nose bleeding

1. Done by
Dr. Nawras Mahir
Farhan

2. Epistaxis - Introduction
• One of the most frequent causes of bleeding.
About 5-10% of population experience an
episode of epistaxis each year
• Epistaxis : is bleeding from nose , through
Ant. Or Post. Nares
• The origin of blood : from nose, nasopharynx,
paranasal sinuses or Ant. Cranial fossa .

3. Local Causes of Epistaxis
• Idiopathic 85%
• Nasal trauma (nose
picking, foreign bodies,
fracture nasal bone
• inflammatory : Allergic,
chronic or infectious
rhinitis Or sinusitis
• Iatrogenic : surgery or
Medications (topical)
• Neoplasms of the nose or
sinuses
• Tumors of the
nasopharynx especially
Nasopharyngeal
Angiofibroma
• Vascular malformation

4. Systemic Causes of Epistaxis
• Anticoagulants : Aspirin , Warfrin
• Systemic arterial hypertension
• Hereditary hemorrhagic telangectasias
• Blood diseases and coagulopathies :
Thrombocytopenia, ITP, Leukemia,
Hemophilia OR Platelet dysfunction
• Hepatorenal diseases

5. Nasal Blood Supply
* A. INTERNAL carotid a. system
via opthalmic a. (ant.&post. Ethmoidal
a.)
Supply the roof of nasal cavity
* B. EXTERNAL carotid a. system
-Via internal maxillary branches)
-Sphenopalatine a. is the major a. of
nasal cavity . Supply the rest of the nasal
(terminal cavity

6. Nasal Blood Supply
LITTLE`S AREA:
•Is higly vascularized
area at anteroinferior
aspect of septum
(confluence of arteries) :
•Supplied by :
-Shenoplalatine a.
- superior labial a.
- ant. Ethmoidal a.
- greater palatine a.

7. LOCATION of Epistaxis
•ANTERIOR :
account for 70% of epistaxis and primarily at
LITTLE`S AREA
•POSTERIOR :
Less common and may be associated more with
hypertension & atherosclerosis …. Most often occur
post. To the middle turbinate (sphenopalatine a.
branch )

8. CLINICAL APPROACH
History & Assessment
•Make sure that the patient is not in shock
• Remember ABC
• Determine :
-Duration
- quantity
- hypovolemia symptoms
- previous Hx. Of epistaxis
- predisposing medical condition
- potentially contributing medication

9. Physical Exam - Equipment
• Protective equipment -
gloves, safety goggles ,
headlight if available, Nasal
Speculum
• Vasoconstricting agent (such
as oxymetazoline)
• Topical anesthetic
• Apply decongestant
• Identify bleeder site by ant.
Rhinoscopy
• Consider cautry with silver
nitrate or suction cautry
• most epistaxis respond to
Ant. Packing

10. NASAL PACKING
ANTERIOR PACKING
*Formed expandable sponges are
very effective &Available in many
shapes, sizes and some are soaked
with antibacterial properties
* Traditional Ant. Pack : by applying 1/2 inch Gauze
which is. Coated with
•topical antibiotic ointment prior to placement

11. NASAL PACKING
POSTERIOR PACKING
* Balloon-type episaxis devices often
easiest by filling balloons” with water,
not air and Oriented in direction as
shown
*Traditional post. Nasal packing
-Note : it need admission +
oxygen

12. GENERAL NOTES
- Pack remain in place 3-5days
- pain medication is essential
- patient should receive AB covering staph. Aureus
(toxic shock)
- ELDERLY patient necessitate ICU observation ,
oximetry & oxygen
- if no site found so x-ray and CT to rule out occuled
malignancy

13. Surgical managment
•Submucosal resection
• A nt. & post. Ethmoidal a. ligation
• Internal maxillary a. ligation
• External carotid a. ligation

14. Complication
• **** of post. Packing
• Must be careful after placement of a
posterior pack to avoid necrosis of the nasal
ala
• Sinusitis
• Abscesses
• Neurogenic syncope
• Toxic shock syndrome
• Persistent bleeding and restart of bleeding,
in spite of above interventions
• **** bilateral silver nitrate cautary cause
septal necrosis

15. THANK YOU