EPISTAXIS

BY
MAJ SAAD BIN QAMAR MIRZA
REGISTRAR ENT
 SEQUENCE OF
PRESENTATION
 Definition
 Introduction and history
 Blood and supply of nasal cavity
 Classification
 Adult primary epistaxis
 Management strategy of adult primary epistaxis
 Adult secondary epistaxis and etiology
 Childhood epistaxis
 Management of childhood epistaxis
 DEFINITION

Bleeding from the nose

 INTRODUCTION AND
HISTORY
 5-10% 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.
 BLOOD SUPPLY OF NASAL
CAVITY
External carotid artery Internal carotid artery

Anterior ethmoidal artery

Superior labial artery

Posterior ethmoidal artery
Facial artery Lateral nasal artery
Ascending palatine artery

Maxillary artery Greater palatine artery

Lateral nasal branch
Sphenopalatine artery
Posterior septal branch
KESSELBACH’S
PLEXUS/LITTLE’S
AREA:
-Anterior Ethmoidal(Opth)
-Superior Labial A (Facial)
-Sphenopalatine A (IMAX)
-Greater Palatine (IMAX)
WOODRUFF’S
PLEXUS:
 CLASSIFICATION
STRUCTURED
CLINICAL
CLASSIFICATION
Primary No proven causal factor

Secondary Proven causal factor

Adult > 16 years

Childhood < 16 years

Anterior Bleeding point anterior to piriform aperture

Posterior Bleeding point posterior to piriform aperture

 ADULT PRIMARY EPISTAXIS
 Aetiological factors include:

Weather ( Autumn and Winter) Proven association

NSAID Proven association

Alcohol Proven association

Hypertension No Proven association

Septal Deviation No Proven association

 MANAGEMENT STRATEGY OF ADULT PRIMARY EPISTAXIS
Resuscitation

Initial Examination
Vessel NOT located Vessel located

Endoscopy
Direct therapy
e.g. bipolar
Vessel NOT located

Indirect Therapy Bleeding Controlled

e.g. anterior packs • Packs 48 hours minimum
• Direct, same day
Continued bleeding discharge
• Posterior packs
• Septal surgery
• Ligation (ESPAL)

Continued bleeding
• Angiography and
embolization
• Repeat above steps
Nasal
speculum
Good light

Catheter Packs
 INITIAL MANAGEMENT
 Position
- sitting upright
- inclined slightly forward
- mouth open
- spit out any blood
- vasoconstrictors ( adrenaline
soaked packs )
 INITIAL MANAGEMENT
 ABC’s
 Medical history/Medications
 Vital signs—need IV?
 Physical exam
 Anterior rhinoscopy
 Endoscopic rhinoscopy
 Laboratory exam
 Hb
 Blood Grouping
 Coagulation Profile
 Specific
 MANAGEMENT - IMMEDIATE

 Pinching of nose
( Hippocratic technique)
 cartilage of nose

 over Little’s area

 constant
5 minute pressure - correct
Incorrect
 DIRECT AND INDIRECT
THERAPIES
 Indirect therapy
 Anterior nasal packing
 Hot water irrigation at 500C
 Injection Transamine (Tranexamic acid) 500 mg I/V TDS
 Direct therapy
 Silver nitrate cautery (Especially for anterior epistaxis)
 Bipolar diathermy
 Electracautery
 Endoscopic control via hot wire cautery or bipolar
diathermy
ANTERIOR NASAL PACKING
 Adrenaline soaked ribbon gauze
 Paraffin Gauze
 BIPP
 Tampoons
 Inflatable Balloons
ANTERIOR NASAL PACKING

