Epistaxis, or nosebleeds, are a common medical issue. The nasal cavity receives its blood supply from both the internal and external carotid arteries through various vessels. Common causes of epistaxis include weather changes, NSAID use, alcohol consumption, and hypertension. Treatment depends on the severity and location of the bleeding. Minor anterior bleeds can be treated by cauterization, while more severe or posterior bleeds may require nasal packing, endoscopic localization and cauterization of the bleeding vessel, or ligation of the main arterial supply through surgical procedures.

1. Epistaxis
Epistaxis is definied as bleeding from nose. The prosaic definition belies the difficulties associated
with one of the otolaryngological’s most common& most difficult to treat emergencies.
Vascular anatomy
The area most frequently implicated in epistaxis is known as Little’s area or kiesselbach plexus.in the
posterior nasal cavity, the vessels are larger than those in little area & can more easily be traced to
their external or internal carotid origin.
External carotid artery: external carotid artery supplies the nasal cavity via facial & maxillary artery.
Maxillary artery supply is via sphenopalatine & greater palatine artery.
Internal carotid artery: internal carotid artery contributes the anterior & posterior ethmoidal
branches of the ophthalmic artery. Middle turbinate marks the watershed between internal &
external carotid arteries.
Woodruff’s plexus : a plexus of prominent blood vessels lying just inferior to the posterior end of the
inferior turbinate.
Anteior ethmoidal artery: the artery can be ligated as a treatment for epistaxis via an external
approach(medial canthal) or endoscopical (transethmoidal).
Sphenopalatine foramen: sphenopalatine foramen is the portal for major arterial supply of the nasal
cavity. Lateral to the foramen lies the pterygopalatine space. The sphenopalatine foramen transmits
the sphenopalatine artery & vein, &maxillary division of trigeminal nerve. A small bony projection
which lies anterior to the foramen, this landmark is called crista ethmoidalis.
Blood supply of inferior turbinate: artery reaching the inferior turbinate, artery divided into three
parallel branches which runs in bony tunnels within the substance of the turbinate. These tunnels
with their periarterial cuffing of fibrous tissue prevent the arterial constriction & may predispose to
post-operative haemorrhage.
Attempts to control haemorrhage following turbinectomy should be directed towards the postero-superior
aspect of the inferior turbinate where the pressure/bipolar to the submucosal segment of
the artery should prove effective.
Classification of epistaxis
Structured clinical classification
Classification of epistaxis
Primary No proven causal factor
Secondary Proven causal factor
Childhood <16 years

2. Adult > 16 years
Anterior epistaxis Bleeding from anterior to pyriform aperture
Posterior epistaxis Bleeding from posterior to pyriform aperture.
Adult primary epistaxis
The condition can occur at any age. Between 7 to 14% of the adults have epistaxis at some time but
only 6% are seen by otolaryngologist. Most cases are minor, selflimiting but nevertheless a
significant number require admission to the hospital. Fewer than 10% of the hospitalized patients
require a general anaesthetic procedure to secure haemostasis. After head & neck cancer, epistaxis
stands out as a prominent cause of mortality in ENT patients.
Aetiology
By definition, the aetiology of primary epistaxis is unknown, but there are clear suggestions may be
important.
Chronobiology: the frequency of admission is greatest in the autumn& winter due to fluctuation of
temperature & humidity. Circadian level shows a biphasic pattern with peaks in the morning&
evening.(subarachnoid haemorrhage)
NSAID: specially aspirin via antiplatelet aggregations effect due to altered platelet membrane
physiology.
Alcohol : alcohol causes prolongation of the bleeding time despite normal platelet counts &
coagulation factors acitivity.
Hypertension: this has long been considered a cause of epitaxis.recently have failed to show a causal
relationship between hypertension & epistaxis.
Septal abnormalities: epistaxis & septal abnormalities could be coincidental. There is no direct
relationship.
Factors of adult primary epistaxis (summary
of
Aetiology)
Weather Proven association
NSAID Proven association
Alcohol Proven association
Hypertension No association
Septal deviation No association

