2. INTRODUCTION
● Epistaxis, derived from the Greek term
epistazein, is defined as bleeding from the nose.
● Most common otorhinolaryngologic emergency.
● Sign, not a disease.
● Can involve any age groups.
● 60% population, only 6% seek medical
assistance.
● Bimodal - <10 and> 35
● Men > women (?oestrogen protective effect on
nasal vasculature)
● Winter ( irritate nasal mucosa )
3. INTRODUCTION
● Mostly due to local mucosal trauma (nose picking), vigorous
nose blowing, or cold and dry climate exposure.
● Vascular anatomy of nose has bilateral supply from both
external and internal carotid systems.
● Initial assessment - evaluate ABCs
● Identify site of bleed
● Conservative measures - pressure, topical vasoconstrictor,
gentle nasal inspiration
● If sources not traced, nasal packing
● Endoscopic sphenopalatine artery ligation and other
surgical management
4. HISTORY
● Hippocrates technique
● Pilz - 1869 first surgically treated epistaxis by
ligation of CCA
● James Little 1879
● Wilhelmina Kisselbach 1880
● Saiffert 1928 via maxillary sinus lighted internal
maxillary artery
● Woodruff 1949
● Sokoloff - first angiographic embolisation for
epistaxis 1972
6. ARTERIAL SUPPLY
● The nasal cavity is the location of principal
internal - external carotid artery
anastomoses in head and neck
● LITTLE’S AREA or KIESSELBACH’S PLEXUS
○ Most common location of anterior epistaxis
○ Site - anterior nasal septum
○ Arterial plexus
○ Confluence of
■ Anterior ethmoidal artery
■ Sphenopalatine artery
■ Greater palatine artery
■ Superior labial artery
○ Frequent turbulent air flow causes local
mucosal drying and increased fragility when
irritated
7. ARTERIAL SUPPLY
● EXTERNAL CAROTID ARTERY
○ Facial artery
■ Superior labial artery - most anterior
part of septum
■ Lateral nasal artery - vestibule
■ Ascending palatine artery - small area
of nasal cavity
○ Maxillary artery
■ Sphenopalatine artery
● Lateral nasal branch
● Posterior septal branch
■ Greater palatine artery - anteroinferior
part of the nasal floor and septum
8. SPHENOPALATINE ARTERY
● SPHENOPALATINE ARTERY IS THE MOST IMPORTANT
SUPPLY TO THE NASAL CAVITY
● Enters the nasal cavity through the sphenopalatine foramen
and immediately divides into posterior septal and posterior
lateral nasal branches.
● Extremely variable branching pattern prior to bifurcation.
● Posterior septal branch
○ Courses from lateral to medial across the superior choana below
sphenoid sinus ostium.
○ Named artery supplying the pedicled vascularized nasoseptal
flap.
○ Commonly injured while extending sphenoidotomy inferiorly.
● Posterior lateral nasal branch
○ Divide to supply superior, middle and inferior turbinates, located
in posterolateral root of each turbinate.
○ Injured or bleed during turbinate reduction or resection
procedures
9. DESCENDING PALATINE ARTERY
● Travels inferiorly into the
greater palatine canal
○ Greater palatine artery - hard
palate, re enter nose via
incisive foramen to supply
anterior inferior septum and
nasal floor
○ Lesser palatine artery - soft
palate
10. INTERNAL CAROTID ARTERY
● Via branches of ophthalmic artery
○ Anterior ethmoidal artery
■ Arise in orbit
■ Runs under superior oblique muscle in anterior ethmoidal canal
via anterior ethmoid foramina
■ Terminate in the region of ethmoid fovea in a meningeal branch
and a larger branch to the nasal, olfactory cleft and superior
turbinate
○ Posterior ethmoid artery
■ Arise in orbit
■ Travels above superior oblique muscle and enters posterior
ethmoid foramina and runs in posterior ethmoidal canal along
with sphenoethmoidal nerve and branch of nasociliary nerve
■ Smaller than AEA
■ Present in 80% population only
■ Divide into a terminal branch and branch to posterosuperior
nasal cavity, olfactory sulcus and sphenoethmoid recess.
○ ~ 30 % patients have middle ethmoid artery too, usually unilateral and
within skull base.
11.
12. VENOUS DRAINAGE
● Veins follow arteries
● Except - periarterial venous cuff surrounding intra
osseous portions of inferior and middle turbinate
arteries.
