Epistaxis, or nosebleeds, are common and usually caused by local trauma or irritation to the nasal mucosa. The nasal septum and Kiesselbach's plexus are frequent bleeding sites. Epistaxis can be anterior or posterior depending on the location of bleeding. Initial management involves resuscitation, arresting the bleeding through local measures like anterior nasal packing, and treating any underlying causes. Refractory epistaxis may require arterial embolization, laser cauterization, or ligation of arteries supplying the nasal mucosa like the sphenopalatine artery. Hospitalization is needed for posterior epistaxis or severe anterior bleeding.

1. Presented by : Dr Siddeshwar K G

2. EPISTAXIS
• Bleeding from inside the nose.
• Peak incidence seen in under 10 yr above 40 yr.
• 60% in there lifetime.
• Presents as an emergency.
• Epistaxis is a sign and not a disease per se.

3. HISTORY
 Cullen – nose bleed
 Lupton 1601 – “consummatus est”
- Jesus christ
- Its finished
 Hippocrates – pinching nostril
 Persian Hakim- boiling blood
 Morgagni
 James lawerence little & Kiesselbach

4. BLOOD SUPPLY OF NOSE :
 External and internal carotid systems, both on the septum
and the lateral walls.
 Vessels run submucosal
NASAL SEPTUM
Internal carotid system :
a) Anterior ethmoidal artery
b) Posterior ethmoidal artery
Branches of ophthalmic artery

5. EXTERNAL CAROTID SYSTEM
a) Sphenopalatine artery (branch of maxillary artery), gives
nasopalatine and posterior nasal septal branches.
b) Septal branch of greater palatine artery (Br. of maxillary
artery).
c) Septal branch of superior labial artery (Br. of facial artery).

6. LATERAL WALL :
Internal carotid system :
a) Anterior ethmoidal
b) Posterior ethmoidal
Branches of ophthalmic artery

7. 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



From sphenopalatine artery
From maxillary artery
From infraorbital branch of
maxillary artery

10. Little’s area
•It is situated in the anterior inferior part of nasal septum, just
above the vestibule.
•1 Anterior ethmoidal
•2 Septal branch of superior labial
•3 Septal branch of Sphenopalatine
•4 The greater palatine
•This area is exposed to the drying effect of inspiratory
current and to finger nail trauma, and is the usual site for
epistaxis in children and young adults.
Kiesselbach’s plexus

11. • Woodruff’s plexus – inferior to posterior end of
inferior turbinate.
• 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

12.  Nasal cavity – principal location of anastomoses in H &N
 Vessels run submucosal
 vessels supplying the middle and inferior turbinate – bony
conduit/tunnels and have periarterial fibrous venous cuff.
 Ant ethmoidal artery - mesentery attached to skull base,
between ethmoid fovea and lamina papyracea.
 Following embolisation/ligation – compensatory anastomosis
flow via facial artery - rebleed
APPLIED ANATOMY

13. CAUSES OF EPISTAXIS :
A) Local (nose or nasopharynx).
B) General
C) Idiopathic

14. LOCAL CAUSES
Nose
1) Trauma
2) Infections
Acute : viral rhinitis, nasal diphtheria, acute sinusitis.
Chronic :All crust-forming disease
3) Foreign bodies.
Non-living: foreign body, rhinolith.
Living: Maggots ,leeches.
.

15. 4) Neoplasms of nose and paranasal sinuses.
Benign : Haemangioma, hemangiopericytoma.
Malignant: Carcinoma or sarcoma
5) Atmospheric changes - High altitudes, sudden decompression
6) Deviated nasal septum

16. NASOPHARYNX :
1) Adenoiditis
2) juvenile angiofibroma
3) Malignant tumours
GENERAL:
1. Hypertension, mitral stenosis,pregnancy( PIH, hormonal)
2. Disorders of blood and blood vessels.
3. Liver disease –cirrhosis, liver failure.
4. Kidney disease. Chronic nephritis.
5. Drugs - salicylates , analgesics & anticoagulant therapy.

17. 6) Mediastinal compression. Tumours of mediastinum
(raised venous pressure in the nose).
7) Acute general infection.
8) Vicarious menstruation (epistaxis occurring at the time of
menstruation).
C) Idiopathic :
• Many times the cause of epistaxis is not clear.

18. SITES OF EPISTAXIS :
1) Little’s area ( 90% ).
2) Above the level of middle turbinate.
3) Below the level of middle turbinate.
4) Posterior part of nasal cavity.
5) Diffuse- septum and lateral nasal wall.
6) Nasopharynx.
.

19. CLASSIFICATION OF EPISTAXIS :
Anterior epistaxis :
Posterior epistaxis :
• Blood flows back into the throat.
• “Coffee coloured” vomitus

20. Difference between anterior and posterior epistaxis
Anterior epistaxis Posterior epistaxis
Incidence
site
More common
Mostly from
Little’s area or anterior part
of lateral wall
Less common
Mostly from
posterosuperior part of
nasal cavity
Age Mostly occurs in children
or young adults
After 40 years of age
Cause Mostly trauma Spontaneous; often due
to hypertension
Bleeding Usually mild, can be easily
controlled by local pressure
or anterior pack
Bleeding is severe
requires hospitalisation;
postnasal pack often
required .

