Epistaxis

• hemorrhage from the nostril, nasal cavity, or

nasopharynx
Anatomy
 Types

•Anterior •Posterior •Recurrent •Constant

occur occur at happens only at nosebleed for
anterior part posterior part certain period of more than 45
of the nose. of nose time. Mainly due to mins
seen in Seen in those dry weather
children or > 40
young adult Common
cause
hypertension
•Sudden •Chronic
nosebleeds nosebleed > 6
that can occur months. Due
at anytime of to chronic
the day disease
Anterior epistaxis Posterior epistaxis
 Causes
Local cause Systemic cause
• Chronic sinusitis • Hemophilia
• Epistaxis digitorum (nose picking) • Hypertension
• Foreign bodies • Leukemia
• Intranasal neoplasm or polyps
• Liver disease (e.g., cirrhosis)
• Irritants (e.g., cigarette smoke)
• Medications (e.g., topical corticosteroids)
• Medications (e.g., aspirin, anticoagulants,
• Rhinitis
nonsteroidal anti-inflammatory drugs)
• Septal deviation • Platelet dysfunction
• Septal perforation • Thrombocytopenia
• Trauma
• Vascular malformation or telangiectasia
 History

• history • Drugs
• duration • NSAID
• severity • warfarin
• side of bleed • heparin
• previous nose bleed • ticlopidine
• hypertension • dipyridamole
• systemic disease
• easy bruising
• prolonged bleeding after
minor surgery
Differential diagnosis Patient Position

• Nasal endometriosis
• Foreign body
• Hemophilia
• Rhinitis
• Sinusitis
• Drug toxicity
 Investigation

• FBC
• LFT
• Coagulation studies
• Rarely CT/MRI to assess anatomy and
determine the presence and extent of
rhinosinusitis, foreign bodies, and neoplasms
 Epistaxis tray

Top row: nasal decongestant sprays and local anesthetic, silver nitrate cautery sticks, bayonet
forceps, nasal speculum, Frazier suction tip, posterior double balloon system and syringe for
balloon inflation. Bottom row: Packing materials, including nonadherent gauze impregnated
with petroleum jelly and 3 percent bismuth tribromophenate (Xeroform), Merocel, Gelfoam,
and suction cautery.
5 minute pressure - Incorrect
correct
 Examination

• Gowns, gloves, and protective eyewear should be worn

•  Assess ABCs (Airway, B reathing, and C irculation). Rarely, severe epistaxis
may necessitate endotracheal intubation.
• Apply direct pressure by pinhcing soft part of nose for 10-15 mins
• Apply icepack to nose
• Partially insert small gauze pad on nose
 Examination

• Visual examination
• Examination with speculum
• Can use vasoconstrictor to reduce hemorrhage
- 4 % cocaine solution
- oxymetazoline
- phenylephrine solution.
• Topical application of local anaesthetic reduces pain
- Lignocaine
 Treatment

• Nosebleed risk factors (blood pressure,

coagulation factors, ongoing therapies with
antithrombotic or anticoagulant drugs) should
be controlled
• Treat other causes concurrently
• Plain packing
• Packing with gelfoam / epinephrine / surgicel
• Refer ENT
• DDAVP in persistent epistaxis
• Cautery
• Arterial ligation
• Embolization
 Indications for surgical intervention
• failure of medical treatment after 72 hours,
• initial hematocrit of <38% (males),
• need for transfusion.
• posterior bleed that will necessitate a posterior pack
is indication enough to pursue surgical treatment.
Epistaxis balloon for posterior epistaxis. Posterior
balloon (A) is inflated with 10 mL and anterior balloon
(B) with 30 mL
Posterior Nose Bleed
 Cautery
Chemical cautery Electrocautery
 Conclusion
Anterior epistaxis

pressure cautery ant.packing

fail
Posterior epistaxis

Post.packing ligation embolization