Management of Epistaxis

1. EPISTAXIS
Dr.Sudha Shahi
Department of ENT HNS
NAMS Bir Hospital

2. INTRODUCTION
Defined as “Bleeding from inside the nose’’
 #Literal meaning:Comes from the Greek word Epistazein
which means bleeding from nose
Can occur in all age groups
Sign NOT a disease in itself
Most often self limited

3. Affects up to 60% of the population in their lifetime
6% require medical attention.
It has been estimated that nosebleeds affect 108 per 100,000
population per year.
In England and Wales, an average of 10.2 per 100,000 patients
are admitted for an average stay of 2.9 days in a 3-month
period,
In the United States, 17 per 100,000 (6%) are admitted.
 Peaks in incidence are seen in those under 10 years of age
and in people aged over 40 years.(Scott B. <16 ->60)
 Women of menstrual age have fewer hospital admissions with
epistaxis, which may be due to estrogens that provide protection of the nasal
vasculature.
 The etiology of epistaxis in the majority of patients is idiopathic,
followed by primary neoplasms and traumatic or iatrogenic
causes.

4. REASON FOR EXCESSIVE BLEEDING
Rich vascularity
Supplied by both internal and external carotid
system
Various anastomoses between arteries and
veins
Blood vessels run under the mucosa
unprotected
Larger vessels on the turbinate run in bony
canals – cannot contract

5. VASCULATURE OF NOSE
▪ Branches of internal carotid system :
. Anterior Ethmoidal artery
. Posterior ethmoidal artery
▪ Branches of external carotid system :
. Sphenopalatine artery*
. Greater palatine artery
. Superior labial branch of facial artery
. Infraorbital branch of maxillary artery

6. Little’s area
In 1879 James Little and 1 year later Kisselbach defined an
arterial plexus in in the anterior inferiror part of the nasal septum
▪ Over the anteroinferior part of
nasal septum, just above the
vestibule
Septal branches of
▪ Anterior ethmoidal
▪ Sphenopalatine
▪ Superior labial
▪ Greater palatine

10. WOODRUFF’S PLEXUS
▪ Inferior to Posterior
end of Inferior
turbinate
▪ Initially thought to be
sphenopalatine
artery anastomoses
with posterior
pharyngeal artery
#But recent studies
suggests venous plexus
▪ Most common site
for posterior
epistaxis

11. 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

12. Sites of epistaxis
▪ Little’s Area (90%)
▪ level of middle turbinate
▪ Posterior part of nasal cavity
▪ Diffuse. ie : septum & lateral wall
#According to literature few studies done to locate the
common site lateral wall vs septum but variable results..

13. Clinical classification of Epistaxis

14. #Primary or Secondary Epistaxis
Primary
( 70 -80%)
Spontaneous bleed without any proven precipiating or casual
factors
Secondary
Clear and definitive causes
# Might differ in management
# 7-14% of adults mostly over 60 ( M>F) have primary epistaxis at some point and
only 6% cases reach Otorhinolaryngologists cause self limiting
Similarly, 30 in 100000 get hospital admission per year in UK and ,< 10 % of
them require GA procedures

15. Adult or childhood
▪ Bimodal age distribution
▪ <16 - >16
▪ Specifically 60 yrs in adult

16. ▪ Anterior Epistaxis
 More common
 Blood flows out from the
front of nose with the
patient is in sitting
position.
 Occurs in children and
young adults
 Usually due to nasal
mucosal dryness
 Alarming as bleeding
seen readily but
generally less severe
▪ Posterior Epistaxis
 Blood flows back into the
throat. Patient may swallow
it and have “coffee-coloured”
vomitus.
** may misdiagnosed as
haematemesis
 Usually older population
 . HTN and ASVD are the
most common causes

 . More severe and
treatment more challenging

17. Local causes
A. Congenital
B. Trauma
C. Inflammatory
D. Non specific
E. Physiological
F. Neoplastic
G. Miscellaneous
 Idiopathic cause
 Systemic cause:
A. Hypertension- Commonest
B. Cardiac –CCF, Mitral
stenosis
C. Pulmonary –COPD
D. Cirrhosis – Vitamin K
deficiency
E. Renal –Nephritis
F. Drugs –
Etiology of epistaxis

18. LOCAL CAUSES
A. Congenital –
 Hereditary telangiectasia ( Osler-Weber-Rendau
syndrome),
 Hemangioma
 Meningocele,Encephalocele
B. Trauma
 Nose picking
 Facial and skull bone fractures(frontoethmoidal
 Foreign body
 Iatrogenic trauma(Nasal examination,Post surgery,NG)
 Hard blowing, violent sneeze

19. C. Inflammatory
o Infective rhinitis
 Viral : Influenza, measles
Bacterial :
Non-specific-
Acute/ chronic rhinitis / sinusitis, atrophic rhinitis
Specific-
Diphtheria, TB, syphilis, other granulomas
Fungal : Rhinosporidiosis, fungal sinusitis
Parasites : maggots