3. Management
First , the patient must be resuscitated, bleeding slowed, the nasal cavity examined& a treatment
plan established.
Resuscitation:
First aid by pinching the ala nasi (Trotter’s method).
History & general examination will help in assessing the amount of blood loss.
In all but the most minor of bleeds, intravenous access is established.
Baseline blood estimations should be done.
A detailed history should be taken,looking for predisposing factors.
Routine coagulation studies in the absence of a positive history are not indicated.
Assessment :
The patient should be assessed in a semi-recumbent position & nersing assistance is
mandatory.
Everyone should wear protective visors & clothing as blood aerosol contamination is
common.
Basic instrument includes; couch or reclining chair, headlight,suction, vasoconstrictor
solutions, (now widely used cocaine solution) , a packs, tempons & cautery apparatus.
More specialized centres should have access to rod lens endoscopy instrument& bipolar
electrodiathermy.
Direct therapy(bleeding point specific therapies):
A committed search for the bleeding vessels should be undertaken. Anterior epistaxis is usually very
straightforward to identify & treat. At present over 90% of cases are controlled with silver nitrate
cautery. The use of packing for anterior epistaxis is unwarranted & should be discouraged.
Posterior epistaxis; systematic examination with a headlight will identify most bleeding points. Once
identified, bleeding points can be directly controlled with bipolar diathermy, chemical
cautery(difficult in posterior bleeds) or direct pressure from miniature targeted packs.
Endoscopic control: failure to locate the bleeding point on initial examination is an indication for
with a rod lens endoscope. Endoscopy identifies the source of the posterior epistaxis in over 90% of
cases. Monopolar diathermy should not be used in the nasal cavity as blindness due to propagation
of current.
Indirect therapies : (failure to find the bleeding point is an indication for
use of indirect strategies).
1.Nasal packing: nasal packing can be anteriorly or posteriorly placed.

4. Anterior nasal pack :
Ribbon gauze impregnated with petroleum jelly or BIPP(bismuth iodoform paraffin
paste) is inserted the entire length of the nasal cavity.
Once inserted , the pack are left in situ for between 24 to 72 hours.
Rebleeding or continued bleeding is observed upto 40% of cases.
Complications of packing include sinusitis, septal perforation alar necrosis, hypoxia,
myocardial infarction.
Antibiotic cover should be given.
Modern alternatives on anterior packing include special tampons(merocel&
kaltostat).
Persistent or rebleeding is an indication for further examination of the nasal cavity.
There is on clear, universally agreed definition of failed packing but who continue to bleed should
proceed to surgical management sooner than later.
2.Hot water irrigation:irrigation of the nasal cavity with at 500 has been proposed as an alternative
to packing( success rate similar to anterior packing Or balloon temponade.) mechanism of action;
reflex vasodilatation & reduction in nasal lumen dimension.
3.Systemic medical therapy: Tranexamic acid & epsilon aminocaproic acid are systemic inhibitors of
fibrinolysis. In epistaxis dose of 1.5gm thrice daily. At present these drugs are best reserved as
adjuvant therapy in recurrent or refractory cases.
Surgical management
Surgical management for continued epistaxis consists of :
Posterior packing
Ligation techniques
Septal surgery techniques
Embolization techniques.
1.Posterior nasal packs
Posterior nasal packing can be carried out under local or general anaesthesia.
Nasophaygeal tamponade is achieved using special gauze packs inserted transorally& positioned by
means of tapes passed from posterior choana to anterior nares bilaterally. These posterior Bellocq
pack are secure against anterior gauze packing.
The securing tapes are tied over gauze piece(padding positioned to protect the columella from
pressure ncerosis.

