EPISTAXIS

Epistaxis , derived from the Greek term epistazein,

is defined as bleeding from the nose.
It is one of the most common ENT emergencies.
Epistaxis, has been reported to occur in up to 60%
of the general population.
It has a bimodal age distribution, with peaks at
ages younger than 10 years and older than 50
years.

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Hippocrates commented that holding pressure
on the nose helped to abate bleeding.
Pilz(1869) was the first to surgically treat
epistaxis with arterial ligation
Kiesselbach and Little (1879) were the first
to identify the nasal septum’s anterior plexus
as a source of nasal bleeding.
 REASONS FOR EXCESSIVE
BLEEDING
Vascularity of nose
Both external and internal carotids.
Anastomsis between arteries and veins.
Blood vessels run just under the mucosa-
unprotected.
Larger vessels on the turbinate run in bony canals-
cannot contract.

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 Arteries of nasal cavity:
1. Branches of
maxillary artery
main supply of
the nose
(Sphenopalatine
artery).
2.Septal branch:
from facial artery.

3-ethmoidal
branches: from
Ophthalmic
artery.

bleeding from the

nose (epistaxis).
 Common bleeding Sites
Kiesselbachs plexus (Little's area)
Woodruffs Area
Retrocolumellar vein
Middle turbinate
Blood supply of nose
 Little’s area

Confluence of :
Anterior Ethmoidal
a.
Greater Palatine a.
Sphenopalatine a.
Sup. Labial a.

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Classification
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 Causes of epistaxis
Idiopathic
Vast majority of cases come under this
category (70-80%)
 Local causes
Trauma :
Epistaxis digitorum (nose picking) ,foreign bodies
& surgery of : nose, PNS & post nasal space.
Irritants (e.g., cigarette smoke)
Medications (e.g., topical corticosteroids)
Rhinitis, Sinusitis (acute and chronic)
Septal deviation & Septal perforation.
Tumors/vascular malformations like angiofibroma,
aneurysms, nasal papilloma , haemangioma & SCC .
 Systemic causes
Haemophilia
Hypertension (no proven association)
Leukemia
Liver disease (e.g., cirrhosis,Factor defeciency)
Medications e.g., aspirin, anticoagulants, nonsteroidal anti-inflammatory
drugs
Platelet dysfunction & Thrombocytopenia
Diffuse oozing, multiple bleeding sites, or recurrent bleeding may
indicate a systemic process
 According to Age

Children;
Nose picking & Foreign body,.
Adults:
Idiopathic & trauma.
Middle age:
tumors.
Old age:
hypertension.

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The management of epistaxis is well
summarized in an age-old dictum:
Resuscitate the patient
Establish the bleeding site
Stop the bleeding
Treat the cause of epistaxis
 TREATMENT
First aid & resuscitation
Definitive treatment
Prevention of recurrences

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 FIRST AID
Lean forward
Pinch the fleshy part of the nose (not
the bridge) for 10-20 min.
Avoid swallowing the blood.
Apply an icepack on the nasal bridge.

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 Resuscitation
Resuscitate as follows in cases of severe epistaxis:
Assess blood loss.
Assess pulse.
Assess blood pressure.
Gain intravenous access.
Set up an intravenous infusion if the blood loss is
great or if there is cardiovascular compromise.
Take a full blood count.
Assess coagulation.
Group and save.

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 DEFINITIVE TREATMENT
Look into the nose.
Locate the point after packing the nose
with 4% xylocaine and 1:1000 adrenaline
mixture

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 CAUTERIZATION
1) Chemicals;
Silver nitrate stick, chromic acid
bead.
2) Electrical

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 Cautrization
Larger vessels generally respond more readily to
electrocautery. However, it must be performed
cautiously to avoid excessive destruction of healthy
surrounding tissues.
Use of electrocautery on both sides of the septum
may increase the risk of septal perforation.
Apply ointment and advise against blowing and
nose picking.
Anterior nasal packing
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ANTERIOR PACKING
Unable to control
bleeding.
Ribbon, tampon,
splints.
BIPP
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 OTHER TREATMENTS
Hot water irrigation
Similar levels of success comparing the hot
water technique to anterior packing & balloon
tamponade.

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 Floseal hemostatic matrix(gelatin+
thrombin)

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 POSTERIOR PACKING
Posterior packing if bleed is posterior.
GA.
Foley's or other inflatable devices
48-72 hours
Admission
Antibiotics.
Transfuse.
Blood gases in children.

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 Complications
Infection
loose pack obstructing airway.
Hypoxia

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 Surgical management
Ligation techniques: for the followings:
* sphenopalatine artery;
* internal maxillary artery;
* external carotid artery;
* anterior/posterior ethmoidal artery.
• Septal surgery techniques;
• Embolization techniques
 How to avoid epistaxis

Avoid damaging the nose and excessive

nose-picking.
Seek medical treatment for any disease
causing the epistaxis.
Get a humidifier if you live in a dry hot
climate .