● Retrocollumellar vein - runs 2 mm behind an parallel
to the collumella, located superficially, common
cause of epistaxis in children.
● WOODRUFF’S PLEXUS - woodruff - 1949
○ Venous plexus
○ Just inferior to the posterior end of inferior turbinate
● The veins of the lateral wall drain through the
sphenopalatine foramen into the pterygoid venous
plexus and to the internal jugular vein.
● Anteriorly, drainage is via superior labial and greater
palatine veins to the facial vein and ultimately the
external jugular system.
16. 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)
17. CLASSIFICATION OF
EPISTAXIS
● Adult or childhood epistaxis
○ Adult - >16 years
○ Childhood - < 16 years
● Primary or secondary epistaxis
○ Primary - no proven causal factors
○ Secondary - proven causal factors
● Anterior or posterior epistaxis
○ Anterior - bleeding anterior to piriform aperture
○ Posterior - posterior to piriform aperture
18. PEDIATRIC EPISTAXIS
● Mostly self resolves with conservative management.
● Most common cause is digital trauma.
● Young children who present with recurrent severe epistaxis
should be screened for bleeding disorders like hemophilia or
von Willebrand disease.
● 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.
● Juvenile angiofibroma considered as D/d for any adolescent
male complaining of unilateral nasal obstruction and
epistaxis.
19. ADULT PRIMARY EPISTAXIS
● By definition , aetiology of primary epistaxis is unknown but certain associations are there.
● Chronobiology - autumn and winter predominance d/t fluctuations in environmental
temperature and humidity.
● Non steroidal anti inflammatory drugs - Adult epistaxis is associated with the use of NSAID
and the action of these drugs is mediated via an anti-platelet aggregation effect.
● Alcohol : The use of alcohol by epistaxis patients is associated with a prolongation of the
bleeding time despite normal platelet count and coagulation factor activities .
● Hypertension : A large number of studies have failed to show a causal relationship between
hypertension and epistaxis. This apparent hypertension in acute admissions may be a result
of anxiety.
● Septal abnormalities :Considering a high prevalence of septal abnormalities ( 1% to 80% of
population ), the perceived association between epistaxis and septal abnormalities could be
coincidence.
29. RESUSCITATION
● First aid by pinching the ala nasi
(the Hippocratic technique)
● Intravenous access should be
established .
● A detailed history should be
taken, looking for predisposing
factors.
30. DETAILED HISTORY
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 (leukaemias, mitral valve
disease, cirrhosis, nephritis).
8. History of drug intake (analgesics, anticoagulants, etc.).
31. GENERAL MANAGEMENT
● 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
32. DIRECT MANAGEMENT
● Bleeding point specific therapies.
● Anterior epistaxis is usually very straightforward to identify and treat and over 90% of
cases can be controlled with silver nitrate cautery or bipolar.
● The use of packing for primary anterior epistaxis is unwarranted and should be strongly
discouraged as packing itself leads to mucosal trauma.
● Posterior epistaxis :
○ can occur from the lateral wall, floor or septum ,and the septum is the principal locus.
○ Examination with a headlight will identify most bleeding points.
○ bleeding points can be directly controlled with bipolar diathermy, chemical cautery , electro-
cautery or direct pressure from miniature targeted packs
33. ENDOSCOPIC CONTROL
● Failure to locate the bleeding point on
initial examination is an indication for
examination with endoscope.
● Endoscopy enables targeted haemostasis
of the bleeding vessel using insulated hot
wire cautery or modern single fibre bipolar
electrodes.
34.
35. INDIRECT THERAPIES
● Failure to find the bleeding point is an indication for use of
indirect therapies.
● NASAL PACKING
○ ANTERIOR NASAL PACKING
■ Nasal pack is directed along the axis of the nasal floor
inferiorly and not superiorly towards the middle turbinate
and the skull base
■ Ribbon gauze impregnated with petroleum jelly or Bismuth
Iodoform Paraffin paste (BIPP) is inserted the entire length
of the nasal cavity in attempt to tamponade the bleeding.
■ Once inserted, the packs are left in situ for between 24 and
72 hours.
36. ■ Modern and now more
frequently used variations
on anterior packing include
special tampons (Merocel
and KaltostatR) and balloon
catheters (Brighton or
Epistat).