20. D. Non Specific
Atrophic rhinitis
E.Physiological
. High altitude
. Extreme cold or hot climate

21. F. Neoplastic
 Benign –
 Juvenile angiofibroma
 Angioma of septum,
 Capillary and cavernous
hemangioma
 Malignant –
 SCC
Olfactory neuroblastoma,
Nasopharyngeal carcinoma
G. Miscellaneous
 Deviated septum &
spur
 Rhinitis sicca
 Spontaneous rupture of
vessels
 Rhinolith

22. Cavernous hemangioma

23. SYSTEMIC CAUSES
A. Hypertension- Commonest
B. Cardiac –CCF, Mitral stenosis
C. Pulmonary –COPD
D. Liver disorders-Cirrhosis –;Vitamin K deficiency,Biliary atresia
E. Renal –Nephritis
F. Drugs – Excessive use of salicylates ,
anticoagulants,Quinine,Tetracyclines,Immunosuppresants,
Chloramphenicol
G. Coagulopathies
H. Hormonal – Vicarious Menstruation, endometriosis,
Granuloma Gravidarum, Hypothyroidism
I . Idiopathic

25. Management :
1. Resuscitation
2. Assessment
3. Definitive management

27. 1.Resuscitaiton
ABC
First aid by pinching the ala nasi
 (Hippocratic method/Trotters method)

28. contd..
.Trotter’s method-
BeforeTrotters method
Helmeichs method famous In
history.
Make patient sit up, pinch the
nose (non bony part) for 10 -20
minutes leaning forward with
mouth open over a bowl to
estimate blood loss.
A cupful of blood is alarming but
not dangerous in adult but if
prolonged duration it is !!
 Ice packs

30. 2. Assessment
Semi recumbent position
ASSISSTANCE mandatory
Protective measures

31. BASIC EQUIPMENTS:
Couch or reclining chair
Headlight
Suction
Vasoconstrictors solution
packs/tampons
Cautery apparatus(Electric or chemical)
Specialised centres SHOULD have access to rod lens
nasal endoscopy equipment and bipolar diathermy in
emergency

32. 3.Definitive Management
a) Direct Therapies
 Cauterization( Chemical
/electric)
 Direct pressure packs
 Endoscopic control
c) Surgical
 Posterior Nasal Packing
 Ligation tecniques
o ESPAL
o IMAL
o ECAL
b) Indirect Therapies
 Nasal packing(Anterior)
 Hot water irrigation
 Systemic medical
o Tranexamic acid
o Epsilon Aminocaproic acid
 Supportive measures
o Vitamin C
o Inj Vitamin K
o Antibiotics to cover infection
o Fresh blood transfusion as
required

33. a) DIRECT
Cauterisation ( Chemical /Electric/Bipolar diathermy)
Endoscopic Control
Direct pressure packs

34. Cauterisation( chemical/electric)
 Only 1 in 5 cases managed by direct control of the
bleeding point
Difficulty locating the bleeding point( confounding factor
junior members involvement)
Anterior epistaxis is more straightforward and >90%
controlled with Chemical cauterisation
o Chemicals used silver nitrate (Most common)
o Trichloroacetic acid
o Liquid nitrogen
o Cocaine in places where it is allowed( LA and vasoconstrictor)

35. Posterior epistaxis ;If bleeding point located
,managed directly by
Bipolar diathermy,
Chemical cautery(difficult)
Electrocautery,or
Direct pressure from miniature targeted packs
# After the procedure the area must be kept moist by placing vaseline
or antibiotic oint inside the nose and milking it around the affected
area~2 wks to prevent drying and scab

36. ▪ Endoscopic control
Failure to locate the bleeding point
Most beneficial when its posterior(80%)
Hemostasis by hot wire Cautery or bipolar (Unipolar
cautery should not be used)

37. b) INDIRECT THERAPIES
Failure to locate a bleeding point
 Nasal Packing
 Hot water irrigation
 Systemic Medical therapy
 Supportive measures

38. #Nasal packing
Most conventional method
Ribbon gauze impregnated with petroleum or bismuith
iodoform paraffin paste used( soframycin )
1metre length by 1.5 cm breadth
Kept in situ for 24 to 72 hrs
Modern variations include tampons(merocel) and balloon
catheters.

