Epistaxis case review nose blood supply common sites of bleeding septal v.s lateral nose bleeding HTN & epistaxis : is there any relation ? literature review

1. Epistaxis
Grand round
Dr. Hussain Alsheef
ENT resident
DMC

2. Contents
• Case scenario
• Blood supply of the nose
• Common sites of bleeding
Septal v.s lateral !
• Literature review

3. History
• 64 y/o .. HTN,hypothyroidism
• Recurrent epistaxis Lt>Rt for 3 days
• No trauma or PSH
• A.R
• No coagulopathy
• On aspirin 81mg OD
• No other ENT symptoms
• No anemic symptoms
• No vomiting

4. Clinically
• Conscious oriented
• Sitting on bed , not on distress
• Not pale
• V/S : BP=112/75 , P=70 , RR=99% R.A , T=37 C
• B/L sofretol nasal packs
• Collection of blood floor of nose
• DNS to Lt.
• Septum no abrasions or bleeding points
• Nasoscope : no bleeding points seen
• Throat : streaks of blood
• Ears : intact TM B/L
• H&N : no lymphadenopathy

5. Management plan
• Sitting position
• IVF
• Blood investigations & cross match
• B/L nasal packing
• Admission for observation
• Antibiotic , zantac , mouth wash and analgesic

9. Nasal septum blood supply
• ICA : opthalmic artery
– Ant.ethomid : pass below SO muscle to ant.ethmoid
canal.
– Post.ethmoid : pass above SO muscle to post.ethmoid
foramen . 5mm ant. To optic canal and 15mm behind
ant.ethmoid foramin
accompanies sphenoethmoid N. & nasociliary N.
• ECA :
– Maxillary A: sphenopalatine A., Greater palatine A.
– Facial A. : sup.labial A.

11. Lateral wall blood supply
• Mainly by sphenopalatine A. from max.A
– Through sphenopalatine foramen just inf. To
horizontal attachment of middle turbinate
– May damaged in excessive enlarge antrostomy
• Greater palatine A.
• Facial A.

12. Venous drainage
• Follow arteries within mucosa
• Lateral wall : sphenopalatine foramen to
pterygoid venous plexus to IJV
• Anteriorly : via sup.labial & greater palatine v.
to ext. J.V
• Retrocolumellar V : common cause of epistaxis
in children.

13. Woodruff’s plexus
• Venous plexus
• Prominent blood vessels just inf. to the post.
end of inf.turbinate.
• Common cause of bleeding in adult
• (post epistaxis)

14. Lateral wall or Septal bleeding?

15. Adult post. epistaxis
• McGarry identified bleeding point in 94%
• (6 % not located despite endoscopy)
• 70% septal
• 24% lateral wall
• No side predection (Rt. 50% , Lt.48% , B/L 2%)

16. Pearson define post. Epistaxis as :
Bleeding point couldn’t be located despite examination with
headlight , VC & suction.

18. HTN !
• number of large studies failed to show causal
relationship between hypertension and
epistaxis
• elevated blood pressure is observed in almost
all epistaxis admissions
– result of anxiety
– and invasive techniques used to control bleeding