■ Complications of packing
include; sinusitis, septal
perforation,alar necrosis,
hypoxia and myocardial
infarction.
37. ● ANP can be done in horizontal and vertical ways.
38.
39. ● POSTERIOR NASAL PACKS
○ The gold standard for nasal packing is placement
of a posterior nasopharyngeal pack followed by
anterior packing.
○ Posterior Bellocq packs : special gauze packs inserted
transorally and positioned by means of tapes passed from
the posterior choana to the anterior nares bilaterally.
○ Foley urethral catheter: Inserted along the floor of the nasal
cavity until the nasopharynx is reached. The Foley catheter is
inflated with 15 ml of water, pulled forward to engage in the
posterior choana and anterior packing is then inserted.
42. SYSTEMIC MEDICAL THERAPY
● Tranexamic acid and epsilon aminocaproic
acid are systemic inhibitors of fibrinolysis.
● Tranexamic acid does not increase fibrin
deposition and so does not increase the risk
of thrombosis.
● Pre-existing thromboembolic disease is a
contraindication.
● Best reserved as adjuvant therapy in
recurrent or refractory cases.
43. TOPICAL TREATMENT
● A randomized controlled trial of silver nitrate
cautery with topical antiseptic nasal carrier
cream(neomycin) 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.
46. ENDONASAL ENDOSCOPIC SPHENOPALATINE
ARTERY LIGATION (ESPAL)
● Ligation procedure of choice in intractable nasal bleed.
● An incision is made approximately 8 mm anterior to and
under cover of the posterior end of the middle turbinate.
● The incision is carried down to the bone and a mucosal
flap is elevated posteriorly until the fibroneurovascular
sleeve arising from the sphenopalatine foramen is
identified.
47. ● Location of sphenopalatine foramen is signalled by crista –
ethmoidalis which is a bony projection and just lies anterior
to foramen.
● Once the main vessel is identified, it can be ligated using
haemostatic clips and divided or coagulated using bipolar
diathermy.
48.
49. ● Clipping or diathermy of the sphenopalatine artery has a
failure rate between 0% and 8%.
● The mistaken belief that the artery enters as a single trunk
into the nose may have led to the failure of these
procedures.
● The main complication, is failure to control epistaxis, which
is usually due to the surgeon’s failure to clip all the
branches of the sphenopalatine artery.
● Other complications are uncommon; they include nasal
crusting, palatal numbness, acute rhinosinusitis, decreased
lacrimation, and septal perforation.
50. INTERNAL MAXILLARY ARTERY LIGATION
(IMAL)
● Artery is exposed trans-antrally via two approaches :
1) Anterior (Sublabial )
2) Medial (Endoscopic)
51. ANTERIOR OR SUBLABIAL APPROACH
● An antrostomy is formed via sublabial approach.
● Mucosa of the posterior wall of the antrum is then
elevated and a window is made through into the
pterygopalatine fossa.
● Branches of the internal maxillary artery are identified
within the fossa and then clipping with haemostatic
clips done.
52. ● The technique is also associated with a higher
complication rate because this procedure is done
through - a Caldwell-Luc approach,
● Complications include sinusitis, facial pain,
oroantral fistula, and cheek and nasal
paresthesia(infraorbital nerve), palatal
paraesthesia (greater palatine nerve) ; also,
dissection in pterygopalatine fossa can result in
blindness, ophthalmoplegia, and decreased
lacrimation (vidian nerve).
53. MEDIAL OR ENDOSCOPIC APPROACH
● An endoscopic variation of sublabial approach
uses a middle meatus antrostomy.
● Occasionally required when control of a
damaged sphenopalatine artery is lost during
ESPAL.
54. ● Maxillary antrostomy is done with
exposure of posterior wall of maxillary
sinus.
● Mucosa overlying the posterior wall is
removed and the underlying bone widely
drilled or removed with Kerrison rongeurs.
● Periosteum of pterygopalatine fossa is
exposed which is preserved and then
electrocauterized to expose the
pterygopalatine fossa fat which contains
the pulsatile maxillary artery. Which can
be clipped and transected. Schematic depicting right maxillary artery in
pterygopalatine fossa and right sphenopalatine
artery as it exits sphenopalatine foramen
55. EXTERNAL CAROTID ARTERY LIGATION
(ECAL)
● A longitudinal incision
parallel with the anterior
border of the
sternocleidomastoid is given.
