Published on

  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide


  2. 2. INTRODUCTION <ul><li>Bleeding from inside the nose is called epistaxis </li></ul><ul><li>Fairly common and is seen in all age groups. </li></ul>
  4. 4. Nasal septum <ul><li>Internal carotid system </li></ul><ul><li>Anterior ethmoidal artery </li></ul><ul><li>Posterior ethmoidal artery </li></ul><ul><li>External carotid system </li></ul><ul><li>Sphenopalatine artery (branch of maxillary artery) gives nasopalatine and posterior medial nasal branches </li></ul><ul><li>Septal branch of greater palatine artery (branch of maxillary artery) </li></ul><ul><li>Septal branch of superior labial artery (branch of facial artery) </li></ul>
  5. 5. Lateral wall <ul><li>Internal carotid system </li></ul><ul><li>Anterior ethmoidal artery </li></ul><ul><li>Posterior ethmoidal artery </li></ul><ul><li>External carotid system </li></ul><ul><li>Posterior lateral nasal branches- from Sphenopalatine artery </li></ul><ul><li>Greater palatine artery- from maxillary artery </li></ul><ul><li>Nasal branch of anterior superior dental- from infraorbital branch of maxillary artery </li></ul><ul><li>Branches of facial artery to nasal vestibule </li></ul>
  6. 6. Little’s area <ul><li>It is situated in the anterior part of nasal septum, just above the vestibule. </li></ul><ul><li>Four arteries- anterior ethmoidal, septal branch of superior labial, septal branch of sphenopalatine and the greater palatine, anastomose here to form a vascular plexus called “ Kiesselbach’s plexus ”. </li></ul><ul><li>Usual site for epistaxis in children and young adults. </li></ul><ul><li>Retrocolumellar vein runs vertically downwards just behind the columella, crosses the floor of nose and joins venous plexus on the lateral nasal wall. This is a common site of venous bleeding in young people. </li></ul>
  7. 8. Woodruff’s area <ul><li>This vascular area is situated under the posterior end of inferior turbinate where sphenopalatine artery anastomoses with posterior pharyngeal artery. </li></ul><ul><li>Posterior epistaxis may occur in this area. </li></ul>
  8. 9. CAUSES OF EPISTAXIS <ul><li>Local, in the nose or nasopharynx </li></ul><ul><li>General </li></ul><ul><li>Idiopathic </li></ul>
  9. 10. Local causes <ul><li>Nose </li></ul><ul><li>1. Trauma- Finger nail trauma, injuries of nose, intranasal surgery, fractures of middle third of face and base of skull, hard-blowing of nose, violent sneeze. </li></ul><ul><li>2. Infections </li></ul><ul><li>Acute: viral rhinitis, nasal diphtheria, acute sinusitis. </li></ul><ul><li>Chronic: all crust-forming diseases, e.g. atrophic rhinitis, rhinitis sicca, tuberculosis, syphilis septal perforation, granulomatous lesion of the nose, e.g. rhinosporidosis. </li></ul>
  10. 11. Local causes… <ul><li>3. Foreign bodies </li></ul><ul><li>Non-living: any neglected foreign body, rhinolith. </li></ul><ul><li>Living: maggots, leeches. </li></ul><ul><li>4. Neoplasm of nose and paranasal sinuses. </li></ul><ul><li>Benign: haemangioma, papilloma. </li></ul><ul><li>Malignant: carcinoma or sarcoma. </li></ul><ul><li>5. Atmospheric changes. High altitudes, sudden decompression (Caisson’s disease). </li></ul><ul><li>6. Deviated nasal septum. </li></ul>
  11. 12. Local causes… <ul><li>Nasopharynx </li></ul><ul><li>Adenoiditis </li></ul><ul><li>Juvenile angiofibroma </li></ul><ul><li>Malignant tumours </li></ul>
  12. 13. General causes <ul><li>Cardiovascular system- hypertension, arteriosclerosis, mitral stenosis, pregnancy (hypertension and hormonal). </li></ul><ul><li>Disorders of blood and blood vessels- Aplastic anaemia, leukemia, thrombocytopenic and vascular purpura, haemophilia, Christmas disease, scurvy, vitamin K deficiency, hereditary haemorrhagic telangectasia. </li></ul><ul><li>Liver disease- hepatic cirrhosis (deficiency of factor </li></ul>
  13. 14. General causes… <ul><li>4. Kidney disease- chronic nephritis </li></ul><ul><li>5. Drugs- excessive use of salicylates and other analgesics, anticoagulant therapy. </li></ul><ul><li>6. Mediastinal compression </li></ul><ul><li>7. Acute general infection- influenza, measles, chickenpox, whooping cough, rheumatic fever, infectious mononucleosis, typhoid, pneumonia, malaria, dengue fever. </li></ul><ul><li>8. Vicarious menstruation. </li></ul>
  14. 15. Sites of epistaxis <ul><li>Little’s area </li></ul><ul><li>Above the level of middle turbinate </li></ul><ul><li>Below the level of middle turbinate </li></ul><ul><li>Posterior part of nasal cavity </li></ul><ul><li>Diffuse- both from septum and lateral nasal wall. </li></ul><ul><li>Nasopharynx </li></ul>
