Epistaxis:
Bleeding from the nose
Assist.Prof.
Dr.Salim hussain
F.I.C.M.S (ENT)
Objectives:
1.Blood supply of the nose.
2.Etiology of epistaxis.
3.Clinical features of epistaxis
4.Types epistaxis.
5. Management of epistaxis.
Arterial blood supply of the nose.
I. Internal carotid artery.
1. Anterior ethmoidal a.
2.Posterior ethmoidal a branches
from ophthalmic artery.
*Supplies* nasal cavity above
the
Level of middle turbinate.and
* ethmoidal and frontal sinuses.
II. External carotid
artery.
1.Sphenopalatine a. 2.Greater palatine a.
both are branches of internal maxillary a.
3.Superior labial a. branch of facial a.
*These supplies the lower part of nasal
cavity
Etiology of epistaxis
I.Idiopathic : Spontaneous bleeding without any proved causes.
*The common cause 70-80%.
*Common in children and adolescents.
II. Local causes :
1. Traumatic. *Nose picking. *Blow to the nose. *Foreign body in the nose.
* Fracture nasal bones and anterior skull base, and fracture sinuses.
*Iatrogenic: Turbinectomy,E ndoscopic sinus surgery.
2. Inflammatory. Rhinitis and sinusitis ,either acute or chronic, specific(diphtheria,TB )
. or non-specific infection.Wegner’s granuloma
3. Neoplastic: Benign or malignant tumor in the
*Nasal . Like haemangioma of
the septum.
*Sinuses. Like angioma of
sinus,sequmous cell ca.
*Nasopharynx. Angiofibroma,
sequamous cell ca.
dryness and crustation.
4. Septal causes. Deviation, perforation. ,septal haematoma .
**Dry and cold air during the autumn and winter months makes epistaxis more common in these
5. Environmental. * Over exposure to air condition, heat,
seasons
smoke, and Industrial fumes results in
III. Systemic causes:
1. Raised blood pressure. Temporary or permanent.
A. Raised arterial pressure. Hypertension common in adult and elderly..
B.Raised venous pressure. like congestive heart failure, emphysema.
whooping cough, pneumonia, associated with venous bleeding.
2. Blood dyscreasia and diseases of blood vessels. Like
Leukemia , Haemophilia , Von wilbrand disease , Osler's
disease,(Hereditary hemorrhagic telangectasia),purpura.etc .
3.Hepatic failure.(hypoprothrombinemia)
4.Renal failure.(Platelet dysfunction)
5.Drugs taken.
*Anticoagulants (heparin , warfarin).
*Antiplatlet aggregation like aspirin and
NSAID.
Site of bleeding :
1. Little's area(Kiesselbach's plexus).
The commonest site of bleeding (90%),located in
the antero-inferior part of the nasal septum,
when anastomosis of poorly supported blood
vessels are;
1. Anterior ethmoidal a.
2.long sphenopalatine a.
3.greater palatine a.
4. Superior labial a.
2.Wood ruff's area. Venous plexus in the
posterior end of inferior turbinate.
3. Retrocolumellar vein.
lies immediately behind the columella is a
common causes of venous epistaxis in children.
4. Above middle turbinate
from anterior and posterior ethmoidal arteries,
usually in case of hypertension.
5. From middle meatus (rare) from maxillary
and ethmoidal sinuses.
. Little'sarea
Clinical feature of epistaxis
Epistaxis is a common ENT emergency.
Bleeding varies in degree from trivial to lethal.
* Usually occur from anterior naries.
May flow back in to the pharynx and in the opposite
nostril.
Occationally inhaled and may be suspected
haemoptysis.
Or swallowed and get haematemesis,malaena in sever
bleeding
*In sever epistaxis hypovolemic shock occurs :
Pallor, Weak rapid pulse , hypotension, cold
extremities, irritability, decreased urine output.
*Anemia in recurrent sever bleeding.
Types epistaxis
Type of epistaxis An Posterior epistaxis
terior epistaxis
Incidence More Common (90%) Less common (10%)
Age Younger patients <18 years Older patients>40 years
Site Common site is little's area *Common site is woodruff's area
Common Cause Idiopathic Hypertension
Localization Easy Difficult
Management Easy to manage More troublesome and serious
Treatment. Cautery,if fail anterior nasal (Endoscopic diathermy),if fail posterior
packing,merocel,nasal nasal pack, nasal balloon(with anterior
balloon. and posterior components)
Management of epistaxis:
In acute active epistaxis priority is given to *control bleeding and**
deal with hypovolemia and blood loss.
*in sever bleeding insert I.V line, take blood sample for blood group and Rh, Hb
%,
give fluid, do cross matching and blood transfusion when needed.
*Air way secured
I. Brief history. Looking for Severity. amount of blood loss and
predisposing factors.
*Duration.(short in venous bleeding, prolonged in arterial bleeding).
*Frequency. Recurrent in angiofibroma , osler's disease,
*Trauma (Facial trauma, nasal surgery)
*Medical history. hypertension.
*Drug history. aspirin, warfaren.
*Family history. Haemophilia , Vonwelbrand disease.
*Nasal symptoms. Obstruction, rhinorrhea.
II. Examination:
*General assessment, Vital sign(PR,RR,B.P,Temp.,Level of
consciousness.)
