epistaxis and its management

1. EPISTAXIS
Dr. Rajendra Singh Lakhawat
Department Of Otorhinolaryngology and Head &
Neck Surgery
SMS Medical College and Hospital, Jaipur, India

2. • Bleeding from inside the nose is called as
epistaxis.
• Epistaxis is the most common otolaryngologic
emergency.
• About 50% population experience nosebleed
in their life but severity to seek medical
consultation in <10%

3. • It is a sign not a disease ,so attempts should
be made to find out the local or constitutional
cause.
• Occurs at any age group
• Children usually have mild anterior nasal
bleeding while elderly have profuse posterior
nose bleeding
• Males affected more than females but after 50
years both the sexes affected equally

4. • The nasal cavity is extremely vascular.
• Terminal branches of the external and internal
carotid arteries supply the mucosa of the
nasal cavity with frequent anastomoses
between these systems.

5. Latex-injected human skull showing the functional vascular anatomy of the nasal
mucosa—internal and external artery supplies with rich anastomoses in between and
also crossover anastomoses.

6. Nasal Septum
Internal Carotid System
• (a) Anterior ethmoidal artery Branches of ophthalmic
• (b) Posterior ethmoidal artery artery
External Carotid System
• (a) Sphenopalatine artery (branch of maxillary artery)
gives nasopalatine and posterior medial nasal
branches.
• (b) Septal branch of greater palatine artery (Br. of
maxillary artery).
• (c) Septal branch of superior labial artery (Br. of facial
artery) .

8. LATERAL WALL
INTERNAL CAROTID SYSTEM
1. Anterior ethmoidal
2. Posterior ethmoidal } Branches of ophthalmic artery
EXTERNAL CAROTID SYSTEM
1. Posterior lateral nasal Branches → From
sphenopalatine artery
2. Greater palatine artery → From maxillary artery
3. Nasal branch of anterior superior dental → From
infraorbital branch of maxillary artery
4. Branches of facial artery to nasal vestibule

11. Little’s Area
• Anterior inferior part of nasal septum, above
vestibule
• Four arteries
– Anterior ethmoidal artery
– Septal branch of superior labial artery
– Septal branch of sphenopalatine
– Greater palatine artery
• Exposed to drying effect of inspiratory current
Forms vascular
Plexus
“Kiesselbach’s
plexus”

12. An endoscopic view
of the posterior
septal artery and its
branches in the
right nasal cavity.
CE crista
ethmoidalis,
PSA posterior
septal artery,
ST br. superior
turbinate branch,
Mucosal br.
mucosal branch to
sphenoid ostium,
SB superior branch,
IB inferior branch

13. An endoscopic
view of the
branches of the
right posterior
lateral nasal
artery
emerging from
behind the
crista
ethmoidalis
(CE).
The posterior
septal artery
(PSA) is visible
in the
background.

14. The arterial supply of the nasal cavity. The nasal cavity has been
deroofed, opened anteriorly and spread like a book in this
diagram.
AEA anterior ethmoidal artery,
PEA posterior ethmoidal artery,
PSA posterior septal artery,
SB superior branch, MB middle branch, IB inferior branch,
ALNA anterior lateral nasal artery,

15. Reterocolumellar Veins
• Runs vertically downwards just behind
columella
• Crosses the floor of nose and joins venous
plexus on lateral nasal wall
• Common site for venous bleed in young
patient

16. Woodruff’s plexus
• Plexus of veins situated inferior to posterior
end of inferior turbinate
• Site for posterior epistaxis in adult

18. Causes
• Local (nose or nasopharynx)
• General
• Idiopathic

19. Etiology
Idiopathic—spontaneous mcc
Trauma:
• Nose picking
• Foreign body
• Nasal oxygen and continuous positive airway pressure
• Nasal fracture
Inflammatory/infectious:
• Common cold, viral rhinosinusitis
• Allergic rhinosinusitis
• Bacterial rhinosinusitis
• Granulomatous diseases (Wegener’s granulomatosis, sarcoid,
tuberculosis)
• Environmental irritants (cigarette smoking,
chemicals,pollution, altitude)

20. Postoperative—iatrogenic:
• Nasal surgery
Primary neoplasm:
• Hemangioma of the septum, turbinates
• Hemangiopericytoma
• Nasal papilloma
• Pyogenic granuloma
• Angiofibroma
• Carcinoma and other nasal malignancies

21. Structural:
• Septal deformity, spurs
• Septal perforation
Drugs:
• Topical nasal steroids
• Cocaine abuse
• Occupational substances
Atmospheric changes(high altitudes, sudden
decompression  Casisson disease)