 BIPP gauze
Bismuth
Iodoform
Paraffin
Paste

Antibiotics if for more than 24 hrs, but not required

if packed with BIPP
PACKING - ANTERIOR
 BIPP
impregnated
gauze in layers
 SURGICAL MANAGEMENT
 Posterior nasal packing
 Ligation techniques
 Endoscopic sphenopalatine artery ligation (ESPAL)
 Endoscopic internal maxillary artery ligation (IMAL)
 Endoscopic external carotid artery ligation (ECAL)
 Anterior/Posterior ethmoidal artery ligation (EAL)
 Septal surgery
 Embolization ( Polyvinyl alcohol, tungsten, gel
foam or steel microcoils)
POSTERIOR NASAL PACKING

 posterior - balloon
- Foley catheter
post nasal
- Classical pack space
- Specially designed balloons
 POSTERIOR PACKS –
ADMISSION
 Elderly and those with other chronic diseases
may need to be admitted to the ICU
 Continuous cardiopulmonary monitoring
 Antibiotics
 Oxygen supplementation may be needed
 Mild sedation/analgesia
ANTERIOR AND POSTERIOR
NASAL PACKING
PACKING – ANTERIOR AND
POSTERIOR
 Inflatable
balloons
 INDICATIONS FOR
SURGERY/EMBOLIZATION

 Continued bleeding despite nasal packing

 Patient refusal/intolerance of packing
 Posterior bleed with failed medical
management >72hrs
 NON-SURGICAL
TREATMENTS – ON
DISCHARGE
 Humidity/emoliants
 Discontinue offending medications
 Nasal saline sprays
 Avoidance of nose picking/blowing
 Sneeze with mouth open
 Avoid straining/bedrest
 ADULT SECONDARY
EPISTAXIS
 Etiological factors include
 Trauma
 Rupture of ICA psuedoaneurysm
 Post-surgery
 Warfarin
 Hereditary haemorrhagic telangiectasias
 Atherosclerosis
 Infections
 Systemic coagulopathies
 Tumours
 Nasopharyngeal angiofibroma (JNAF)
 Haemangiopericytoma (HPC)
 LOCAL FACTORS - TRAUMA
 Nose picking
 Nose blowing/sneezing
 Nasal fracture
 Nasogastric/nasotracheal intubation
 Trauma to sinuses, orbits, middle ear, base of
skull
 Barotrauma
 Surgical trauma
 SYSTEMIC FACTORS –
INFECTION/INFLAMMATION

 Tuberculosis
 Syphillis
 Wegener’s Granulomatosis
 Periarteritis nodosa
 SLE
 SYSTEMIC FACTORS –
COAGULOPATHIES
 Thrombocytopenia
 Platelet dysfunction
 Systemic disease (Uremia, Severe liver disease)
 drug-induced (Coumadin/NSAIDs/Herbal supplements)
 Clotting Factor Deficiencies
 Hemophilia
 VonWillebrand’s disease
 Hepatic failure
 Hematologic malignancies
 Vitamin C & K deficiencies
 CHILDHOOD EPISTAXIS
 Mostly from anterior part of septum, which is thin
mucosa and more exposed to dry air
 Often the bleed is from retrocolumellar vein
 Aetiological associations include
 Infection
 Trauma (From nose picking)
 URTI
 Foreign body
 DNS
 Mostly idiopathic
 MANAGEMENT STRATEGY OF CHILDHOOD EPISTAXIS
Acute bleed

• Pinching of nose
If bleeding persist
• Leaning head
forward
Reassurance

Anterior Rhinoscopy

Direct therapy
e.g. Silver nitrate

Bleeding profuse
and uncontrollable

Resuscitation
• Indirect therapy with pack or
balloon
• Posterior pack under GA if
anterior pack fails
 RECURRENT CHILDHOOD
EPISTAXIS
 Ask about
 Allergy
 Site of bleed
 Any use of intranasal sprays
 Family history of bleeding, easy bruising then blood counts
and coagulation profile should be advised.
 Look for
 Vestibulitis (may be due to FB)
 Bleeding from other sites (ITTP, Von Willebrand’s disease)
 In adolescent boys always rule out
 JNAF
 MANAGEMENT
 Prophylactic application of petroleum jelly
 Use of oil-based antiseptic cream (Chlorhexidine)
 Nasal cautery using silver nitrate
 Electrocautery
 Endoscopic diathermy or ligation (rarely done)
 Associated condition should be addressed
 CONCLUSION
Epistaxis is associated with very severe
morbidity and mortality. Good resuscitative
measures, Active intervention and early
identification of the cause may save a life of
an individual or may be a whole of the family.
THANKS