Epistaxis

Dr Amit Jha MBBS, MS

Associate Professor
Chitwan Medical College and Teaching Hospital
Bharatpur-10, Chitwan
Definition & Epidemiology
Bleeding from within the nasal cavity.
• Greek word-epistazo
• Epi=above/over
• Stazo= to drip (from nostrils)

Commonest otolaryngologic emergency

Affects 60% of the population in their lifetime

6% of them require medical attention

 Blood Supply of Nose
• Supplied by both internal and external
carotid systems, both on the septum
and the lateral wall
 Septum
• Internal Carotid System
– Anterior Ethmoidal Artery
– Posterior Ethmoidal Artery
Both of these are branches of ophthalmic artery
• External Carotid System
– Sphenopalatine artery (branch of maxillary
artery)
– Septal branch of greater palatine artery
(branch of maxillary artery)
– Septal branch of superior labial artery (branch
of facial artery)
 Lateral Nasal Wall
• Internal Carotid System
– Anterior Ethmoidal Artery
– Posterior Ethmoidal Artery
Both of these are branches of ophthalmic artery
• External Carotid System
– Posterior lateral nasal branches from
sphenopalatine artery
– Greater Palatine Artery from Maxillary Artery
– Nasal branch of anterior superior dental artery
from infraorbital branch of maxillary artery
– Branches of facial artery to nasal vestibule
 Little’s Area
• Identified by James Little in 1879
• As arterial plexus on the anterior
septum as a frequent site of bleeding
• Same plexus described a year later by
Kiesselbach.
• Exposed to drying effects of inspiratory
current and finger nail trauma
Formed by four ateries viz.
•Anterior ethmoidal artery
•Septal brach of superior labial artery
•Septal branch of sphenopalatine artery
and
•The greater palatine artery
 Retrocolumellar Vein
• Runs vertically downwards just (2mm)
behind the columella
• Crosses the floor and joins the venous
plexus on the lateral nasal wall
• This is a common site of bleeding in
young people
 Woodruff’s Plexus
• Plexus of veins situated inferior to the
posterior end of the inferior turbinate
• Site of posterior epistaxis in adults
Causes:

1. Idiopathic (55 %)

2. Local

3. General
Local causes (nose & P.N.S.)
 Congenital: hereditary telengiectasia

 Trauma: nose picking, injury to nose / face /

skull base, nasal surgery, foreign body

 Infection: vestibulitis, sinusitis, atrophic

rhinitis, rhinosporodiosis, rhinoscleroma

 Neoplasms: angiofibroma, hemangioma,

inverted papilloma, malignancy

 Deviated nasal septum (spur)

 General causes
• Hypertension
• Bleeding disorders: haemophilia,

thrombocytopenia, leukemia
• Drugs: aspirin, anticoagulants
• Physiological: cold + dry climate, high
altitude, vicarious menstruation,
violent exertion, barotrauma
• Liver failure
• Exanthematous fevers
Common causes of epistaxis
• Child: nose picking, foreign body,

exanthematous fever

• Adolescent: nasopharyngeal angiofibroma,

trauma, sinusitis

• Adults: sinusitis, trauma

• Elderly: hypertension, malignancy

 Common sites of epistaxis
• Little’s area (80-90 %): Kiesselbach’s arterial
plexus at antero-inferior part of septal cartilage.
Common in children.

• Woodruff’s venous (?) plexus: near posterior

end of inferior turbinate. Common in elderly,
hypertensives.

• Retro-columellar vein: common in adults.

Common sites of epistaxis
Common sites of epistaxis
 Anterior Posterior
Epistaxis Epistaxis
Incidence More common Less common

Localization Easy Difficult

Common site Little’s area Woodruff plexus

Age < 18 yr > 40 yr

Common Cause Trauma Hypertension

Treatment Anterior pack Posterior pack

 Evaluation of pt. with epistaxis
• Mode of onset. Spontaneous or finger nail trauma?

• Duration and frequency of bleeding

• Amount of blood loss

• Side of the nose from where bleeding is occurring

• Whether bleeding is anterior or posterior

• Any known bleeding tendency in the patient or family?