22. General Cause
• Cardiovascular system:
– Hypertension
– Arteriosclerosis
– Mitral stenosis
– Pregnancy(hypertension and hormonal)
• Disorders of blood and blood vessels
– Aplastic anaemia
– Leukemia
– von Willebrand’s disease
– Thrombocytopenia
– Vascular purpura
– coagulopathies (e.g., warfarin,liver disease)

23. General Cause
• Liver disease
– Hepatic cirrhosis(deficiency of factor II,VII,, IX, and X)
• Kidney disease(Chronic nephritis)
• Drugs
– Saslicylates and other analgesic
– Anticoagulant therapy
• Mediastinal compression(tumor causing raised
venous pressure)
• Acute general infection(influenza, measles,
whooping cough)

24. Sites of Epistaxis
• Little’s area(90% of cases)
• Above level of middle turbinate(anterior and
posterior ethmoidal artery)
• Below level of middle turbinate(from branch of
sphenopalatine artery)
• Posterior part of nasal cavity(blood to pharynx)
• Diffuse(from septum and lateral nasal wall)
• Nosopharynx

25. Classification of Epistaxis
• Anterior Epistaxis
– Blood flow out from front nose with patient in
sitting position
• Posterior Epistaxis
– Blood flow back into the throat

27. Epistaxis in Children
• In children with epistaxis in whom no prominent
vessel can be seen, the regular local application
of a cream can help.
• As many as 5% to 10% of children with recurrent
nosebleeds may have undiagnosed von
Willebrand’s disease.
• Children who have leukemia or are undergoing
chemotherapy often have epistaxis associated
with thrombocytopenia.
• Older children, adolescents, and adults often
bleed from Little’s area or a maxillary spur.

28. Epistaxis in Adults
• The caudal end of the septum Little’s area or
Kiesselbach’s plexus, is the most common site of
bleeding in adults.
• The association between hypertension and
epistaxis is disputed.
• Some patients with seasonal allergic rhinitis
complain of more nosebleeds in the hay fever
season, and
• topical nasal steroids aggravate the bleeding in
approximately 4% of users.

29. A range of drugs has been linked with epistaxis,
• warfarin being one of the most common
• Nearly a third of patients admitted with epistaxis who were
taking warfarin INR value above the upper limit of the
therapeutic range.
• The need to reverse anticoagulation is uncertain as long as
the INR value is within the therapeutic range.
• In over-anticoagulated patients, fresh frozen plasma, clotting
factor extracts, and vitamin K help.
• Vitamin K takes more than 6 hours to work, however, and it
can delay anticoagulation for 7 days after warfarin is started.
• If the INR value is greater than 4, the warfarin should be
stopped, and fresh frozen plasma given.
• Clotting factor extracts should be given with extreme caution
because of the risk of thromboembolic complications.

30. • Tranexamic acid, an antifibrinolytic agent, has
NOT been shown to help. (Cummings 5th ed.)
• Tranexamic acid has been shown to reduce the
severity and risk of re-bleeding in epistaxis at a
dose of 1.5 g three times a day. Pre-existing
thromboembolic disease is a contraindication.
(Scott-Brown 8th ed.)
• At present antifibrinolytics are best reserved as
adjuvant therapy in recurrent or refractory cases.

31. • Other drugs associated with bleeding are aspirin,
which interferes with platelet function for up to 7
days, clopidogrel, and nonsteroidal antiinflammatory
drugs.
• In patients who do not have a history of a bleeding
disorder or undergoing anticoagulant therapy,
routine clotting studies do not add to the
management.
• There is a higher incidence of epistaxis in patients
with a high alcohol intake, even when there is no
laboratory evidence of a coagulation abnormality.

32. In any case of epistaxis, it is important to know:
• 1. Mode of onset- Spontaneous or finger nail trauma.
• 2. Duration and frequency of bleeding.
• 3. Amount of blood loss.
• 4. Side of nose from where bleeding is occurring.
• 5. Whether bleeding is of anterior or posterior type.
• 6. Any known bleeding tendency in the patient or
family.
• 7. History of known medical ailment (hypertension,
leukaemias, mitral valve disease, cirrhosis, nephritis).
• 8. History of drug intake (analgesics, anticoagulants,
etc.).

33. Management
• First aid
• Cauterization
• Anterior Nasal packing
• Posterior Nasal Packing
• Endoscopic Cauterization
• Elevation of Mucoperichondrial flap and
submucous resection(SMR) Operation
• Ligation of vessels

34. • The philosophy of management for epistaxis
is:
• (1) establish the site of bleeding
• (2) stop the bleeding, and
• (3) treat the cause.

