This document provides a comprehensive overview of epistaxis, including its definition, causes, and management strategies. It discusses both local and systemic factors contributing to nasal bleeding, as well as detailed treatment modalities ranging from first-aid measures to surgical interventions. Key topics covered include anatomical considerations, diagnostic evaluations, and the role of various medical conditions and medications in the occurrence of epistaxis.

1. Epistaxis
Dr. Krishna Koirala
2023-07-11

2. • Write down the causes of epistaxis & its management.
• List various causes for epistaxis. Name the vessels which
contribute in the formation of Little’s area.
• Enumerate common local causes for epistaxis. Describe
Keisselbach's plexus with diagram.
• Discuss possible treatment modalities to manage a case of
epistaxis in a 30 years old person, who could not be managed
by first aid measures
• Write about the blood vessels in the nose causing epistaxis.
Enumerate the different non-surgical and surgical methods
for control of epistaxis.

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

4. Local and locoregional causes
• 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

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

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

7. 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 children
• Others: Septal turbinate, hemorrhagic nodules

9. 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

10. 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

11. 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.)
• Contrast C.T. scan of nose and paranasal sinus

12. 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

13. 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

14. Anterior epistaxis
• Pinch nostrils + apply ice pack
• Insert cotton pledgets soaked in 1: 1000 adrenaline in
nasal cavity
• Chemical cautery with AgNO3 (20%)
• Electrocautery (if bleeder is localized)
• Anterior nasal packing

16. Adrenaline soaked pledget

17. Chemical cautery

18. 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

19. 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

21. Merocel nasal tampoon

22. Simpson’s nasal balloon

23. 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

24. Antero-Posterior Nasal Packing
with gauze pack

25. 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

26. • 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

27. Posterior nasal gauze pack

28. Catheter introduction

29. Tying of pack to catheter tip

30. Guiding pack into the nasopharynx

31. Tying of anterior strips

32. Anterior nasal packing

33. Outer nasal packing

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

35. Foley’s catheter

36. Catheter introduction

37. Catheter tip in nasopharynx

38. Anterior nasal packing

39. Fixation of Catheter

40. Brighton’s nasal balloon

41. Epistat nasal balloon

42. Bivona triple lumen catheter

43. 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)

45. External Carotid ligation

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

48. Angiography + Embolization

49. Endoscopic clipping

50. MCQs
1. Commonest cause of epistaxis in elderly is
a. Hypertension
b. Sinusitis
c. Trauma
d. Malignancy
2. Commonest cause of epistaxis in children is
a. Adenoids
b. Infection
c. Nasal allergy
d. Nose picking

51. 3. Toxic shock syndrome is causedby
a. Staph aureus
b. Streptococcus
c. E. coli
d. Gonococcus
4. In hereditaryHemorrhagic telangiectasia:
a. Bleedingtime is prolonged
b. Clotting time is prolonged
c. Platelet count is decreased
d. Coagulation profile is normal