Case Report

ANTERIOR EPISTAXIS

Presentator : dr. Mustika Prasetyastuti Paramita

Moderator : Dr.dr. Sagung Rai Indrasari,M.Kes,Sp.T.H.T.K.L, (K),FICS

Bagian Ilmu Kesehatan Telinga Hidung Tenggorok – Kepala Leher

Fakultas Kedokteran Universitas Gadjah Mada/ RS DR.SardjitoYogyakarta
2017

1
 Epistaxis (from Greek "to drip [from the
nostrils]") or a nosebleed is the relatively
common occurrence of hemorrhage from the
nose, usually noticed when the blood drains
out through the nostrils.1
Epistaxis is a common problem ranging
from minor traces of blood of blood or clot
to isolated massive bleeds that may be life-
threatening .Most patients have self-limiting
episodes that do not require medical care
1
and thus the true incidence is unknown .
Epistaxis is common otolaryngology
emergency,with an estimated annuual
incidence of 108 cases per 100.000.Epistaxis
accounts for 0,46 % of all US emergency
departement visit.Approximately 60 % of
individuals experience epistaxis at least once
in their lifetime,although only 6% of the
cases require medical treatment .Epistaxis is
bimodal age distribution. Most cases in the
2-10 or 50-70 year-old group2
The nasal blood supply comes from both
internal and external carotid artery systems .The
external carotid provides arterial flow via the
facial and internal maxillary artery (IMA). The
facial artery forms the superior labial artery,
which supplies the septum and nasal alae. The
IMA terminates into 5 branches:
sphenopalatine, pharyngeal, greater palatine,
infraorbital, and superior alveolar arteries. Of
these 5 branches, only the sphenopalatine,
pharyngeal, and greater palatine supply the
nasal cavity. The sphenopalatine and its
terminal branches supply the septum and
middle and inferior turbinate area. The
pharyngeal artery also supplies the inferior
aspect of the lateral nasal wall, and the greater
palatine transverses the greater palatine canal
and supplies the anterior aspect of the septum. 1
The internal carotid artery supplies the
nose via the terminal branches of the
ophthalmic artery and the anterior and
posterior ethmoid arteries.
Kiesselbach plexus is an anastomosis
with branches from both the internal and
external carotid artery systems. The anterior
ethmoid, greater palatine, sphenopalatine,
and superior labial arteries all form a plexus
of vessels in the anteroinferior nasal septum.
Kiesselbach plexus is the source of the
majority of nose bleeds. Epistaxis can be
divided into local and systemic etiologies.
Furthermore, the most common causes of
epistaxis will change as the patient ages.
One constant among etiologies, though, is
that epistaxis increases in frequency during
winter months. The decreased humidity
along with decreased temperature inhibits
the nasal humidification. The nasal mucosa is
2
subject to poor local wound healing and is medicines and herbal and home remedies.
therefore more susceptible to bleeding.1 When hypertension is suspected in the setting
of epitaxis, it should be investegated and
There are two types of epitaxis: anterior
managed appropriately 3
(the most common), and posterior (less
common, more likely to require medical
The relationship between hypertension and
attention). Most cases of epistaxis occur in the
epistaxis is often misunderstood. Patients with
anterior part of the nose, with the bleeding
epistaxis commonly present with an elevated
usually arising from the rich arterial
blood pressure. Accumulation of
anastomoses of the nasal septum (Kiesselbach’s
atheroscerotic plaques in the blood vessels
plexus). Posterior epistaxis generally arises from
of these patients replaces the muscular wall.
the posterior nasal cavity via branches of the
This replacement of muscular wall reduces
sphenopalatine arteries. Such bleeding usually
the ability of the blood vessels to constrict
occurs behind the posterior portion of the
facilitating epistaxis4
middle turbinate or at the posterior superior
roof of the nasal cavity. Clinical features to note in patients with
epistaxis are 1)bleeding from anterior or
Causes of epitaxis are multifactorial,epitaxis posterior, 2)Estimated number of bleeding,
can be caused by local cause,systemic or 3)Continuous or intermittent bleeding, 4)
idiopatic disorders. hemoptisis or hematemesis, 5) Anxietas , 6)
Local cause are chronic sinusitis,foreign Shock can occur when bleeding a lot . 6
bodies,trauma and intranasal neoplasm etc. Anterior epistaxis patient will show
Systemic causes are hemophilia, bleeding from the nose with varying amounts of
hypertension,and Platelet dysfunction bleeding, may be few or many to be harmful.
.1,3
thrombocytopenia, etc Bleeding can come from the anterior or
Most causes of nasal bleeding can be posterior (post nasal), where the blood can be
identified readily through a directed history and swallowed or spit out the patient. The nature of
physical examination. The patient should be bleeding can be continuous (continuous) or
asked about the initial presentation of the disappear (internitten). Sometimes patients also
bleeding, previous bleeding episodes and their complain of hemoptysis or hematemesis and
treatment, comorbid conditions, and current usually come with anxious state. Even in cases
medications, including over-thecounter of severe bleeding can occur shock. 6

