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Little's Area
It is situated in the anterior inferior part of nasal septum, just above the vestibule. Four
arteries-anterior ethmoidal, septal branch of superior labial, septal branch of
sphenopalatine and the greater palatine, anastomose here to form a vascular plexus called
"Kiesselbach's plexus". This area is exposed to the drying effect of inspiratory current
and to finger nail trauma, and is the usual site for epistaxis in children and young adults.
Retrocolumellar vein. This vein runs vertically downwards just behind the columella,
crosses the floor of nose and joins venous plexus on the lateral nasal wall. This is a
common site of venous bleeding in young people.
Woodruff's Area
This vascular area is situated under the posterior end of inferior turbinate where
sphenopalatine artery anastomoses with posterior pharyngeal artery. Posterior epistaxis
may occur in this area.
CAUSES OF EPISTAXIS time of menstruation).
They may be divided into:
A. Local, in the nose or nasopharynx.
B. General.
C. Idiopathic.
A. Local Causes
Nose
1. Trauma. Finger nail trauma, injuries of nose, intranasal surgery, fractures of middle
Posterior Epistaxis
Mainly the blood flows back into the throat. Patient may swallow it and later have a
"coffee coloured" vomitus. This may erroneously be diagnosed as haematemesis. The
differences between the two types of epistaxis are tabulated herewith (Table 33.1).
Management
In any case of epistaxis, it is important to know:
1. Mode of onset. Spontaneous or finger nail trauma.
2. Duration and frequency of bleeding.
3. Amount of blood loss
4. Side of nose from where bleeding is occurring.
5. Whether bleeding is of anterior or posterior type.
6. Any known bleeding tendency in the patient or family.
7. History of known medical ailment (hypertension, leukaemias, mitral valve disease,
cirrhosis, nephritis).
8. History of drug intake (analgesics, anticoagulants,
etc.). .
First Aid
Most of the time, bleeding occurs from the Little's area and can be easily controlled by
pinching the nose with thumb and index finger for about 5 minutes. This compresses the
vessels of the Little's area. In Trotter's method patient is made to sit, leaning a little
forward over a basin to spit any blood, and breathe quietly from the mouth Cold
compresses should be applied to the nose to cause reflex vasoconstriction. Cauterisation
This is useful ll1 antenor epistaxIs when bleedll1g point has been located. The area is
first anaesthetised and the bleeding point cauterised with a bead of silver nitrate or
coagulated with electrocautery.
Endoscopic Cautery
Posterior bleeding point can sometimes be better located with an endoscope. It can be
coagulated with suction cautery. Local anaesthesia with sedation may be required.
Elevation of Mucoperichondrial Flap and
SMR Operation
In case of persistent or recurrent bleeds from the septum, just elevation of
mucoperichondrial flap and then repositioning it back helps to cause fibrosis and constrict
blood vessels. SMR operation can be done to achieve the same result or remove any
septal spur which is sometimes the cause of epistaxis.
Ligation of Vessels
(a) External carOM. When bleeding is from the external carotid system and the
conservative measures have failed, ligation of external carotid artery above the origin of
superior thyroid artery should be done. It is avoided these days in favour of embolisation
or ligation of more peripheral branches.
(b) Maxillary artery Ligation of this artery is done in uncontrollable posterior epistaxis.
Approach is via Caldwell-Luc operation. Posterior wall of maxillary sinus is removed
and the maxillary artery or its branches are blocked by applying clips. Endoscopic
ligation of the maxillary artery can a lso be done through nose.
(c) Ethmoidal arteries. In anterosuperior bleeding above the middle turbinate, not
controlled by packing, anterior and posterior ethmoidal arteries which supply this area,
can be ligated. The vessels are exposed in the medial wall of the orbit by an external
ethmoid incision.
General Measures in Epistaxis
1. Make the patient sit up with a back rest and record any blood loss taking place through
sp itting or vomiting
2. Reassure the patient. Mild sedation should be given.
3. Keep check on pulse, BP and respiration.
4. Maintain haemodynamics. Blood transfusion may be required.S. Antibiotics may be
given to prevent sinusitis, if pack is to be kept beyond 24 hours.
6. Intermittent oxygen may be required in patients with bilateral packs because of
increased pulmonary resistance from nasopulmonary reflex.
7. Investigate and treat the patient for any underlying local or general cause.
Hereditary haemorrhagic telangectasia: It occurs on the anterior part of nasal septum and
is the cause of recurrent bleeding. It can be treated by using Argon, KTP or Nd: YAG
laser. The procedure may require to be repeated several times in a year as telangectasia
recurs in the surrounding mucosa. Some cases require septodermoplasty where anterior
part of septal mucosa is excised and replaced by a split skin graft