This document discusses epistaxis (nosebleeds). It defines epistaxis as bleeding from the nose. The main blood vessels that can cause epistaxis include the anterior and posterior ethmoidal arteries, greater palatine artery, and sphenopalatine artery. The most common site of bleeding is Little's area, found at the caudal end of the nasal septum. Epistaxis can be caused by local factors like trauma or inflammation, or systemic factors like hypertension or liver disease. Management involves treating shock, controlling the bleeding through cauterization, nasal packing, or arterial ligation, investigating the underlying cause, and treating any complications.

1. EPISTAXIS
Dr Ahmed H.Tohow

2. Definition
 It is bleeding per nose

3. Blood vessels

The main blood vessels that
contributes in epistaxis are :

1. Anterior and posterior ethmoidal
artery – from the internal carotid artery

2. Greater palatine artery

3. Sphenopalatine artery

4. Superior labial artery

4. Blood supply of the nose

5. Common Site of Bleeding
 1-Kiesselbachs plexus Littles area is
most common site of bleeding 75-90 %

Is an area at caudal end of the nasal
septum about ¼ an inch behind the
columella is formed under the mucosa of
this area

1. Anterior ethmoidal artery – from the
internal carotid artery

2. Greater palatine artery

3. Sphenopalatine artery

4. Superior labial artery

6. 
2-Wood rough’s area : it is a venous
plexus in the posterior end of the
inferior turbinate and it is the
commonest site of bleeding in
hypertensive patients

7.  3-Above the middle turbinate : arises
from anterior ethmoidal artery.

8. CLASSIFICATION OF
EPISTAXIS

A-ANTERIOR

Most common in children

Usually from littre,s area

Usually controlled with conservative
treatment

9. 
B-POSTERIOR

Usually occurs in older age

Hypertension is common contributing
factor

May also have deviation of nasal
septum

It is difficult to control

10. Causes.

:

A. Local :

1.Idiopathic > 90%

2. Trauma

3. Change of weather cold or hot

4.Foreign body nose

5. Inflammatory e.g chronic sinusitis

6-tumors

11. General :

1. Hypertension

2.Raised venous pressure in cardiac
or pulmonary diseases e. g miteral
stenosis

3. Renal failure

4. hepatic diseases e g liver
cirrhosis or liver failure

12. 
5. Hematological diseases :

- Leukaemia

- Haemophelia

- - Von Willebrand’s disease

- Familiar haemorrhegic telangectasia
(Osler – Rendu disease

13. Alarm sign for severe
Epistaxis

1-Heavy bleeding :- severe bleeding .

2-Signs of shock :- Palpitation,
shortness of breath and turning pale.

3-Swallowing large amounts of blood,
which will cause you to vomit.

14. Management

Short history and examination:

General ex:

Check Bl pr , pulse (for hypertension or signs
of shock which are hypotension, rapid weak
pulse, cold extremeties, pallor irritability,
decreased UOP)

Local ex:

Nose: anterior and posterior rhinoscopy, +/-
endoscopic ex to detect the site of bleeding
(Little’s area, superior to middle turbinate “ant
&/or post ethmoidal arteries” or posterior to
middle turbinate “sphenoplatine artery”)

Oropharynx : for postnasal bleeding.

15. Treatment:

I- treatment of shock:

Patient supine, head down, keep
warm

Secure IV line , IV fluids (Ringer’s
solution or saline), blood transfusion
(according to Hb% and hematocrite
value).

IV steroids(antishock

16. 
II-control bleeding:

A-first aid

positioning: patient sits head flexed forward (to avoid trickling
of blood in the throat)

Pressure: of the anterior cartilaginous part of the nose
between the thumb and index fingers( to compress Little’s
area)

a piece of cotton soaked in lidocaine- oxymetazoline
(xylocaine-afrin) mixture can be applied in the anterior part of
the nasal cavity. This may stop mild bleeding. Local
anesthesia prepares the nose for application of anterior
nasal pack or cautery.

Keep patient in this position with pressure for 5-10 min,
during which he’s asked not to swallow but spit in a dressing
to detect postnasal bleeding.

Then the pressure is released, cotton removed. Nose is
inspected. Bleeding may stop, become less or may continue

17. 
B-cauterization: if bleeding becomes less
and a definitive point of bleeding can be
seen.

Done under local anesthesia, using
chemical cautery (silver nitrate or
chromic acid), or electric cautery
(diathermy). Endoscope may be used in
posterior bleeding.

If done during active bleeding with no
definitive point identified it may increase
bleeding

18. 
C-anterior nasal packing:

Using vaseline gauze, merocel, inflatable
tampoons or absorbable packing (oxidized
cellulose or gelatin sponge)

Throat inspection to exclude posterior trickling

Pack is left for 24-48 hours, under broad
spectrum antibiotic coverage.

D- posterior nasal packing:

Done if anterior nasal pack fails to control
bleeding,or if bleeding is posterior.

Done using ball of vaseline gauze applied under
GA, Foley’s catheter, or ready made inflatable
tampoons

19. Anterior nasal pack

20. Posterior nasal Pack

21. 
E- arterial ligation:

If the above measures fail

Ligation of the maxillary artery (
transantral) or the anterior ethmoidal
artery ( via the orbit)

22. 
Investigations :

Done after control of bleeding

CBC ,Ht value, complete coagulation
profile(Pt,Ptt,BT), liver and kidney
function test

CT nose and PNS for suspected
tumors

23. 
III- treatment of the cause: local (
tumors ,DS..), systemic (hypertension,
liver disease, hemorrhagic blood
disease, drugs with anticoagulant or
antiplatelet effect

IV –treatment of complications: eg.
Anemia

24. 
Medications:

Decongestant drops Afrin, otrivin,
presoline …etc.

Vitamin K K-viton, konakion

Support capillaries Dicinone, Ruta-C,
daflon, ...etc