal br. Of sphenopalatine
b) Anterior ethmoidal
c) Septal br. Of superior labial
d) greater palatine arteries .

8. WOODRUFF’S PLEXUS
• Posterior end of middle
turbinate
• Most common site for
posterior epistaxis
• Anastomosis between
a)Sphenopalatine artery.
b)Posterior pharyngeal
artery

9. SITES OF EPISTAXIS :
• Little’s area. In 90% cases.
• 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.

10. CLASSIFICATION
Anterior epistaxis Posterior epistaxis
Blood flows out from Blood flows back into the
the front of nose with throat. Patient may
the patient in sitting swallow it and have
position. “COFFEE- COLOURED VOMITUS”

13. ETIOLOGY
LOCAL CAUSES OF EPISTAXIS
• A. Congenital – Hereditary telengiectasia
• B. Trauma
. Nose picking
. Facial and skull bone fractures
. Foreign body
. Iatrogenic trauma
. Hard blowing, violent sneeze
• C. Inflammatory
. Infective rhinitis

14. • D.Specific
. Acute – Diphteria
. Chronic granulomatous- TB, Leprosy, Syphilis,
Rhinosporiodiasis.
• E. Non Specific
. Viral – Common cold, Influenza
. Bacterial – Secondary bacterial rhinitis sinusitis
. Fungal rhinosinusitis
. Atrophic rhinitis
• F.Physiological
. High altitude
. Extreme cold or hot climate

15. • Neoplastic
. Benign – Juvenile angiofibroma, angioma of septum,
capillary and cavernous hemangioma
. Malignant – SCC, Olfactory neuroblastoma,
Nasopharyngeal carcinoma
• Miscellaneous
. Deviated septum & spur
. Rhinitis sicca
. Spontaneous rupture of vessels
. Rhinolith

16. SYSTEMIC CAUSES
• Hypertension- commonest
• Cirrhosis – Vitamin K
deficiency
• Renal –Nephritis
• Drugs – Excessive use of
salicylates , anticoagulants
• Coagulopathies –
- Clotting disorders
- bleeding disorders
-Agranulocytosis
- Leukemia
-Exanthematous fevers
• Hormonal – Vicarious
Menstruation, endometriosis,
granuloma gravidarum
• Idiopathic Causes

17. PATIENT HISTORY
• Previous bleeding episodes
• Onset, duration, frequency, amount of blood loss
• h/o trauma
• Family history of bleeding
• Hypertension
• Hepatic diseases
• Drug history
• Any other medical ailment

18. MANAGEMENT
• Locate the bleeding site
• Anterior and Posterior rhinoscopy
• Diagnostic Nasal Endoscopy

19. 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

20. TREATMENT OF EPISTAXIS
• Control significant bleeding or hemodynamic instability before
obtaining a lengthy history
• Steps:
– First aid and resuscitation
– Assess blood loss
– Localize bleeding
– Control bleeding
– Prevention

21. First Aid & Resuscitation
• Address ABC
• Neck should not be hyperextended to prevent blood flow into the
stomach or possible aspiration
• Trotter’s triad
– Blood in mouth should not be swallowed
– Mouth breathing
– Direct pressure over the cartilaginous part of the nose
– 5 – 10 minutes is usually sufficient
• Gauze moistened with epinephrine may be placed to promote
vasoconstriction

23. Assess blood loss
• Vital signs and signs of shock.
• Patient with significant hemorrhage should receive an IV
line and crystalloid infusion and reptilase/ethamsylate in
bolus or infusion.
• Cross match for 2 units packed RBC
• Continuous cardiac monitoring and pulse oximetry.

24. Localization of Bleeding
• Pledgets soaked with anesthetic-vasoconstrictor solution are
inserted into the nasal cavity to anesthetize and shrink nasal
mucosa
• Allow them to remain for 10 – 15 minutes
• Visualize cavity with speculum + good light source
• Aspirate excess blood and clots
• If the bleeding originated from Little’s area, it is clearly visible

25. • Rigid endoscope is used to localize posterior bleeding
– Superior optics
– Allow endoscopic suction and cauterization
• Points suggesting posterior source:
– Anterior surface cannot be visualized
– Bilateral bleeding
– Constant dripping of blood in the posterior pharynx
– Bleeding in the pharynx with the anterior nasal packing in place

26. Control of Bleeding
• Topical vasoconstrictors
- Otrivin (xylomethazoline)
-Cocaine
• Chemical cauterization with silver nitrate stick
-Rolled over mucosa until a grey eschar forms
-Only one side should be cauterized to prevent
septal necrosis or perforation
• Thermal cauterization with an electrocautery device
for more aggressive bleeding under LA or GA

28. Anterior Nasal Packing
• Roller gauze soaked with petroleum jelly and
an antibiotic ointment
• Anterior nasal packs
-Merocel – Nasal Tamponde
-Vaseline Gauze
-Inflatable Packs
-Surgicel or Gelfoam
• Success rate 85%

30. Posterior Nasal Packing
• Indications:
– Failure of anterior packing
– High suspicion of posterior bleeding
– Older patient with atherosclerosis
– Patient with bleeding diathesis
• Contraindications
- Facial traum
- Shock
- Altered mental status

31. Foleys catheter

32. Double-balloon catheter

33. Surgical Intervention
• Indications:
– Bleeding continues despite adequate packing and
resuscitation
– Nasal anomaly (septal deviation)
• Patient’s refusal or intolerance to packing

34. • Arterial ligation
– External carotid artery
– Internal maxillary artery transorally or transnasally
– Ethmoidal arteries
– Most commonly ligated vessel is
SPHENOPALATINE ARTERY
• Angiography and vessel embolization

35. Prevention
• Control of hypertension
• Correction of bleeding disorders Humidifier or vaporizers
• Nasal saline sprays, ointment, vaseline
• Avoid hard nose blowing or sneezing
• Sneeze with mouth open
• Avoid nose picking
• Control the use of medications