5. An easier alternative is to insert a foley’s catheter(size 12 or 14). The catheter inflated with 15ml of
water.
Ligation techniques
The ligation should be performed as close as possible to likely bleeding point.
1.Shenopalatine artery
2.Internal maxillary artery
3.External carotid artery
4.Anterior/posterior ethmoidal artery
1.Endonasal shenopalatine artery ligation(ESPAL)
Under G/A or L/A,an incision is made approximately 8mm in length, anterior to & under cover of
the posterior end of the middle turbinate. The incision is carried down upto bone & a mucosal flap is
elevated posteriorly until neurovascular sleeve arising from the sphenopalatine foramen is
identified. Its location is signalled by the crista ethmoidalis. Once major vessel identified, it can be
ligated using haemostatic clips & divided or coagulated using bipolar diathermy. Success rate almost
100%
2. Internal maxillary artery ligation
Internal maxillary ligation was more frequently prior to the development of ESPAL. In sublabial
approach, an antrostomy is formed taking care to preserve the infrorbital nerve. The mucosa of the
posterior wall is elevated & a window is made through into pterygopalatine fossa. The branches of
internal maxillary artery are identified pulsating within the fat of the fossa & are carefully dissected
out prior to clipping with haemostatic clips. The proximal internal maxillary artery, descending
palatine, & sphenopalatine branches are clipped & ideally divided.
An endoscopic variation of this techniques1)uses a middle meatal antrostomy as an instrument port
2)with 4mm endoscope is inserted through a canine fossa antrostomy.
Transantral ligation control haemorrhage in 89% of cases.
3.External carotid artery ligation
Uder G/A or L/A a skin crease incision or longitudinal incision along parallel with anterior border of
sternomastoid. Carotid bifurcation is identified, double check for arterial branches , then ligation in
continuity. Success rate 14-15%.
4.Anterior or posterior ethmoidal artery ligation
Ligation of anterior /posterior ethmoidal artery is adjuvant to above procedures or ethmoidal
fracture.
Medial canthal incision which is carried down to the bone of the anterior lacrimal crest. Periosteal
elevator are used to elevate & lateral retract of bulbur fascia into anterior ethmoidal foramen. The

6. vassel are identified & clipped & divided. The dissection is continued to identify the posterior artery
which is located approximately 12mm behind.
Septal surgery
When epistaxis originates behind a prominent septal deviation or vomeropalatine spur, septoplasty
or SMR may be required. Some authors have advocated a septal surgery as a primary treatment for
failed packing.
The rationale is that by elvationing the mucoperichondrial flap for septoplasty or SMR, the blood
supply to the septum is interrupted & haemostasis is secured.
Embolization
Under L/A, transfemoral seldinger angiography is used to identify the bleeding point & display nasal
circulation. It is essential to identify the arteriovenous malformation, aneursyms, fistula prior to
embolization. Once the bleeding vessel identified, a fine catheter is passed into the internal maxillary
circulation & particles (polyvinyl alcohol,,tungsten, or steel microcoils) are used to embolize the
vessels. The ipsilateral facial artery is also embolize in order to prevent recirculation
Complication are skin necrosis, paresthesia, CVA, groin haematoma. Similar efficacy to ligation
techniques.
Secondary epistaxis
Commomly observed in patients with coagulopathy secondary to liver disease, leukemia,
myelosuppression. In addition, trauma, post-surgery, warfain therapy deserve special care.
Best clinical practice
First line: direct therapy (bipolar/cautery,endoscopic if required)
Second line: indirect therapy (anterior packing)
Third line: surgical therapy (ESPAL)
Fourth line: angiography &embolization.

7. vassel are identified & clipped & divided. The dissection is continued to identify the posterior artery
which is located approximately 12mm behind.
Septal surgery
When epistaxis originates behind a prominent septal deviation or vomeropalatine spur, septoplasty
or SMR may be required. Some authors have advocated a septal surgery as a primary treatment for
failed packing.
The rationale is that by elvationing the mucoperichondrial flap for septoplasty or SMR, the blood
supply to the septum is interrupted & haemostasis is secured.
Embolization
Under L/A, transfemoral seldinger angiography is used to identify the bleeding point & display nasal
circulation. It is essential to identify the arteriovenous malformation, aneursyms, fistula prior to
embolization. Once the bleeding vessel identified, a fine catheter is passed into the internal maxillary
circulation & particles (polyvinyl alcohol,,tungsten, or steel microcoils) are used to embolize the
vessels. The ipsilateral facial artery is also embolize in order to prevent recirculation
Complication are skin necrosis, paresthesia, CVA, groin haematoma. Similar efficacy to ligation
techniques.
Secondary epistaxis
Commomly observed in patients with coagulopathy secondary to liver disease, leukemia,
myelosuppression. In addition, trauma, post-surgery, warfain therapy deserve special care.
Best clinical practice
First line: direct therapy (bipolar/cautery,endoscopic if required)
Second line: indirect therapy (anterior packing)
Third line: surgical therapy (ESPAL)
Fourth line: angiography &embolization.