35. First aid
• First aid measures include- apply constant firm
pressure over the lower (non-bony) part of the nose for
20 minutes (Hippocratic method) and
• Lean forward with the mouth open over a bowl so that
further blood loss can be estimated.
• Bleeding from Little’s area can be stopped by pinching
the nose for 5-10 min
• Trotter’s method
– Patient is made to sit
– Leaning a little forward
– Breath quietly from the mouth
– Cold compression is applied (reflex vasoconstriction)

36. Topical Treatment
• An RCT of silver nitrate cautery with topical
antiseptic nasal carrier cream versus topical alone
showed both to be effective.
• A study of patients applying weekly
triamcinolone 0.025% and daily petroleum jelly
reported that 89% of patients had no further
bleeding.
• Collagen-derived particles with bovine-derived
thrombin have been found to be better than
nasal packs.

37. Cauterization
• Useful in anterior epistaxis when bleeding point has
been located
• Once the clots have been sucked out, the nasal
airway should be inspected, initially with a
headlamp and then, if the bleeding point cannot be
located, with an endoscope.
• Topically anaesthetized.
• Phenylephrine has a significant decongestant effect
at 6 minutes and a maximum anesthetic effect after
9 minutes, so time must be allowed for it to take
effect.
• An injection of local anesthetic and epinephrine
gives better analgesia

38. • Bleeding point cauterization with bead of
silver nitrate or coagulated with
electrocautery.

39. • After cautery the patient should be advised against
blowing the nose for about 10 days to allow the area to
heal.
• A greasy antiseptic barrier cream should be applied
several times daily for 2 weeks to prevent the eschar
from drying and coming off with a resulting rebleed.
• Ointment should not be placed directly on the area
treated but is best placed inside the rim of the nostril
with the tip of the finger, and “milked up” by
massaging the nostril rims, and then sniffed up.
• Controlling the bleeding avoids the discomfort
associated with nasal packing and also avoids hospital
admission.

40. • Rarely, nasal tumors can manifest as epistaxis,
so it is important to check for a nasal mass,
especially beyond a septal deviation.

41. Endoscopic Cauterization
• Topical or general anesthesia, bleeding point is localized
with rigid endoscopy and cauterized
• Procedure is effective with less morbidity and decreased
stay.
• Endoscopic cauterization achieves hemostasis in more than
80% of patients with posterior epistaxis at the first attempt
and more than 90% after a second attempt.
• Complications associated with this procedure are
uncommon, palatal numbness from thermal damage to the
greater palatine nerve, damage to the lacrimal duct, and
possible damage to the optic nerve if cautery is used in a
patient who already has undergone an ethmoidectomy.

42. Nasal Packing
• If a bleeding point cannot be found, ideally the nose is
packed with an absorbable hemostatic agent that
produces minimal mucosal trauma.
• Various non absorbable packs have been used, but
their insertion is uncomfortable, as is their presence
once in position.
• The insertion of a pack can cause local mucosal trauma
and complicate localization of the bleeding point.
• The morbidity and physical discomfort associated with
nasal packing includes pain, hypoxia, alar necrosis, and
toxemia.

43. Anterior Nasal Packing
• Use of a ribbon gauze soaked
with liquid paraffin(1 m gauze;
2.5 cm wide gauze in adult and
12 mm in children)
• Can be done with vertical layer
and horizontal layer
• Can be removed with 24 hour
and can be kept upto 2-3 days
• Systemic antibiotic should be
given to prevent sinus infection
and toxic shock syndrome

44. • If anterior packing fails, a posterior balloon may
have to be placed and inflated in the postnasal
space.
• An anterior pack is then placed, and gentle
traction used to pull the balloon forward against
the anterior pack; this arrangement is held by
placement of a clip over the catheter anteriorly as
it emerges through the anterior pack.
• Clip used to secure the catheter does not rest on
the skin of the nostril; a clip in this position could
produce necrosis of the area in as little as 4 hours

45. Posterior Nasal Packing
• For posterior nasal bleed
• Can be carried through different instrument
– Gauze
– Foley’s Catheterization
– Nasal balloon

47. Nasal packing by Foley’s catheter

50. • If the patient does not experience rebleeding
within 12 to 24 hours, the packs should be
removed.
• The nose should be inspected with a rigid
endoscope, if this procedure has not already
been performed prior to packing, to exclude
any disease that may have been responsible
for the bleeding.

