Epistaxis

Learning outcomes
• Describe the anatomy of nose and paranasal sinuses
• Describe the blood supply of nasal cavity
• List the function of nose and paranasal sinuses
• List the causes of epistaxis
• Discuss management of epistaxis
Nose Anatomy
External nose

•pyramidal in shape with its root up and the base directed downwards
Cont
Nasal process of frontal bone

• Bony part
• Cartilaginous part
• Nasal musculature
• Nasal skin

•Upper 1/3 of the external nose is bony while lower 2/3 are cartilaginous.
Supratip depression

• Septa cartilage
Support dorsum of nose

D/t septal abscess

Submucosal resection operation (SMR)
Cartilages
• 1. Upper lateral cartilages.
 extend from the undersurface of the nasal bones above, to the alar cartilages below
 fuse with each other and with the upper border of the septal cartilage in the midline anteriorly
 lower free edge of upper lateral cartilage is seen intranasally as limen vestibuli or nasal valve on each side.

2. Lower lateral cartilages (alar cartilages)

 U-shaped
 has a lateral crus which forms the ala and a medial crus which runs in the columella
 Lateral crus overlaps lower edge of upper lateral cartilage on each side .

• 3. Lesser alar (or sesamoid) cartilages

 >2 in number
 lie above and lateral to alar cartilages
 connected with one another and with the adjoining bones by perichondrium and periosteum
 Most of the free margin of nostril is formed of fibrofatty tissue and not the alar cartilage.

4. Septal cartilage
 anterosuperior border runs from under the nasal bones to the nasal tip
 supports the dorsum of the cartilaginous part of the nose.
 In septal abscess or after excessive removal of septal cartilage as in SMR (submucosal resection) operation, support of nasal dorsum is
lost and a supratip depression results.
Muscle- CN7
Contraction of this muscle pulls the
eyebrows downward to produce
transverse wrinkles over the nose.

The transverse part compresses the

nares, and the alar part opens the
nares.

 It pulls the nose inferiorly, opening the nares.

 Nasal skin
• Over nasal bone and upper lateral cartilages- thin and mobile

• Alar cartilage- thick & adherent, contains sebaceous glands.

Can give rise to rhinophyma (lobulated tumour)
Danger triangle of face
• facial vein and cavernous sinus, via
the ophthalmic vein

• retrograde spread of infection from

nose
1. cavernous sinus thrombosis,
2. meningitis or
3. brain abscess.
Internal nose

2 openings

Exterior thru nostril

Posterior into
nasopharynx via choana
Lateral wall- conchae / turbinates

• Bony projection
• Scroll like
Lateral wall- conchae / turbinates
Meastus = passage

^ Surface area of the nasal

cavity

^ Contact with the cavity

walls.

The air can be humidified and

warmed

Disrupt the fast, laminar flow

posterior
roof
Little’s area / Kiesselbach's plexus
Lateral wall-lining
Vestibule
• lined by skin containing hair, hair follicles and sebaceous glands.

Olfactory region
• Upper one-third of lateral wall (up to superior concha), corresponding part of the nasal
septum and the roof of nasal cavity form the olfactory region.
• mucous membrane is paler in colour.

Respiratory region
• Lower two-thirds of the nasal cavity form the respiratory region.
• mucous membrane shows variable thickness being thickest over nasal conchae especially
at their ends, quite thick over the nasal septum but very thin in the meatuses and floor of
the nose.
• highly vascular & contains erectile tissue
• lined by pseudostratified ciliated columnar epithelium (goblet cells)
 Nerve supply of nose
(a) Olfactory nerves
• sense of smell & supply olfactory region of nose.
• pass through the cribriform plate and end in the
olfactory bulb.

(b) Nerves of common sensation (touch, pain, etc)

1. Anterior ethmoidal nerve- supplies anterior and
superior part of the nasal cavity , lateral wall and
septum.
2. Branches of sphenopalatine ganglion- posterior
two-thirds of nasal cavity (both septum and lateral
wall)
3. Branches of infra-orbital nerve-supply vestibule of
nose both on its medial and lateral side.