21. Quick evaluation
Resuscitate
Arrest Bleeding
Find & treat the cause

22.  How frequent? Last episode?
 How much? Quantify – in equivalents.
 Which side? Anterior / posterior?
 How does it stop?
 Colour of blood? Does it drip drop by drop or is it
brown and vomited out?
 Any drugs being taken?
 Any recent or current infection?
 Any recent RTA / Head injury?
 Any bleeding from other sites ?

23.  General look
 Air Hunger - Tachypnoea
 Pulse – Tachycardia
 BP – Hypotension/ Hypertension
 Active Bleeding?
 Anterior
 Posterior
 Any evidence of a generalized bleed?

26. First aid :
•Trotter’s method
•Cold compresses - reflex vasoconstriction.
Cauterisation :
•In anterior epistaxis when bleeding point has been located.
•The area is first anaesthetised and the bleeding point
cauterised with a bead of silver nitrate or coagulated with
electrocautery.

27.  Decongestant nasal
drops ,AMICAR spray
 Adrenaline soaked
cotton pledget
 Naseptin or tramcilone
+ petroleum jelly, silver
nitrate, TCA , H2O2

28.  Using nasal endoscope and bipolar cautery
 Not always available in emergency settings
 Requires surgical expertise
 Excellent results

29. Topical
Anaesthesia
2.5/1.2 cm ribbon
gauze , Liquid
paraffin
Neosporin/ BIPP
Nasal Speculum
Tilley’s Forceps
Illumination
Suction
ANTERIOR NASAL PACKING

30. Anterior nasal packing :
•If bleeding is profuse and/or the site of bleeding is difficult
to localise, anterior packing should be done.
•Ribbon gauze soaked with liquid paraffin.
•One or both cavities may need to be packed.
•Can be removed after 24 hours if bleeding has stopped.
•If kept for 2 to 3 days; systemic antibiotics given to prevent
sinus infection and toxic shock syndrome.

31. Anterior nasal packing

32.  Highly absorbent (up to 21 times
its weight in fluid)
 Biocompatible, Polyviny alcohol
 Hemostatic attributes (tamponade
effect with light pressure)
 Aggregates clotting factors
 Adhesion prevention
 Excellent wet state elasticity
 Durable and long-lasting
 Strong/non-shredding
 X-ray detectable
 Impregnated with various
compounds
 Soft and compressible for easy
insertion

33. Topical / General
Anaesthesia
Posterior Nasal Pack
Liquid paraffin
Neosporin/BIPP.
Nasal Speculum
Tilley’s Forceps
Red Rubber Catheters
Illumination
Suction
POSTERIOR NASAL PACKING

34. Posterior nasal packing :
• Method
• Patients requiring postnasal pack always be hospitalised.
• Folley’s catheter can also be used.
• Nasal balloons are also available.
.

36. OTHER OPTIONS
Rapid Rhino anterior balloon tampon
carboxymethylcellulose, a hydrocolloid material, acts as
platelet aggregator and forms a lubricant upon contact with
water. The Rapid Rhino balloon has a cuff that is inflated by
air. The hydrocolloid preserves the newly-formed clot
during tampon removal.

39. Elevation of mucoperichondrial flap and SMR
operation :
• In case of persistent or recurrent bleeds from the
septum, elevation of mucoperichondrial flap and
then repositioning it helps to cause fibrosis and
constrict blood vessels.
• SMR operation remove any septal spur

40.  Sphenopalatine artery(ESPAL)
 Anterior ethmoidal artery /Posterior ethmoidal
artery
 External carotid artery
 Internal maxillary artery

41. ANTERIOR ETHMOID
ARTERY LIGATION
SPHENOPALATINE
ARTERY LIGATION

42. EXTERNAL CAROTID ARTERY
LIGATION
External carotid
artery is ligated distal
to its first branch i.e.
SUPERIOR
THYROID ARTERY

43.  Arterial embolization: selective.
 Lasers
 Coblation

45. General Measures in Epistaxis :
1) The patient put in semi recumbent position and record
any blood loss through spitting or vomiting.
2) Reassure the patient. Mild sedation.
3) Keep check on pulse, BP and respiration.
4) Maintain haemodynamics: Blood transfusion.
5) Antibiotics to prevent sinusitis, if pack is be kept beyond
24 hours.
6) Investigate and treat the patient for any underlying local
or general cause.

46.  Commonly seen condition
 Most of the patients respond to conservative
therapy
 Follow the management protocol for best
results
 Endoscopic methods are very accurate
 Arterial ligations are last options in cases of
intractable epistaxis
 Newer methods have excellent outcome but
expensive

47.  Scott-browns otolaryngology 7th edition
 Cummings otolaryngology and head &neck
surgery 6rd edition.