3
 The diagnosis of epistaxis is more
emphasized in underlying disorders or diseases,
so a careful history, physical examination and
investigation are required. In the history it is
necessary to ask whether the blood mainly
flows into the throat (posterior) or out of the
front (anterior) nose, duration of bleeding and
frequency, previous history of bleeding, family
history of bleeding disorders, hypertension,
diabetes mellitus, liver disease, nasal trauma
coagulation disorder not long ago and the
6
consumption of drugs
The three main principles in the treatment
of epistaxis are to stop bleeding, prevent
complications, and prevent recurrence of
epistaxis. Management of epistaxis is divided
into the management of acute circumstances
and definitive management. Acute management
is an attempt to identify the source of bleeding
and stop the bleeding, whereas definitive
management is to determine the cause of the
epistaxis. 2,6
Management of epistaxis involves four step
: 1) Initial first- aid measures,2) Assesment of
blood lose, 3) Evaluation of the causes, 4)
Procedures to stop continued bleeding7
The principle of the first epistaxis
management is to maintain 1) the airway: make
sure the airway is not blocked or free, position
the patient sitting and bow 2) breathing: make
sure the breathing process can take place,
4
cough or release blood flowing backwards
throat, 3) circulation: make sure the bleeding
process does not interfere with the body's
blood circulation, make sure the intravenous
line infusion if there is circulatory disturbance .8
Epistaxis prognosis is generally good but
varied. With adequate therapy and regular
disease control, most patients do not
experience rebleeding. In some patients,
epistaxis can resolve spontaneously without
treatment. Few patients require more
aggressive treatment.9
CASE REPORT
55-year-old male came to the Emergency
Room in Sardjito with the main complaint of
blood out of the left nose. Complaints are felt
since 30 minutes before hospitalization . Blood
came out slightly but continuously and the
patient pressed and gagged his left nose with a
tissue but the blood still flowed out. Patients do
feel any swallowed blood, nasal congestion or
nose pain. Before the patient bleeding is not
fever, cough ,runny nose and no trauma.
Examination of patient's vital signs, blood
pressure 190/113 mmHg, pulse 98x / min,
respiration 20x / minute, temperature 36.50C,
patient's general condition is good, calm and
stable. From the physical examination of the ear
is obtained aurikula dextra and sinistra within
normal limits, from otoskopi examination
obtained membran tympani dextra and sinistra
intak with reflex cone of light (+). On anterior
rhinoscopic examination the blood appears out
of the left rice septum, the outer location of the
bleeding is difficult to assess, on posterior
rhinoscopy examination bleeding appears from
the posterior wall of the nasal cavity. On
oropharynx examination bleeding appears .
Patients claimed to have had a nosebleed
once in seven days ago. History of Hypertention
since 1 years ago. Patient take amlodipin 5 mg
when he feels his blood pressure is rising. The
patient denies any history of blood clotting
disorders, diabetes mellitus and liver disease.
Patients were diagnosed with anterior epistaxis.
In these patients given an anterior
tampon was observed for 2-3 day. Patients are
hospitalized.Patient were given Infusion Ringer
Laktat 20 rpm ,hemostatic injection (tranexamic
acid per 8 hours) and consulted with interna.
The problem in this case is recurrence.
Discusion
Epistaxis (nosebleed) may be defined as
acute bleeding from the nasal cavity or
nasopharynx. Epistaxis is bleeding from the
nose, which varies cause and manifestation.
Epistaxis is bleeding from the nose that can
5
occur as a result of a variety of causes, both
trauma and malignancy, with the amount of
bleeding varying from a few to many. 6,10
Epistaxis or nasal bleeding is a relatively
common case in both the child and the elderly,
with an incidence rate of 7% -14% of the total
population per year. Epistaxis is often a
symptom or a manifestation of another disease.
Most are mild cases and can often stop
themselves without the need for medical
help.1,11
The anterior epistaxis often originates from
the front of the septum, which is rich in
anastomosis from the branches of the
sphenopalatine artery, the anterior etmoid
artery, the superior labial artery and the major
palatine artery called the plexus kiesselbach
(little's area). The kiesselbach plexus is
superficial and is easily injured by trauma, so it
is often a source of epistaxis in children. Patients
with anterior epistaxis will see bleeding coming
out of the nose with varying amounts of
bleeding, may be slight or continuous resulting
in harm.6
The two most important factors of
epistaxis are 1) Minor Trauma such as nose,
nose, sneezing, coughing or straining. 2) Fragile
nasal mucosa such as upper respiratory tract
infections, mucosal dryness.6 Congenital
abnormalities that often cause epistaxis are the installation of adrenaline tampons and
Rendu-Olser-Weber disease. In addition lidocaine 2,8 If the bleeding soureces difficult to
epistaksis can occur in the diver due to changes assess used anterior tampon is recomended.13
in atmospheric pressure. Besides other causes
Summary
of epistaxis is the presence of foreign objects in
the nasal cavity, nasal polyps, blood disorders, It has been reported that 55 year-old male
blood vessel disorders and tumors in the patients with an anterior epistaxis diagnosis.
nasopharyngeal region and patient with
In these patients given an anterior
hypertension2,6
tampon was observed for 2-3 day. Patients are
Epistaxis is more common in hypertension hospitalized.Patient were given Infusion Ringer
patients, perhaps owing to vascular fragility Laktat 20 rpm ,hemostatic injection (tranexamic
from long-standing disease. epistaxis was acid per 8 hours) . Patient removed anterior
more difficult to control in hypertensive tampon after 2 day in hospital and sugessted to

