Epistaxis

1. Epistaxis
Dr. Krishna Koirala, MS ENT-HNS
Associate Professor
Dept. of ENT
MCOMS, Pokhara
Nepal
2020-06-29

2. •Definition
–Bleeding from inside the nasal cavity
•Causes
–Idiopathic (55 %)
–Local
–General

3. Local causes (Nose & PNS)
• Congenital:
– Hereditary hemorrhagic telengiectasia
• Trauma:
– Nose picking, injury to nose / face / skull base, nasal
surgery, foreign body
• Infection:
– Vestibulitis, sinusitis, atrophic rhinitis, rhinosporodiosis,
rhinoscleroma
• Neoplasms:
– Angiofibroma, hemangioma, inverted papilloma,
malignancy
• Deviated nasal septum with spur

4. General causes
• Hypertension
• Bleeding disorders
– Hemophilia, thrombocytopenia, leukemia
• Drugs
– Aspirin, anticoagulants
• Physiological
– Cold + dry climate, high altitude, vicarious
menstruation, violent exertion, barotrauma
• Liver and kidney failure
• Exanthematous fevers

5. Common causes of epistaxis
• Children: Nose picking, foreign body, viral exanthemas
• Adolescent: Nasopharyngeal angiofibroma, trauma,
sinusitis
• Adults: sinusitis, trauma
• Elderly: hypertension, malignancy

6. Sites of epistaxis
• Little’s area/Kiesselbach’s plexus (80-90 %)
– Common in children and young people
• Woodruff’s venous (?) plexus
– Common in elderly, hypertensives
• Retro - columellar vein
– Common in young adults
• Others
– Septal turbinate, hemorrhagic nodules

8. Anterior
Epistaxis
Posterior
Epistaxis
Incidence More common Less common
Localization Easy Difficult
Common site Little’s area Woodruff’s plexus
Age < 18 yr > 40 yr
Common Cause Trauma Hypertension
Treatment Anterior pack Posterior pack

9. Evaluation of patients with epistaxis
• Mode of onset, duration, frequency, amount, side,
site, previous bleeding
• Nasal trauma, purulent nasal discharge
• Hypertension, hepatic diseases, family history of
bleeding, bleeding from other sites, use of
anticoagulants, aspirin
• Measurement of pulse and blood pressure

10. Investigations
• Hemoglobin, Packed Cell Volume, platelet count
• Blood grouping
• Bleeding Time, Clotting Time
• Activated Partial Thromboplastin Time
• Prothrombin Time
• Diagnostic Nasal Endoscopy (D.N.E.)
• C.T. scan paranasal sinus

11. General treatment
• Record pulse and blood pressure
• Reassurance
• Bed rest in sitting position with back rest / support
and leaning forward
• Adequate sedation (Diazepam)
• Inj. Ethamsylate 500 mg IV TDS
• Amlodipine / Nifedipine for hypertension
• IV fluids / blood transfusion for shock

12. Anterior epistaxis
• Pinch nostrils + ice pack
 Bleeding continues
• Insert cotton pledgets soaked in 1: 1000 adrenaline
in nasal cavity
 Bleeding continues
• Chemical cautery with AgNO3 or electrical cautery (if
bleeder is localized) or anterior nasal packing

13. Anterior epistaxis
• Pinch nostrils + apply ice pack
• Insert cotton pledgets soaked in 1: 1000 adrenaline
in nasal cavity
• Chemical cautery with AgNO3
• Electrical cautery (if bleeder is localized)
• Anterior nasal packing

15. Adrenaline soaked pledget

16. Chemical cautery

17. Anterior nasal packing
• Performed with
– Liquid paraffin & antibiotic cream in ribbon gauze
– Vaseline gauze
– Bismuth Iodoform Paraffin Paste gauze
– Merocel tampoon
– Simpson balloon
• Left inside the nostrils for 48 -72 hrs under antibiotic
cover

18. Anterior nasal packing with ribbon gauze
• Ribbon gauze soaked in liquid paraffin and antibiotic
cream/ BIPP Pack/ Vaseline
• Both nasal cavities packed tightly by layering from
floor to roof
• Pack removed after 48 -72 hrs
• Systemic antibiotics administered to prevent sinus
infection and toxic shock syndrome

20. Merocel nasal tampoon

21. Simpson’s nasal balloon

22. Posterior epistaxis
• Posterior + anterior nasal packing
– Post nasal gauze pack
– Foley’s catheter
– Brighton balloon (double lumen)
– Epistat balloon (double lumen)
– Bivona balloon (triple lumen)
• Pack left in situ for 48-72 hrs under antibiotic cover

23. Antero-Posterior Nasal Packing
with gauze pack

24. Posterior nasal packing
• Post nasal pack prepared by tying 3 ribbon gauze
strips to a piece of gauze roll
• 2 Foley’s catheters passed through each nostril and
their ends brought out via mouth
• 2 ends of gauze strips attached to nasal pack are tied
to catheter tips & withdrawn from nose

25. • Pack that follows ribbon gauze strips, is guided
into nasopharynx with index finger
• Ribbon gauze strips tied over a gauze piece on
columella and anterior nasal packing done
• 3rd gauze strip brought out from mouth and
taped to cheek
• Pack removed after 48-72 hrs

26. Posterior nasal gauze pack

27. Catheter introduction

28. Tying of pack to catheter tip

29. Guiding pack into the nasopharynx

30. Tying of anterior strips

31. Anterior nasal packing

32. Outer nasal packing

33. Antero - Posterior Nasal
Packing with Foley’s
catheter

34. Foley’s catheter

35. Catheter introduction

36. Catheter tip in nasopharynx

37. Anterior nasal packing

38. Fixation of Catheter

39. Brighton’s nasal balloon

40. Epistat nasal balloon

41. Bivona triple lumen catheter

42. Surgical intervention for refractory/
intractable epistaxis
1. Arterial ligation by external approach
– External carotid artery ligated in neck, distal to
superior thyroid artery
– Internal maxillary artery ligated in pterygo-palatine
fossa (Caldwell-Luc operation)
– Anterior or posterior ethmoidal artery ligated in
orbit (Lynch- Howarth incision)

44. External Carotid ligation

46. 2. Angiography and embolization
3. S.M.R. or Septoplasty
– Impacted DNS
4. Septo-dermoplasty
– Hereditary hemorrhagic telengiectasia
5. Endoscopic cautery and clipping:
– Anterior or posterior ethmoidal artery
– Sphenopalatine artery

47. Angiography + Embolization

48. Endoscopic clipping