51. • Posterior epistaxis controlled by posterior
nasal packing has a failure rate between 26%
and 52% and a complication rate between 2%
and 68.8%.
• The complications noted in two studies were
synechia, angina, periorbital cellulitis,
sinusitis, toxic shock syndrome, hypoxia, and
otitis

52. • Endoscopic sphenopalatine artery ligation (ESPAL;
see later) has replaced the need for posterior
nasal packs, other than in an emergency
situation, to control profuse bleeding.
• The goal is to achieve a high success rate and a
low morbidity.
• Especially elderly patients with multiple medical
problems (arteriosclerosis, hypertension,
diabetes, hepatic and renal disease) tolerate
packing poorly, and complications occur
frequently;
• Therefore, in such patients, the clinician should
consider an early surgical intervention rather
than packing of the nose.

53. Ligation of Vessels
• Ligation can be done to
– External Carotid(ligation on origin of superior
thyroid artery)
– Maxillary artery
– Ethmoidal artery

54. Maxillary Artery Ligation
• ligation of the internal maxillary artery in the
pterygopalatine fossa to control posterior epistaxis.
• success rate of approximately 90%.
• Treatment failures are due to the difficulty in finding the
artery and its branches.
• The technique is also associated with a complication rate of
28% Because this procedure is done through- a Caldwell-
Luc approach,
• complications include sinusitis, facial pain, oroantral fistula,
and facial and dental paresthesia; also, dissection in
pterygopalatine fossa can result in blindness,
ophthalmoplegia, and decreased lacrimation.

55. Ligation of the External Carotid Artery
• Ligation of the external carotid artery has been
advocated, but the rich anastomoses of vessels in
the nose means that this procedure is not very
effective.
• There are reports of cerebrovascular ischemia
and infarction following external carotid ligation
in elderly atherosclerotic patients, whose
cerebral circulation has partially relied on
anastomotic connections from the external to the
internal carotid system.

56. Endoscopic Sphenopalatine Artery
Ligation
• If bleeding cannot be controlled after endoscopic
examination and cautery and/or nasal packing.
• Then, examination with use of either a general
anesthetic or a local anesthetic with sedation is
indicated.
• Bipolar diathermy of any bleeding points or
ESPAL is then the treatment of choice.
• The morbidity associated with ESPAL is low
compared with that for ligation of the maxillary
or external carotid artery and for embolization.

57. • An incision is made over the posterior
fontanelle area, anterior to the horizontal part
of the base middle turbinate as it joins the
lateral nasal wall, a submucosal flap is lifted,
and the anterior branch is identified with its
origin just posterior to the crista ethmoidalis.
• The anterior branch is then identified and
then undergoes clipping or diathermy.

58. • The endoscopic sinus surgeon views the
sphenopalatine artery at the level of the
sphenopalatine foramen or a few millimeters
medial to it.
• The sphenopalatine artery normally starts to
branch lateral to the crista ethmoidalis, and these
branches vary widely.
• It is important as more than 97% of individuals
have two or more branches medial to the crista
ethmoidalis, 67% have three or more branches,
and 35% have four or more branches

60. A, Intraoperative endoscopic view of the dissection of the
sphenopalatine artery just behind the ethmoidal crest (asterisk).
Bipolar cautery is applied to the first branch just below the
ethmoidal crest.
B, Final view after cautery of all 4 branches, two below and two
above the ethmoidal crest, suction within the right sphenoid sinus.

61. Haemostatic clips applied to
main trunk of
sphenopalatine artery (left)
in procedure of ESPAL.
Crista: crista ethmoidalis,
SPF: sphenopalatine
foramen

63. Embolization
• Arterial embolization has been shown to be
effective in the treatment of intractable
epistaxis.
• However, the procedure carries a risk of
complications, which include cerebrovascular
accident, hemiplegia, ophthalmoplegia, facial
nerve palsy, seizures, and soft tissue necrosis.

64. Bilateral superselective angiograms of the
sphenopalatine arteries.
A, The crossover anastomosis of the septal mucosa
artery supply.
B, Postembolization view.

65. Elevation of Mucoperichondrial Flap
and Submucous Resection(SMR)
Operation
• For persistant or recurrent bleeds from
septum-
• Elevation of mucoperichondrial flap
• Repositioning flap back help to cause fibrosis
and constrict blood vessel.
• SMR can be done to achieve the same or
remove ant septal spur (which sometime
cause of epistaxis).

66. General Measures in Epistaxis
• Making patient sit up with back rest and record any blood
loss taking place through spitting or vomiting
• Mild sedation should be given
• Checking pulse, BP and respiration
• Maintenance of hemodynamics (Blood transfusion may
required)
• Antibiotics can be given to prevent sinusitis, if pack is to be
kept beyond 24 hours
• Intermittent oxygen may be required in patients with
bilateral packs because of increased pulmonary resistance
from nasopharynx reflex
• Investigation and treatment for any underlying local or
general cause

67. Management algorithm.

68. Thank you

69. Management protocol for epistaxis.