patients. 4 control one more week.Take home message for

the patient are educated to take anti
Recurrences that occur in this patients
hypertension drug regularly, changing diet and
perhaps patient do not take medication
lifestyle.
regularly so that uncontrolled blood pressure
may be the triger of epistaxis. Therefore Bibiliography
patients are educated to take anti hypertension
1. Schlosser,J,Rodney, Bleier,SB,
drug regularly, changing diet and lifestyle
Epistaxis, In Baley BJ & Johnson JT,
Otolaryngology Head & Neck
Management of anterior epistaxis is adjusted Surgery-. 5th edition. Lippincott
to the patient's condition.When hypertension is Williams & Wilkins. 2014.P: 501-7.
suspected in the setting of epistaxis, it should be 2. Steve Caroll DOEM Basic Epistaxis.

investigated and managed appropriatley. 1 Departement of Defense, the US

Improvement of the patient's general condition. Army, or the SAUSHEC EM

In mild epistaxis bleeding can be stopped by Residency.2014.

sitting, head up and then nostrils pressed with
the finger towards the septum for 15 minutes.
After determining the location of the bleeding,

6
3. Kucik,CJ et al, Management Of 11. Calder,N,et,al. A double blind
Epistaxis, American Academy of randomized controlled trial of
Family Physician management of reccurent nosebleeds
Journal,Florida,2005 in children. Otolaryngology Head &
Neck Surgery. 2009.
4. Quoc A Nguyen,Epistaxis,American 12. Henri Traboulsi,et.al. Changing trend
Academy of Otolaryngology Head and in management of epistaxis.
Neck Surgery,2017
Departement Otolaryngology Head &

5. Fatakia,adil et al,Epistaxis:A Neck Surgery, American University

Common Problem, The Ochsner of Beirut Phase I, 6th floor Medical

Journal,2010 Cebtre, Libanon 2015.

13. Perhati-Kl Group Study,Giideline
6. Chethan Kumar,et.al. A clinic study Penyakit THT -KL di Indonesia, 2007
Of Epistaxis, International Journal of
Clinical and Diagnostic research
volume 2, Issue 4, Jul-Aug 2014.

7. Dhillon, RS, Ear,Nose and Throat and

Head and Neck Surgery, 2th edition,
Churchill Livingstone,2000

8. Kalzi,AE (eds), Lea and Febiger

Manual of Otolaryngology Head
anad Neck Therapeutic Philadelphia.
2004.
9. S. Gailard et,al. Tranexamid acid for
epistaxis in hereditary hemorrhagic
teleangiectasis patients. Juornal of
homeostasis, Europe. 2014.
10. Vikram,V,J et.al, Aetiology and
management of epistaxis in Children,
Otoloaryngology Online Journal Vol.
4 issue 4.2014.