This document discusses epistaxis (nosebleed), including its definition, epidemiology, etiology, risk factors, clinical features, complications, differential diagnoses, treatments, and prevention. It provides details on: the prevalence being 5-10% annually with peaks among those under 10 and over 50; common causes like trauma, infections, hypertension, and coagulopathies; signs like nasal or throat bleeding; potential complications like anemia or aspiration; and treatments including nasal packing, cauterization, or arterial embolization for severe cases.

1. DR MARTIN KAMOMGA (MD)
2/17/2023 1

2.  Definition
 Epidemiology
 Etiology
 Risk factors
 Clinical features
 Complication
 Differentials
 Treatments
 Prevention
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3.  Epistaxis is bleeding from the nose from any
cause.
 Most of the time, bleeding is self-limited, but
can often be serious and life-threatening.
 Epistaxis occurs anteriorly or posteriorly of
the nasal cavity.
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4. Prevalence
o5-10% of the population experience an
episode of epistaxis each year. 10% of those
will see a physician. 1% of those seeking
medical care will need a specialist.
Incidence
oEpistaxis is very common. The incidence
seem to be higher during the low humidity
season.
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5. Age
◦ Nosebleeds occurs with peak incidences in
those under the age of ten and over the age of
50.
◦ Anterior nasal bleed is common in young age
and posterior is common in old age people.
Sex
◦ It occurs more in males than females.
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6.  The nasal cavity get blood supply from
internal and external carotid arteries.
 Many arterial and venous tend to
anastomose.
 Kiesselbach’s plexus (Little’s area) found in
anterior septum, common site for epistaxis.
 Woodruff’s plexus is found in posterior
septum
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7. External Carotid Artery
-Sphenopalatine artery
-Greater palatine artery
-Ascending pharyngeal artery
-Posterior nasal artery
-Superior Labial artery
Internal Carotid Artery
-Anterior Ethmoid artery
-Posterior Ethmoid artery
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9. Kesselbach’s Plexus/Little’s
Area:
 Anterior Ethmoid
 Superior Labial
 Sphenopalatine
 Greater Palatine
Woodruff’s Plexus:
 Pharyngeal & Post. Nasal
AA of Sphenopalatine
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11.  Nosebleeds are due to the rupture of a
blood vessel within the richly perfused
nasal mucosa.
 Rupture may be spontaneous or
initiated by trauma. An increase in
blood pressure (e.g. due to general
hypertension) tends to increase the
duration of spontaneous epistaxis
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12.  Anticoagulant medication and disorders of
blood clotting can promote and prolong
bleeding.
 Spontaneous epistaxis is more common in
the elderly as the nasal mucosa (lining)
becomes dry and thin and blood pressure
tends to be higher.
 The elderly are also more prone to
prolonged nose bleeds as their blood vessels
are less able to constrict and control the
bleeding.
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13.  Causes can be
Local
Systemic
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14. 1.Trauma
 Nose picking
 Nose blowing/sneezing
 Nasal fracture
 Trauma to sinuses, orbits, middle
ear, base of skull
 Foreign bodies
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15. 2. Neoplasm
Juvenile nasopharyngeal
angiofibroma
Sinonasal tumor
Nasopharyngeal
carcinoma
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16. 3. Infection and
inflammation
Rhinitis/Sinusitis
◦Allergic
◦Bacterial
◦Viral
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17. 4. Iatrogenic nasal injury
 Functional endoscopic sinus
surgery (FESS)
 Nasogastric /nasotracheal
intubation
 Rhinoplasty
 Nasal reconstruction
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18. 5. Dessication
 Cold, dry air—more common in
wintertime where the nasal mucosal
becomes dry and easily cracked when
sneezing/blowing the nose then
bleeding occurs.
 Nasal oxygen
 Atrophic rhinitis
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19. 6.Others
 Septal perforation
 Septal deviation
 Septal varices
 Chemical irritants (cocaine, nasal
sprays, etc.)
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20. 1.Vascular
Hypertension/Arteriosclero
sis
Hereditary Hemorrhagic
Telangectasias (Osler
Rendu Weber Syndrome)
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21. 2.Coagulopathies
Thrombocytopenia
 Platelet dysfunction
◦ Systemic disease (Uremia)
◦ drug-induced (warfarin, NSAIDs)
 Hematologic malignancies
Clotting Factor Deficiencies
◦ Hemophilia (factor VIII)
◦ VonWillebrand’s disease (vWF)
◦ Hepatic failure
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22. 3.Infection
/Inflammation
Tuberculosis
Wegener’s
Granulomatosis
SLE
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23.  Children
◦ foreign body, nose picking
 Adults
◦ trauma, idiopathic
 Middle age
◦ tumors
 Old age
◦ hypertension
In about 10% of the cases the condition remains
idiopathic.
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24.  Drugs
 Trauma
 Infections
 Hypertension
 Coagulopathies
 Septal abnormalities
 Vascular abnormalities
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25. Nasal bleeding
Coughing/Vomiting blood
Bleeding down the back of the
throat
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26.  Anemia
 Sinusitis
 Aspiration
 Balloon migration
 Vasovagal episode
 External nasal deformity
 Mucosal pressure necrosis
 Septal hematoma/ parforation
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27.  Tumor
 Trauma
 Leukemia
 Hemophilia
 Hepatic failure
 Allergic rhinitis
 Cocaine toxicity
 Chemical irritants
 Thrombocytopenia
 Nasal foreign bodies
 Disseminated intravascular coagulation
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28. This includes
 A good history
 Thorough physical examination
 Investigation
 Treatment
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29.  Nasal trauma
 Hypertension
 Hepatic diseases
 Use of anticoagulants
 Family history of bleeding
 Previous bleeding episodes
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30.  General condition of the patient
 ABC’s
 If the patient is pale
 Vital signs- PR,BP,T,RR
 Anterior rhinoscopy
 Endoscopic rhinoscopy
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31. (a) Full blood picture
(b) Bleeding and coagulation-Indices
(c) Para nasal sinus X-ray
(d) Chest X-ray
(e) Liver function tests
(f) Renal function tests
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32.  Pinching the nose for 5-10
minutes.
 Anterior nasal packing by using
Vaseline gauze socked with iodine.
 Also packing can be done by using
special expandable sponge packs.
 Silver nitrate cautery
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34. 2/17/2023 34