(c) Autonomic nerves

• Parasympathetic nerve fibres supply the nasal glands
and control nasal secretion. They cause vasodilation.
• Sympathetic nerve fibres causes vasoconstriction.
Excessive rhinorrhoea in cases of vasomotor and
allergic rhinitis can be controlled by section of the
vidian nerve.
 Functions of nose
1. Respiration
• Natural pathway for breathing
• Mouth breathing – acquired act through learning
• So natural is instinct to breath thru nose
(newborn infant with choanal atresia may asphyxiate to death if no urgent measure taken.)
2. Air-conditioning of inspired air
• Filtration & purification
• Nasal vibrissae at the entrance of nose acts filter to sift larger particles while finer particles
adhere to mucus

• Temperature control of the inspired air

• Regulated by large surface of nasal mucosa (region of middle and inferior turbinates and
adjacent parts of the septum) which is highly vascular with cavernous spaces or sinusoids which
control the blood flow.
• This increases / decreases the size of turbinates.
• to warm up the cold air or cool hot air to the level of body temperature.

• Humidification
• Nasal mucous membrane adjusts the relative humidity of the inspired air to 75% or more.
• Water is provided by the nasal mucous membrane which is rich in mucous and serous secreting
glands.
• Moisture is essential for integrity and function of the ciliary epithelium.
• Dry air predisposes to infections of the respiratory tract.
• Also sigificant effect on gas exchange in lower airway
3. Protection of lower airway
• Mucociliary mechanism
• Nasal mucosa is rich in goblet cells, secretory glands both mucous and serous.
• Their secretion forms a continuous sheet called mucous blanket which consists of a superficial mucus layer and a deeper serous
layer
• The inspired bacteria, viruses and dust particles are entrapped on the viscous mucous blanket and then carried to the nasopharynx
to be swallowed. (like a “conveyer belt”)
• Presence of turbinates almost doubles the surface area to perform this function.

• Enzymes and immunoglobulins

• Nasal secretions contain muramidase (lysozyme) → kills bacteria and viruses.
• Immunoglobulins IgA and IgE, and interferon → provide immunity against URTI.

• Sneezing
• A protective reflex which expels foreign particles which irritate nasal mucosa.
• Copious flow of nasal secretions that follows irritation by noxious substance helps to wash them out.
4. Vocal resonance
• Nose forms a resonating chamber for certain consonants in
speech.
• In phonating nasal consonants (M/N/NG), sound passes through
the nasopharyngeal isthmus and is emitted through the nose.
When nose (or nasopharynx) is blocked, speech becomes denasal,
i.e. M/N/NG are uttered as B/D/G, respectively.
5. Nasal reflex functions
• Smell of a palatable food cause reflex secretion of saliva and gastric juice.
• Irritation of nasal mucosa causes sneezing.
• Nasal function is closely related to pulmonary functions thru nasobronchial &
nasopulmonary reflex.
• Nasal obstruction leads to ↑pul.resistance (reversed after surgically treatment)
• Long standing nasal obstruction (tonsil and adenoid hypertrophy) can cause pul.HPT or cor pulmonale
(reversed after removal of tonsil and adenoid)
• Olfaction
• Olfactory pathways
• Smell is perceived in the olfactory region of nose which is situated high up in the nasal
cavity. This acts as a sensory receptor to receive odorous substances.
• Disorders of smell
• Anosmia is total loss of sense of smell while hyposmia is partial loss.
• Parosmia is perversion of smell; the person interprets the odours incorrectly. Often these
persons complain of disgusting odours.
Functions of paranasal sinuses
• It is not clear why nature provided paranasal sinuses.
• Probable functions are:
1. Air-conditioning of the inspired air by providing large surface area over which the air
is humidified and warmed.
2. To provide resonance to voice.
3. To act as thermal insulators to protect the delicate structures in the orbit and the
cranium from variations of intranasal temperature.
4. To lighten the skull bones.
5. To provide extended surface for olfaction; olfactory mucosa is situated in the upper
part of nasal cavity and extends over ethmoid as well.
6. To provide local immunologic defence against microbes.
7. To act as buffers against trauma and thus protect brain against injury, e.g. frontal,
ethmoid and sphenoid sinuses.
Epistaxis
Bleeding from the nose
Causes
Genera
l

