EPISTAXIS

- Varsha U.L.
DEFINITION:
• Bleeding from inside the nose is called epistaxis.
• Sign and not a disease per se.
Blood supply of nose:
Causes of epistaxis:
May be divided into:
• Local
• General
• Idiopathic
Local causes:
Nose:
TRAUMA: Finger nail trauma, injuries of nose, intranasal surgery, fractures of middle
third of face and base of skull, hard-blowing of nose and violent sneeze.

INFECTIONS: 1. Acute- Viral rhinitis, nasal diphtheria, acute sinusitis.

2. Chronic- All crust-forming diseases, e.g., atrophic rhinitis, rhinitis sicca,
tuberculosis, syphilis septal perforation, granulomatous lesion of the
nose, e.g., rhinosporidiasis.
FOREIGN BODIES: 1.Nonliving: Any neglected foreign body, rhinolith.
2. Living: Maggots, leeches.
 Contd…
NEOPLASMS OF NOSE AND PARANASAL SINUSES:
1.Benign- Haemangioma, papilloma.
2.Malignant- Carcinoma or Sarcoma.
ATMOSPHERIC CHANGES: High altitudes, sudden decompression (Caisson disease).
DEVIATED NASAL SEPTUM

Nasopharynx:
1.Adenoiditis
2.Juvenile angiofibroma
3.Malignant tumours
General causes:
• CVS: Hypertension, arteriosclerosis, mitral stenosis, pregnancy ( HTN, hormonal).
• DISORDERS OF BLOOD VESSELS AND BLOOD: Aplastic anaemia, leukaemia,
thrombocytopenic and vascular purpura, haemophilia, Christmas disease, scurvy,
Vit.K deficiency and hereditary haemorrhagic telangiectasia.
• LIVER DISEASE: Hepatic cirrhosis
• KIDNEY DISEASE: Chronic nephritis
• DRUGS: Excessive use of salicylates, analgesics and anticoagulant therapy.
• MEDIASTINAL COMPRESSION: Tumors of mediastinum
• ACUTE GENERAL INFECTION: Influenza, measles, chickenpox, whooping cough,
rheumatic fever, infectious mononucleosis, typhoid, pneumonia, malaria and dengue
fever.
• VICARIOUS MENSTRUATION
SITES OF EPISTAXIS:
• LITTLE’S AREA: In 90% of cases.
• ABOVE THE LEVEL OF MIDDLE TURBINATE: Generally from the anterior
and posterior ethmoidal vessels.
• BELOW THE LEVEL OF MIDDLE TURBINATE: Bleeding from br. of
sphenopalatine artery.
• POSTERIOR PART OF THE NASAL CAVITY: Blood flows directly into the
pharynx.
• DIFFUSE: From septum and lateral nasal wall seen in systemic disorders and
blood dyscrasias.
• NASOPHARYNX
 CLASSIFICATION:
• Anterior Epistaxis: When blood flows out from the front of nose with the
patient in sitting position.
• Posterior Epistaxis: Blood flows back into the throat which might be swallowed
by the patient resulting in coffee-coloured vomitus – may be diagnosed as
haematemesis.
 ANT. VS POST. EPISTAXIS
ANTERIOR EPISTAXIS
• More common
• Mostly from Little’s area or anterior
part of the lateral wall.
• Mostly occurs in children or young
adults.
• Mostly caused by trauma.
• Mild bleeding, controlled by local
pressure or anterior pack.
POSTERIOR EPISTAXIS
• Less common
• Mostly from the posterior part of the
nasal cavity.
• After 40 yrs of age.
• Spontaneous and is often due to
hypertension or arteriosclerosis.
• Severe bleeding which requires
hospitalisation and often a posterior
nasal pack.
HISTORY TAKING:
• Mode of onset – Spontaneous or finger nail trauma.
• Duration and frequency of bleeding.
• Amount of blood loss
• Side of nose from where bleeding is occurring.
• Whether the bleeding is of anterior or posterior type.
• Any known bleeding tendency in patient or family.
• H/O known medical ailment ( hypertension, leukaemia, mitral valve disease, cirrhosis
and nephritis)
• H/O drug intake (analgesics, anticoagulants, etc.).
Examination:
• A combined local anaesthetic/vasoconstrictor solution should be applied topically
to the nose and anterior rhinoscopy performed with a headlight and Thudichum’s
nasal speculum.
• Nasal cavity cleared of all clots and then inspected to view to identifying an
anterior bleeding point.
• If an anterior source is not visualized, rigid nasendoscopy should be performed to
identify a bleeding point more posteriorly in the nasal cavity.
• Even following successful identification of anterior bleeding points, nasendoscopy
should be performed to exclude other posterior bleeding points to avoid inadvertent
cauterization of normal nasal anatomy.
Management:
• First aid
• Cauterization
• Anterior nasal packing
• Posterior nasal packing
• Endoscopic cauterization
• Elevation of mucoperichondrial flap and submucous resection (SMR) operation.
• Ligation of vessels
• Transnasal Endoscopic Sphenopalatine Artery Ligation (TESPAL)
• Embolization
 FIRST AID:
• Bleeding from Little’s area and can be easily controlled by pinching the nose
with thumb and index finger for 5 minutes which compresses the vessels of the
Little’s area.
• 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 compress applied to cause reflex vasoconstriction.
CAUTERIZATION:
• Done mostly in anterior epistaxis when bleeding point has been located.
• The area is first topically anaesthetized and bleeding point cauterized with a
bead of silver nitrate or coagulated with electrocautery.
 Anterior nasal packing:
• Done when bleeding is profuse and localization of site is difficult.
• Ribbon gauze soaked with liquid paraffin (1m) is required- 2.5 cm wide in adults
and 1.2 cm in children for each nasal cavity.
• First few centimeters of gauze folded upon itself and inserted along the floor and
then the whole nasal cavity is packed tightly by layering the gauze from floor to the
roof and from before backwards.
• Packing can also be done vertically from back to front.
• One or more cavities may need to be packed.
• Removed after 24 hrs if bleeding has stopped.
• Sometimes kept for 2-3 days where systemic antibiotics are given to prevent sinus
infection or toxic shock syndrome.
Posterior nasal packing:
• For patients bleeding posteriorly into the throat.
• Prepared by tying three silk ties to a piece of gauze rolled into the shape of cone.
• A rubber catheter is passed through the nose and its end brought out from the
mouth.
• Ends of threads are tied and catheter withdrawn from the nose.
• Pack which follows the silk thread, is now guided into the nasopharynx with the
index finger.
• Anterior nasal cavity is now packed and silk threads tied over a dental roll.
• The third silk thread is cut short and allowed to hang in the oropharynx for easy
removal of pack later.
• Patients requiring post nasal pack should always be hospitalised.
CONTD…