● Carotid bifurcation identified
,external carotid artery
identified and then ligated.
● Complications include
wound infection,haematoma
and neurovascular damage.
56.
57. ANTERIOR / POSTERIOR ETHMOIDAL
ARTERY LIGATION (EAL)
● The arteries are approached by a medial canthal incision
which is carried down to the bone of the anterior lacrimal
crest.
● Periosteal elevators are then used to elevate and laterally
retract the bulbar fascia.
● The anterior ethmoidal artery is seen as a fibro-neurovascular
mesentery running from the bulbar fascia into the anterior
ethmoidal foramen.
● The vessel is clipped and divided .
● Dissection is continued to identify the posterior artery which is
located approximately 12 mm behind.
58. ● Done either as an adjuvant to
other surgical management or
in confirmed ethmoidal
bleeding cases like naso -
orbito - ethmoidal fracture or
iatrogenic AEA tear in skull
base surgery or endoscopic
surgery.
● Risk factors for low - lying
anterior ethmoidal arteries
include a supraorbital ethmoid
air cell, high Keros
Classification (deeper olfactory
fossa) and increased distance
between the anterior wall of
the frontal sinus to the skull
base.
59. The progressive distances between the
anterior lacrimal crest, anterior ethmoidal
foramen, posterior ethmoidal foramen and
optic canal are 24, 12 and 6 mm
respectively.
62. Elevation of mucoperichondrial flap and
Submucous Resection (SMR) operation
● If due to septal deviation or vomero-
palatine spur is present.
● By Elevating mucoperichondrial
flap,blood supply to septum is
interrupted and hemostasis secured.
● SMR can be done to achieve the
same or remove ant septal spur
(which sometime cause of epistaxis).
63. EMBOLIZATION
● Transfemoral Seldinger angiography is used to identify the bleeding
points and display the nasal circulation.
● Exclude arteriovenous malformations, aneurysms and fistulae prior to
embolization.
● After identifying bleeding vessels , a fine catheter is passed into the
internal maxillary circulation and particles (polyvinyl alcohol, tungsten
or steel microcoils) are used to embolize the vessels.
● Advantage - avoiding the need or general anaesthesia and used in
poor surgical candidates
● Complications include skin necrosis, paraesthesia, cerebrovascular
accident and groin haematomas, acute kidney injury due to iodinated
contrast material administration
64. ● Maxillary artery is the most commonly selected target vessel for
embolization in patients with epistaxis.
● Certain conditions when embolization is preferred over surgical
management -
○ Control of epistaxis due to nasopharyngeal carcinoma and other tumours
of sinonasal tract. It is an effective strategy to obliterate tumour feeding
vessels.
○ Preoperative embolization is helpful for vascular tumours, especially
Juvenile nasopharyngeal Angiofibroma, prior to surgical resection and has
been shown to decrease intraoperative blood loss.
○ In cases of craniofacial trauma with distorted anatomy and mobile bone
fragments, embolization is helpful in controlling oronasal hemorrhage.
○ Epistaxis from the carotid artery is best managed definitely with local
control at the site of intranasal bleeding followed by interventional
radiological treatment.
65. Bilateral superselective angiograms of the sphenopalatine arteries.
A, The crossover anastomosis of the septal mucosa artery supply
B, Postembolization view.
66.
67.
68. HEREDITARY HEMORRHAGIC
TELANGIECTASIA ( HHT )
● HHT; also known as Osler-Weber-Rendu syndrome is an
autosomal dominant multisystemic disorder.
● characterized by telangiectasia that affects cutaneous and
mucosal surfaces as well as arteriovenous malformations in the
pulmonary, cerebral, and hepatic circulations.
● The most common symptom in patients with HHT is epistaxis,
which affects more than 90% of individuals.
69. ● methods of treatment for epistaxis due to
HHT including –
○ medical strategies(hormonal manipulation
and the use of antifibrinolytic agents)
○ surgical options, including laser
coagulation, septodermoplasty, and nasal
closure
○ Closure of the nasal cavity — Young’s
procedure — is based on the principle that -
the absence of desiccating airflow through
the nasal cavity prevents the breakdown of
mucosa overlying the fragile
telangiectasias.
○ An alternative to nasal closure is the use of
70. SEPTODERMOPLASTY - split thickness
skin grafts are harvested and secured
over septal perichondrium.