39. ANTERIOR NASAL PACKING

40. NASAL SPONGE PACK/TAMPON

41. COMPLICATIONS OF NASAL PACKING
SEPTAL HAEMATOMA / ABSCESS
SINUSITIS
PRESSURE NECROSIS
TOXIC SHOCK SYNDROME
#15 % of cases are not controlled by packing
Sudden death mostly in patients who
 Impending respiratory conditions
NECROSISOF ALA

42. #Hot water irrigation
Water at 50deg
 Exact mechanism unclear but may paradoxically involve
vasodilatation and reduction in the nasal lumen dimensions
Alternative to packing

43. #Systemic medical therapy
More of an adjuvant therapy and preserved for refractory or
recurrent cases
Contraindicated if preexisting thromboembolic disorder
Tranexamic acid
Epsilon Aminocaproic acid

44. #Supportive measures
o Vitamin C
o Inj Vitamin K
o Antibiotics to cover infection
o Fresh blood transfusion as required

45. c) Surgical
 Posterior Nasal Packing
 Ligation tecniques
o ESPAL
o IMAL
o ECAL

46. c) SURGICAL MANAGEMENT
#Posterior nasal packing
GA preferred
Packs inserted trans orally passed anterior from choana
Alternative is to insert a Foleys catheter(12-14G)along the
floor of nasal cavity followed by anterior nasal packing
More prone to complications like hypoxia secondary to soft palate
edema,sinusitis, middle ear effusions,necrosis of septum and
columella

47. POSTERIOR NASAL PACKING
▪ If bleeding does not stop after anterior packing
▪ Posterior epistaxis

48. FOLEY’S CATHETER and EPISTAXIS
BALLOON

50. #LigationTechniques
Intractable bleeding with no definitive source
Hierarchy of ligation
Sphenopalatine artery
Internal maxillary artery
External carotid artery
Anterior /Posterior artery

51. #Endonasal Sphenopalatine artery ligation(ESPAL)
# Surgical anatomyof SP foramen
Portal of major arterial supply of nasal cavity
Lies medial to pterygopalatine space
Formed by U shaped notch in vertical portion of palatine bone
closed postrosuperiorly by Sphenoid bone
Surgically localised by the small bony projection which lies
anterior to the foramen c/a crista ethmoidalis
This foramen transmits SP artery,Vein and nasopalatine nerve

52. ▪ ESPAL contd..
Performed with an operating microscope or more commonly
rod lens endoscope
GA/LA
Incision- Approx 8 mm anterior to and under the cover of
posterior end of middle turbinate
Incision carried down to bone and mucosal flap raised until
fibrovascular sleeve arising from SP foramen is identified
Ligation of the main artery by Hemostatic clips followed by
coagulation by bipolar diathermy
100 % success rate
# rebleeding d/t anastomosis,infection, adhesions less
common

55. Internal maxillary artery ligation(IMAL)
More frequent prior to development of ESPAL
Transantral via anterior (sublabial)or combined anterior
or medial (endoscopic ) techniques to
Traditional sublabial approach

56. Antrostomy –
Mucosa of the antrum elevated- window made into
pterygopalatine fossa – branches of internal maxillary artery
pulsating within the fat of the fossa identified,dissected and clipped
Proximal Internal maxillary artery ,Descending palatine and SP
branches are all clipped

57. ▪ Endoscopic variation –
Middle meatus antrostomy used -4 mm endoscope
inserted through a small canine fossa antrostomy
Success rates 89%
Complications: Damage to Infraorbital nerve
 oroantral fistula
Dental damage
Rarely opthalmoplegia and blindness

58. ▪ External Carotid Artery Ligation
Extreme cases source away from nasal
LA/GA
Incision- skin crease or longitudinal parallel to ant border
of SCM
Carotid bifurcation identified confirmed and external
carotid confirmed and ligated in continuity
14/15 secured hemostasis
#some authors advocate the Anterior and Posterior
Ethmoidal artery ligation as an adjuvant
Complications- infection, hematoma ,neurovascular
damage

59. • Anterior or posterior artery ligation
Best reserved as adjuvant to the ECAL
Prefered only in cases where confirmed ehtmoidal
bleeding is done
Incision-
Medial canthal incision carried down to bone of
anterior lacrimal crest
Bulbar fascia laterally retracted
Anterior ethmoidal artery seen as fibroneurovscular
mesentry running from the bulbar fascia into anterior
ethmoidal foramen
Clipping of the vessel done and dissection continued
to identify posterior artery 12mm behind

60.  Septal Surgery
Septal deviation or vomeropalatine spur
Septoplasty or Submucosal Resection surgery to
access bleeding point
Rationale –
Elevation of the mucoperichondrial flad interrupts
the the bood supply to the septum and
hemostasis maintained

61. ▪ Embolisation
Under angiographic guidance
82-97% success rate
LA / Transfemoral Seldinger Angiography used
Bleeding points identified and nasal circulation visualised
Foleys catheter is passed into the Internal maxillary artery
circulation
Particles ( Polyviny alcohol,tungsten,microcoils) used to embolize
vessels
Ipsilateral facial artery is also embolized to prevent recirculation
# Complications more frequently than ESPAL skin necrosis,

64. THANK YOU