Epistaxis, or nosebleed, is bleeding from inside the nose. The nasal cavity has a rich blood supply from branches of the internal and external carotid arteries. The most common site of epistaxis is Little's area, located on the anterior nasal septum. Other vascular areas prone to bleeding include the retrocolumellar vein and Woodruff's area on the inferior turbinate. Anterior epistaxis is more common and usually mild, while posterior epistaxis is rarer but more severe. The leading cause of epistaxis is local trauma from nose picking, but it can also arise from systemic issues like hypertension or medications like aspirin. Proper management depends on identifying the source and

1. Epistaxis

2. Define epistaxis.
 Bleeding from inside the
nose, either anterior nasal or
posterior nasal.
 Epi : from above
 Staxis : drop by drop drip of fluid.

3.  Epistaxis is a sign, NOT a disease
 It should never be treated as a
harmless event.

4. Anatomical considerations
 Nasal cavity: mucosa and turbinates
are very vascular
 Receives blood supply from branches
of both internal and external carotid
arteries.
 Network of arteries : Kiesselbach’s
plexus, woodruff’s plexus

5. Blood supply
 Nasal septum
 Lateral wall of nose

6. Question 1
Describe the blood supply of
the nose.

7. Blood supply of nasal septum

8. Blood supply of the lateral wall of
nose

9. Little’s area
 Situated over the anteroinferior part of
nasal septum, just above the vestibule
 Caudal part of the nasal septum which
has a rich submucosal arterial
network(Kiesselbach’s plexus) by septal
branches of
 - anterior ethmoidal
 - sphenopalatine
 - superior labial
 - greater palatine

10.  Prone for
drying (effect
of inspired air )
and
microtrauma
by nose
picking
 Commonest
site for
epistaxis in
children

11. Question 2
 The following is true regarding little’s area of
the nose, except:
A) Situated over the anteroinferior part of the
lateral wall of the nose
B) Has a rich submucosal vascular plexus
named Kiesselbach’s plexus
C) Bleeding from Retrocolumellar vein is one
of the differential diagnoses of little’s area
epistaxis
D) The kiesselbach’s plexus is formed by the
septal branches of anterior
ethmoidal, sphenopalatine, greater
palatine, and superior labial arteries

12. Answer :
 A.
 Little’s area is situated over the
anteroinferior part of the nasal septum

13. Retrocolumella vein
 This vein runs vertically downwards
behind the columella.
 It crosses the floor of nose & joins venous
plexus on the lateral wall of nose.
 Common site of venous bleeding in young
people

14. Question 3
 Which statement is true about
Retrocolumellar vein?
A. This vein runs vertically downwards below
the columella.
B. It crosses the floor of nose & joins venous
plexus on the nasal septum.
C. It crosses the floor of nose & joins venous
plexus on the lateral wall of nose.
D. It crosses the roof of nose & joins venous
plexus on the lateral wall of nose.
E. Common site of venous bleeding in old
people.

15. Answer
 C

16. Woodruff’s Area
 Vascular area situated over the
posterior end of inferior turbinate
 Sphenopalatine artery anastomoses
with posterior pharyngeal artery
 Posterior epistaxis occur

17. Question 4
 Which statement is true about Woodruff’s
area?
A. Site for anterior epistaxis
B. Greaterpalatine artery anastomoses with
posterior pharyngeal artery here
C. Vascular area situated under posterior
end of inferior turbinate
D. Vascular area situated above posterior
end of inferior turbinate
E. Vascular area situated under posterior
end of middle turbinate
Answer : C

18. Sites of epistaxis
 Little’s Area (90%)
 Above the level of middle turbinate
 Below the level of middle turbinate
 Posterior part of nasal cavity
 Diffuse. ie : septum & lateral wall
 Nasopharynx

19. Question 5
 Which is the commonest site of
epixtaxis?
A. Above the level of middle turbinate
B. Below the level of middle turbinate
C. Posterior part of nasal cavity
D. Little's area

20. Answer
 D, 90% of the epistaxis site is from
little’s area.

21. Epistaxis
Anterior epistaxis Posterior
epistaxis
Blood flows out from the Blood flows back into
front of nose with the the throat. Patient may
patient is in sitting swallow it and have
position. “coffee-coloured”
vomitus.
** may misdiagnosed as
haematemesis

22. Differences between anterior and
posterior epistaxis
Anterior epistaxis Posterior epistaxis
Incidence more Less
site Little’s area or anterior Posterosuperior part of
part of lateral wall nasal cavity; difficult to
localise the bleeding
point
age Children and young adult >40 years
cause Trauma Spontaneous; often due
to hypertension or
arteriosclerosis
Bleeding Mild bleeding, can be Severe bleeding;
controlled by local requires hospitalisation
pressure or anterior nasal and postnasal pack
pack

23. Question 6
 Which of these statements are true?
A. Anterior epistaxis is usually caused by
hypertension
B. Posterior epistaxis is more common
C. Anterior epistaxis does not usually
occurs in children and young adults
D. Anterior epistaxis bleeding is usually
mild

24. Answer
 D, posterior epistaxis is more
severe, usually requires
hospitalisation and postnasal
pack;while anterior epistaxis is usually
mild bleeding.

25. Etiology of epistaxis
 Local causes
 Systemic causes
 Idiopathic ( primary )

26. Local causes
 I) congenital: Telengectasia ( Osler-
Weber-Rendau syndrome), hemangioma
 II) Infections :
*Viral : Influenza, measles
*Bacterial : (non-specific)- acute/
chronic rhinitis / sinusitis, artophic rhinitis
(specific)-
diphtheria, TB, syphilis, other
granulomas
*Fungal : rhinosporidiosis, fungal
sinusitis
*Parasites : maggots

27.  III) Trauma:
◦ Microtrauma – nose picking
◦ Foreign body
◦ Accidental
◦ Iatrogenic
◦ Barotrauma : Caisson’s disease

28.  IV) Neoplastic :
◦ Benign : JNA, Inverted
papilloma, hemangioma
◦ Malignant : Nose, PNS, Nasopharynx
 V) Miscellaneous :
◦ Deviated nasal septum,spur, rhinolith

29. Systemic causes
 CVS
oHypertension
oAtherosclerosis
oMitral stenosis
oPregnancy (HTN & hormonal)
 Liver Cirrhosis
oVitamin K deficiency
oDeficiency of factor ii, vii,ix and x

30.  Hemotological
oAplastic anaemia
oThrombocytopenia
oLeukemia
oLymphoma
oAgranulocytosis
oScurvy
oVitamin K deficiency

31.  Renal disease
oChronic nephritis
 Drugs
oSalicylates
oAnalgesics
oAnticoagulant
 Mediastinal compression
oTumours of mediastinum raised venous
pressure in the nose

32.  Acute general infection
oInfluenza
oMeasles
oChicken pox
oWhooping cough
 Vicarious menstruation

33.  What is the commonest cause of
epistaxis?
A. Idiopathic
B. Deviated nasal septum
C. Fracture to the base of skull
D. Hypertension
E. Finger nail trauma

34. Answer
 A, idiopathic

35. Referrence
 Disease Of Ear, Nose, Throat. 5th
Edition. PL Dhingra & Shruti Dhingra
 ENT secrets. 2nd Edition. Bruce W.
Jafek

36.  Thank you