*Inspection ,Pallor,Osler,s disease,purpura, uremia,
jundice,..
*Hypertension
*Fever.
2. Local examination to identify the bleeding
site.
* Anterior rhinoscope.
*Posterior rhinoscope.
*Endoscopic examination.
III. Arrest bleeding.
1.First aid measures.
*Pressure:Pinching the ala nasi to compress the vessels of anterior part of the
septum which common site of epistaxis by thumb and index finger for 5-10 minutes.
*Position:Lean forward slightly with the flexion of the head tilted to
prevent
blood get to post nasal space, and breathing quietly through the mouth.
*Ice or cold packing to the bridge of the nose causes reflex
vasoconstriction.
*Local vasoconstriction (Pseudo ephedrine. Oxymetazoline drops.)
*In Hypo volemic shock. Insert I.V line, take blood sample for blood
group
and Rh,Hb%, give fluid, do cross matching and blood transfusion.
Incorrect Correct
II.Cauterization. when identify the bleeder site.
*Using of local decongestant and local anesthesia ;;Either
1.Chemical cautery using caustic agents (silver nitrate sticks,Trichloracetic
acid).
2. Electrical cautery. (Gelvanic cautery, Bipolar diathermy.)
3.Endoscopic guidance using hot wire cautery, or modern single fiber
bipolar electrodes ,for posterior bleeding.
Post cautery give lubricants ,antibiotics, and sedation.
Avoid bilateral septal cautery results in septal perforation
Post cautery instructions:
*No manipulation.
*No nose blowing.
*Open mouth when sneezing.
*No straining, lifting or strenuous activity for one week.
*No smoking or alcohol for one week.
*No hot drink or food for one week.
*Elevate the head of the bed for one week.
*No aspirin,warfaren,or similar drugs for one week.
*Cold mist humidifier at the bed time.
*lubricant drops (normal saline)for one week.
Little’s area
Silver nitrate stick
III. Nasal packing:
When fail of medical treatment , cauterization or not see the bleeder
site.
1. Anterior nasal packing:
Using ribbon gauze(half inch)lubricated with petroleum gelly or Bismuth Iodoform
Paraffin Past(BIPP).done under local anesthesia ,done in layers without traumatizing
the nasal mucosa using Tilly's forceps, inserted along the floor of the nose then
build mup in successive loop from floor upward till every part of nasal cavity finally
fitted. Usually done bilaterally to increase pressure on nasal septum.
Pack usually left for 24-72 hours depend on patient’s condition,
With antibiotic cover.
if bleeding restart needs further evaluation and reinserted or do
posterior packing
• Complications; sinusitis, septal perforation, hypoxia.
**Modern variations. using special tampons, Merocel , Gelfoam,
and nasal balloon
• *Merocel ;is compressed dehydrated sponge, which can inserted
in the nasal cavity then rehydrated by blood, expanding to 3
times it is normal size filling nasal cavity.
• Nasal balloon,for anterior epistaxis ( from
Merocel nasal packing(Tampon) little's area).
2.Posterior nasal packing: when failure of anterior nasal packing ,or
bleeding arise from back(ex. sphenopalatine a. in postnasal space)
*Can be carried under local anesthesia ,but general anesthesia is
preferable.Using
1.gauze packs inserted transorally and positioned by means of tapes
pass from the posterior choana to anterior naries bilaterally.
2. Foley urethral catheter.and anterior nasal packing inserted.
3. Nasal ballon:use anterior and posterior nasal balloon –integral airway.
**Pack should be left in position for minimum for 48hours.
.
.
Anterior and posterior nasal balloon –integral airway. Alar nasal necrosis.using
Folly's catheter
Complications of posterior nasal pack:
*Necrosis of septum and columella , and alar nasi ,*Sinusitis,* otitis
media.
*Hypoxia so the patient must admitted in the hospital in elderly (ICU).
Antibiotics, and analgesia are necessary.
* Never pack the nose of unconscious patient when skull fracture or
cribriform plate injury is suspected
IV. Arterial ligation :
Indications: Intractable bleeding cannot be
located or controlled by the methods described above.
1*Ligation of external carotid a.
2*Ligation of internal maxillary a.
3*Ligation of anterior/posterior ethmoidal a.
4*Endonasal sphenopalatine a. ligation.
**.Selective angiography and Embolization
•Indications: Intractable bleeding from surgically inaccessible
sites, patient not fit for surgery.
It can be done under local anesthesia .it is diagnostic (defines
bleeding site) and therapeutic, may be repeated
Only able to embolize external carotid & branches
**Hot water irrigation.
V:Search for causes treated.
Investigations:
Lab. Tests :CBP ( Hb, WBC and differential count, Blood film,Platlete count, PT, PTT, CT,
Factor assay ,Liver function test, B. urea, Serum creatinine, …
Radiological tests. tailored accordingly
Plane X- ray, CT scan, MRI of nose and paranasal sinuses. *Angiography angiofibroma
*Biopsy for mass
Treatment.
Systemic
medical
therapy.
* systemic
inhibitors of
fibrinolysis.
Tranexamic acid
and epsilon
aminocaproic
acid .
*Control
Hypertension.
treat renal 20
failure ,thrombo