  15. 16. Classification <ul><li>Anterior epistaxis </li></ul><ul><li>More common </li></ul><ul><li>Mostly from Little’s area or anterior part of lateral wall </li></ul><ul><li>Mostly occurs in children or young adults </li></ul><ul><li>Mostly trauma </li></ul><ul><li>Usually mild, can be easily controlled by local pressure or anterior pack </li></ul><ul><li>Posterior epistaxis </li></ul><ul><li>Less common </li></ul><ul><li>Mostly from posterosuperior part of nasal cavity </li></ul><ul><li>After 40 years of age </li></ul><ul><li>Spontaneous; often due to hypertension or arteriosclerosis </li></ul><ul><li>Bleeding is severe, requires hospitalization; postnasal pack often required </li></ul>
  16. 17. Management <ul><li>In any case of epistaxis, it is important to know: </li></ul><ul><li>Mode of onset. Spontaneous or finger nail trauma. </li></ul><ul><li>Duration and frequency of bleeding. </li></ul><ul><li>Amount of blood loss. </li></ul><ul><li>Side of nose from where bleeding is occurring. </li></ul><ul><li>Whether bleeding is of anterior or posterior type. </li></ul><ul><li>Any known bleeding tendency in the patient or family. </li></ul><ul><li>History of known medical ailment (hypertension, leukemias, mitral valve disease, cirrhosis, nephritis). </li></ul><ul><li>History of drug intake (analgesics, anticoagulants, etc.). </li></ul>
  17. 18. First aid <ul><li>Little’s area- pinching the nose with thumb and index finger for about 5 minutes- compression of vessels. </li></ul><ul><li>Trotter’s method- patient is made to sit, leaning a little forward over a basin to spit any blood, and breathe quietly from mouth- cold compresses should be applied to nose to cause reflex vasoconstriction. </li></ul>
  18. 19. Cauterisation <ul><li>Useful in anterior epistaxis. </li></ul><ul><li>The area is first anaesthetised and the bleeding point cauterised with a bead of silver nitrate or coagulated with electrocautery. </li></ul>
  19. 20. Anterior nasal packing <ul><li>If bleeding is profuse and/or the site of bleeding is difficult to localise, anterior packing is done. </li></ul><ul><li>For this, a ribbon gauze soaked with liquid paraffin is used. </li></ul><ul><li>About 1 metre gauze (2.5 cm wide in adults and 12 mm in children) is required for each nasal cavity. </li></ul><ul><li>Pack can be removed after 24 hours if bleeding has stopped. </li></ul>
  20. 21. Posterior nasal packing <ul><li>It is required for patients bleeding posteriorly into the throat. </li></ul><ul><li>A postnasal pack is first prepared by tying three silk ties to a piece of gauze rolled into the shape of a cone. </li></ul>
  21. 22. Endoscopic cautery <ul><li>Posterior bleeding point can sometimes be better located with an endoscope. </li></ul><ul><li>It can be coagulated with suction cautery. </li></ul><ul><li>Local anaesthesia with sedation may be required. </li></ul>
  22. 23. Elevation of Mucoperichondrial flap and SMR operation <ul><li>In case of persistent or recurrent bleeds from the septum, just elevation of mucoperichondrial flap and then repositioning it back helps to cause fibrosis and constrict blood vessels. </li></ul><ul><li>SMR operation can be done to achieve the same result or remove any septal spur which is sometimes the cause of epistaxis. </li></ul>
  23. 24. Ligation of vessels <ul><li>External carotid- above the origin of superior thyroid artery. </li></ul><ul><li>Maxillary artery- approach is via Caldwell-Luc operation. </li></ul><ul><li>Ethmoidal arteries- in anterosuperior bleeding above the middle turbinate. </li></ul>
  24. 25. General measures in epistaxis <ul><li>Make the patient sit up with a back rest and record any blood loss taking place through spitting or vomiting. </li></ul><ul><li>Reassure the patient. Mild sedation should be given. </li></ul><ul><li>Keep check on pulse, BP and respiration. </li></ul><ul><li>Antibiotics may be given to prevent sinusitis, if pack is to be kept beyond 24 hours. </li></ul><ul><li>Intermittent oxygen may be required in patients with bilateral packs because of increased pulmonary resistance from nasopulmonary reflex. </li></ul><ul><li>Investigate and treat the patient for any underlying local or general cause. </li></ul>
  25. 26. Hereditary Haemorrhagic Telangectasia <ul><li>It occurs on the anterior part of nasal septum and is the cause of recurrent bleeding. </li></ul><ul><li>It can be treated by using Argon, KTP or Nd: YAG laser. </li></ul><ul><li>Some cases require septodermoplasty where anterior part of septal mucosa is excised and replaced by a split skin graft. </li></ul>