Epistaxi
s

Loca Idiopathi
c
l
Sites of Epistaxis
• 90% of nose bleed -> Kiesselbach’s plexus (localized at anterior
portion of septum> Little’s area)
• Above level of middle turbinate (nasal concha), bleeding from ->
Anterior and posterior ethmoidal vessels (internal carotid system).
• Below the level of middle turbinat, bleeding is from -> the branches of
sphenopalatine artery. It may be hidden, lying lateral to middle or
inferior turbinate.
• Diffuse -> Both from septum and lateral nasal wall.
Local Causes
Nose
1) Trauma >> Finger nail trauma, injuries of nose, intranasal surgery, fractures of middle third of face
and base of skull, hard-blowing of nose, violent sneeze
2) Infections
Acute: Viral rhinitis, nasal diphtheria, acute sinusitis
Chronic: All crust-forming diseases, e.g. atrophic rhinitis, rhinitis sicca, tuberculosis, syphilis septal
perforation, granulomatous lesion of the nose, e.g. rhinosporidiosis
3) Foreign bodies
Non-living: Neglected foreign body, rhinolith
Living: Maggots leeches
4) Neoplasms of nose and paranasal sinuses
Benign: Haemangioma, papilloma
Malignant: Carcinoma or sarcoma
5) Atmospheric changes >> High altitudes, sudden decompression (Caisson's disease).
6) Deviated nasal septum
Local Causes
Local Causes
Nasopharynx
1) Adenoiditis
2) Juvenile angiofibroma
3) Malignant tumours
 General Causes
1) Cardiovascular system >> Hypertension, arteriosclerosis, mitral stenosis,
pregnancy (hypertension and hormonal).
2) Disorders of blood and blood vessels >> Aplastic anaemia, leukaemia,
thrombocytopenic and vascular purpura, haemophilia, Christmas disease,
scurvy, vitamin K deficiency, hereditary haemorrhagic telangiectasia.
3) Liver disease >> Hepatic cirrhosis (deficiency of factor II, VII, IX & X).
4) Kidney disease >> Chronic nephritis.
General Causes
5) Drugs >> Excessive use of salicylates and other analgesics (as for
joint pains or headaches), anticoagulant therapy (for heart disease).
6) Mediastinal compression >> Tumours of mediastinum (raised
venous pressure in the nose).
7) Acute general infection >> Influenza, measles, chickenpox,
whooping cough, rheumatic fever, infectious mononucleosis,
typhoid, pneumonia, malaria, dengue fever.
8) Vicarious menstruation >> occur at time of menstruation.
Classification of Epistaxis
Anterior epistaxis - When blood flows out from the front of nose with
the patient in sitting position.

Posterior epistaxis - Mainly the blood flows back into the throat.
Patient mistakenly be diagnosed as hematemesis.
Classification of Epistaxis
Management
of epistaxis
By Ruth Foo Yau Yuet
 Important Things 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, leukae- mia, mitral valve
disease, cirrhosis and nephritis).
8. History of drug intake (analgesics, anticoagulants, etc.).
 GENERAL MEASURES IN EPISTAXIS

1. Make the patient sit up with a back rest and record any blood loss taking place
through spitting 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 .
5. Antibiotics may be given to prevent sinusitis, if pack is to be kept beyond 24 h.
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.
 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
min. 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.
 CAUTERIZATION