• Instead of a post nasal pack a Foley’s catheter (12-14 F) can also be used.
• After insertion balloon is inflated with 5-10mL of saline.
• Bulb inflated with saline and pulled forward so that the choana is blocked and
then anterior nasal pack is kept in the usual manner.
• Nasal balloons are also available, where it has two bulbs- one for postnasal space
and the other for nasal cavity.
 ENDOSCOPIC CAUTERIZATION:
• Using topical or general anaesthesia, bleeding point is localised with a rigid
endoscope.
• Cauterization with a malleable unipolar suction cautery or a bipolar cautery.
• Effective procedure with less morbidity and decreased hospital stay.
• Cannot be done in case of profuse bleeding which dos not allow localization of
the site.
Elevation of mucoperichondrial flap and
SMR
• For persistent and recurrent bleeds from the septum.
• Elevation of mucoperichondrial flap and repositioning it back helps to cause
fibrosis and constrict blood vessels.
• SMR can be done to achieve the same or in cases of septal spur to remove it.
LIGATION OF VESSELS:
• External carotid: Done above the origin of superior thyroid artery should be
done. Avoided these days in favour of embolization or ligation of more peripheral
br. of sphenopalatine artery.
• Maxillary artery: Done in uncontrollable posterior epistaxis. Approach is via
Caldwell-Luc operation. Posterior wall of maxillary sinus is removed and
maxillary artery and its br. are blocked by applying clips.
• 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 (Lynch) incision.
 TESPAL:
• Done with rigid endoscopes under topical anaesthesia with sedation or general
anaesthesia.
• A mucosal flap is lifted in posterior part of lateral nasal wall, sphenopalatine
artery is localized as it exits the foramen and closed with a vascular clip.
• Distal br. of artery can be additionally cauterized and then flap is reposited.
• Anterior ethmoidal artery can also be ligated by Lynch incision as an adjunctive
procedure.
• SPA ligation gives high success in control of refractory posterior bleed.
 Embolization:

• Done by interventional radiologist through femoral artery catheterization.

• Internal maxillary artery is localized and the embolization is performed with
absorbable gelfoam or polyvinyl alcohol or coils.
• Both ipsilateral or bilateral embolizations may be required for unilateral epistaxis
because of cross circulation.
• It is generally safe but may have potential risks like cerebral thromboembolism,
haematoma at local site.
• Ethmoidal arteries cannot be embolized.
 Hereditary haemorrhagic telangiectasia:
• Occurs in the anterior part of nasal septum and is the cause of recurrent bleeding.
• Treated by using Argon, KTP or Nd: YAG laser.
• Procedure may be repeated several times in a year as telangiectasia recurs in the
surrounding mucosa.
• Some cases septodermoplasty is done where anterior part of septal mucosa is
excised and replaced by a split-skin graft.
Thank you.