• History of known medical ailment (hypertension, leukemia, mitral

valve disease, cirrhosis and nephritis)

• History of drug intake (analgesics and anti-coagulants)

 General treatment
• Record pulse & blood pressure

• Reassurance + bed rest in sitting posture with

back rest

• Adequate sedation (Diazepam)

• Amlodipine / Nifedipine for hypertension

• IV fluids / blood transfusion for shock

 Investigations
• Hemoglobin, Packed Cell Volume
• Blood grouping & cross-matching
• Bleeding Time, Clotting Time
• Activated Partial Thromboplastin Time
• Prothrombin Time
• Platelet count
• Diagnostic Nasal Endoscopy (D.N.E.)
• C.T. scan paranasal sinus
Diagnostic Nasal Endoscopy
 Anterior epistaxis
• Pinch nostrils (Hippocratic Technique)+ ice pack
 Bleeding continues
• Insert cotton pledgets soaked in 1: 1000
adrenaline in nasal cavity
 Bleeding continues
• Chemical cautery with AgNO3 or TCA
(TrichloroAcetic Acide) or electrical cautery (if
bleeder is localized) or anterior nasal packing
General treatment
General treatment
 Trotter’s method
Elderly pt in sitting
position, leaning forward,
mouth open allowing
bleeding to continue till
hypotension develops.
Adrenaline soaked pledget
Chemical cautery
 Anterior nasal packing
Anterior nasal packing for 48-72 hrs  antibiotic
cover with:
• Liquid paraffin + antibiotic cream gauze

• Vaseline gauze

• Bismuth Iodoform Paraffin Paste gauze

• Merocel tampoon

• Simpson balloon
Anterior nasal gauze packing
Anterior nasal gauze packing
 Anterior nasal gauze packing
• Ribbon gauze (1m long. 25mm wide for adults,

12mm for children) soaked with liquid paraffin +

antibiotic cream used.

• Both nasal cavities packed tightly by layering

from floor to roof. Pack removed after 48 hrs.

• Systemic antibiotics given to prevent sinus

infection & toxic shock syndrome.

Merocel nasal tampoon
Simpson’s nasal balloon
 Posterior epistaxis
• Posterior + anterior nasal packing for 48-72
hrs  antibiotic cover with:

• Post nasal gauze pack

• Foley’s catheter

• Brighton balloon (double lumen)

• Epistat balloon (double lumen)

• Bivona balloon (triple lumen)

Antero-Posterior
Nasal Packing
with gauze pack
Posterior nasal gauze pack
Catheter introduction
Tying of pack to catheter tip
Guiding pack into nasopharynx
Tying of anterior strips
Anterior nasal packing
Outer nasal packing
 Posterior nasal packing
• Post nasal pack prepared by tying 3 ribbon

gauze strips to piece of gauze roll

• 2 Foley’s catheters passed through each nostril

& their ends brought out via mouth

• 2 ends of gauze strips attached to nasal pack

tied to catheter tips & withdrawn from nose

 Posterior nasal packing
• Pack that follows ribbon gauze strips, is guided

into nasopharynx with index finger.

• Anterior nasal packing done. 2 ribbon gauze

strips tied over a gauze piece on columella.

• 3rd gauze strip brought out from mouth & taped

to cheek. Pack removed after 48-72 hr.

Antero-Posterior
Nasal Packing
with Foley’s
catheter
Foley’s catheter
Catheter introduction
Catheter tip in nasopharynx
Anterior nasal packing
Anterior nasal packing
Anterior nasal packing
Outer packing
Brighton’s nasal balloon
Epistat nasal balloon
Epistaxis set
Surgical intervention
for refractory
epistaxis
1. Arterial ligation by external approach

• external carotid artery: ligated in neck, distal to

superior thyroid artery

• internal maxillary artery: ligated in pterygo-

palatine fossa (Caldwell-Luc opn)

• anterior or posterior ethmoidal artery: ligated in

orbit (Lynch-Howarth incision)

External Carotid ligation
2. Angiography and embolization

3. Submucosal Resection of septum

4. Septo-dermoplasty:

for hereditary telengiectasia

5. Endoscopic cautery & clipping:

 Sphenopalatine artery

 Anterior or posterior ethmoidal artery

Angiography + embolization
Endoscopic clipping
Thank You

Alau VDC
Parsa
Jan 28, 2017