• This is useful in anterior epistaxis when bleeding point has been located.
The area is first topically anaesthetized and the bleeding point cauterized
with a bead of silver nitrate or coagulated with electrocautery.
 ANTERIOR NASAL PACKING

• In cases of active anterior epistaxis, nose is cleared of blood clots by suction

and attempt is made to localize the bleeding site. In minor bleeds, from the
accessible sites, cauterization of the bleeding area can be done.
• If bleeding is profuse and/or the site of bleeding is difficult to localize,
anterior packing should be done.
 ANTERIOR NASAL PACKING

• For this, use a ribbon gauze soaked with liquid paraffin.

• About 1 m gauze (2.5 cm wide in adults and 12 mm in children) is required for
each nasal cavity.
• First, few centimetres of gauze are 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 in vertical layers from back to the front (Figure 33.3).
• One or both cavities may need to be packed. Pack can be removed after 24 h, if
bleeding has stopped. Sometimes, it has to be kept for 2–3 days; in that case,
systemic antibiotics should be given to prevent sinus infection and toxic shock
syndrome.
 POSTERIOR NASAL PACKING

• It is required for patients bleeding posteriorly into the throat.

• A postnasal pack is first prepared by tying three silkties to a piece of gauze
rolled into the shape of a cone.
• A rubber catheter is passed through the nose and its end brought out from
the mouth (Figure 33.4).
• Ends of the silk threads are tied to it and catheter withdrawn from 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.
 POSTERIOR NASAL PACKING

• The third silk thread is cut short and allowed to hang in the oropharynx.
• It helps in easy removal of the pack later. Patients requiring post- nasal pack
should always be hospitalized.
• Instead of postnasal pack, a Foley’s catheter size 12–14 F can also be used.
After insertion balloon is inflated with 5–10 mL of saline.
• The bulb is inflated with saline and pulled forward so that choana is blocked
and then an anterior nasal pack is kept in the usual manner.
• These days nasal balloons are also avail- able (Figure 33.5). A nasal balloon
has two bulbs, one for the postnasal space and the other for nasal cavity.
 ENDOSCOPIC CAUTERIZATION

• Using topical or general anaesthesia, bleeding point is localized with a rigid

endoscope.
• It is then cauterized with a malleable unipolar suction cautery or a bipolar
cautery.
• The procedure is effective with less morbidity and decreased hospital stay.
• The procedure has a limitation when profuse bleeding does not permit
localization of the bleeding point.
ELEVATION OF MUCOPERICHONDRIAL FLAPAND
SUBMUCOUS RESECTION (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

• 1. External carotid. 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 favours of embolization or ligation of more
peripheral branches of sphenopalatine artery.
 LIGATION OF VESSELS

• 2. Maxillary artery. Ligation of this artery is done in uncon- trollable

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.
• This procedure is now superceded by transnasal endoscopic sphenopalatine
artery ligation.
 LIGATION OF VESSELS

• 3. 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.
TRANSNASAL ENDOSCOPIC SPHENOPALATINE
ARTERY LIGATION (TESPAL)

• The procedure can be done with rigid endoscopes under topical anaesthesia
with sedation or under a general anaesthesia.
• A mucosal flap is lifted in posterior part of lateral nasal wall,
sphenopalatine artery (SPA)is localized as it exits the foramen and closed
with a vascular clip.
• Distal branches of the artery can be additionally cauterized and the flap
then 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

• It is done by an interventional radiologist through femoral artery

catheterization.
• Internal maxillary artery is localized and the embolization is performed with
absorbable gelfoam and/ or polyvinyl alcohol or coils.
• Both ipsilateral or bilateral embolizations may be required for unilateral
epistaxis because of cross circulation.
• Embolization is generally a safe procedure but may have potential risks like
cerebral thromboembolism, haematoma at local site. Ethmoidal arteries
cannot be embolized.