35.  Formed expandable
sponges are very
effective
 Available in many
shapes, sizes and
some are
impregnated with
antibacterial
properties
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36.  Foley catheter is used to pack posteriorly
 Balloon-type epistaxis devices can also
be used
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37. 2/17/2023 37

38.  The balloons are filled
with water, not air
 It is orient in direction
shown
 Posterior balloon are
filled first, then anterior
 Document volumes
used to fill balloons
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39.  Must be careful after
placement of a posterior
pack to avoid necrosis
of the nasal ala
 Often this can be
avoided by
repositioning the ports
of the balloon pack and
close monitoring of the
site
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40.  The patient need to remain with pack
for 48-72 hours.
 The patient must be on antibiotic to
decrease risk of infection
 The patient avoid straining, bending
forward or removing packing early
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41. (i) Chemical cauterization by
Silver nitrate stick (superficial cauterization
(ii) Electrocautery
- Deeper cautery in case of recurrence after
chemical cautery
(iii) Laser photo cauterization
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42.  Ligation of the external carotid artery
 Clipping of the internal maxillary artery to
which the sphenopalatine is a branch.
 Embolization of the sphenopalatine artery.
 Embolization most effective in patients who
◦ Still bleeding after surgical arterial ligation
◦ Bleeding site difficult to reach surgically
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43. 2/17/2023 43

44.  Bull. P.D (1996):Lecture Notes on diseases of the Ear
Nose and Throat,8th Edition. Blackwell science
 Fonseca R.J,(1998) Oral and Maxillofacial Surgery,2nd
ED ,Saunders
 Hall& Colman's (1995):Diseases of Nose throat head
and neck.14th Ed. Churchill Livingstone
 Hupp, J.,& Tucker, M.R.(Eds).(1998).Contemporary
oral and maxillofacial surgery(3rd ed.,pp.355-390) St
Louis, MO: Mosby
 Ross & Wilson (2001):Anatomy and physiology in
Health and illness.9th Ed. Churchill Livingstone
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