EpistaxisJeetendra Bhandari

Blood supply of Nasal septum

Blood Supply of lateral wall of nose

Little’s Area

• Anterior inferior part of nasal septum, above vestibule

• Four arteries• Anterior ethmoidal artery

• Septal branch of superior labial artery

• Septal branch of sphenopalatine

• Greater palatine artery

• Exposed to drying effect of inspiratory current

Forms vascular Plexus

“Kiesselbach’splexus”

Reterocolumellar Veins

• Runs vertically downwards just behind columella

• Crosses the floor of nose and joints venus plexus on lateral nasal wall

• Common site for venous bleed in young patient

Woodruff’s plexus

• Plexus of veins situated inferior to posterior end of inferior turbinate

• Site for posterior epistaxis in adult

Introduction to Epistaxis

• Definition• Bleeding from inside the nose

• About 50% population experience nosebleed in their life but severity to seek medical consultation in <10%

• Some patients present as an emergency

• Occurs at any age group

• Children usually have mild anterior nasal bleeding while elderly have profuse posterior nose bleeding

• Males affected more than females but after 50 years both the sexes affected equally

Causes

• Local (nose or nasopharynx)

• General

• Idiopathic

Local causes

• Trauma• Finger nail trauma• Injury of nose• Intranasal surgery• Fracture of middle third of face and base of skull• Hard blowing of nose• Violent sneeze

• Infection• Acute: viral rhinitis, acute sinusitis, nasal diphtheria• Chronic: Crust forming Disease(rhinitis sicca, tuberculosis); Granulamatous

lesion of nose(rhinosporidosis)

Local cause

• Foreign bodies• Nonliving: any neglected foreign body

• Living: Maggots, leeches

• Neoplasms of nose and paranasal sinus• Benign: Hemangioma, papilloma

• Malignant: Carcinoma, sarcoma

• Atmospheric changes(high altitudes, sudden decompression Casissondisease)

• Deviation of nasal septum

General Cause

• Cardiovascular system:• Hypertension

• Arteriosclerosis

• Mitral stenosis

• Pregnancy(hypertension and hormonal)

• Disorders of blood and blood vessels• Aplastic anaemia

• Leukemia

• Thrombocytopenia

• Vascular purpura

General Cause

• Liver disease• Hepatic cirrhosis(deficiency of factor II,VII,, IX, and X)

• Kidney disease(Chronic nephritis)

• Drugs• Saslicylates and other analgesic

• Anticoagulant therapy

• Mediastinal compression(tumor causing raised venous pressure)

• Acute general infection(influenza, measules, whooping cough)

• Vicarious menstruation

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 sphenopalatineartery)

• Posterior part of nasal cavity(blood to pharynx)

• Diffuse(from septum and lateral nasal wall)

• Nosopharynx

Classification of Epistaxis

• Anterior Epistaxis• Blood flow out from front nose with patient in sitting position

• Posterior Epistaxis• Blood flow back into the throat

Difference of Anterior and posterior epistaxis

Management

• First aid

• Cauterization

• Anterior Nasal packing

• Posterior Nasal Packing

• Endoscopic Cauterization

• Elevation of Mucoperichondrial flap and submucous resetion(SMR) Operation

• Ligation of vessels

First aid

• Bleeding from Little’s area can be stopped by pinching the nose for 5 min

• Trotter’s method• Patient is made to sit

• Leaning a little forward

• Breath quietly from the mouth

• Cold compression is applied(vasoconstriction)

Cauterization

• Useful in anterior epistaxis when bleeding point has been located

• Topically anaesthetized

• Bleeding point cauterization with bead of silver nitrate or coagulated with electrocautery

Anterior Nasal Packing

• Done if localized bleeding is profuse or bleeding point is not localize

• Use of a ribbon gauze soaked with liquid paraffin(1 m gauze; 2.5 cm gauze in adult and 12 mm in children)

• Can be done with vertical layer and horizontal layer

• Can be removed with 24 hour and can be kept upto 2-3 days

• Systemic antibiotic should be given to prevent sinus infection and toxic shock syndrome

Posterior Nasal Packing

• For posterior nasal bleed

• Can be carried through different instrument• Gauze

• Foley’s Catheterization

• Nasal balloon

Nasal pack by Gauze

Nasal packing by Foley’s catheter

Endoscopic Cauterization

• Topical or general anesthesia, bleeding point is localized with rigid endoscopy and cauterized

• Procedure is effective with less morbidity and decreased stay

• With profuse bleeding it is very difficult to localize so this procedure can’t be carried out

Elevation of Mucoperichondrial Flap and Submucous Resection(SMR) Operation• For persistant or recurrent bleeds from septum

• Elevation of mucoperichondrial flap

• Reposining flap back help to cause fibrosis and constrict blood vessel

Ligation of Vessels

• Ligation can be done to• External Carotid(ligation on origin of superior thyroid artery)

• Maxillary artery

• Ethmoidal artery

Other process

• Transnasal Endoscpoic Sphenopalatine Artery Ligation(TESPAL)

• Embolization of artery

General Measures in Epistaxis

• 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

References

• Disease of Ear, Nose and Throat and head and neck surgery. DhingraPL, Dhingra S. 6th ed. Epistaxis. 176-80.

• Disease of Ear, Nose and Throat. Bhansal M. 1st ed. Nose and Paranasal Sinuses. 295-7.

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