Epistaxis
Nanang Mardiraharjo, dr., Sp.THT-KL
Epistaxis
a common condition
presenting in 7% to 14% of the general population
each year.
Most patients: bleed is minor and usually stops
quickly do not seek medical attention.
Incidence : higher in males than females, more
frequent in the winter months than the summer
months.
Vascular Anatomy of the Nose
blood supply of the nose:
The major portion : the external carotid system
smaller component : the internal carotid system.
internal maxillary artery
greater palatine artery
the sphenopalatine artery
pharyngeal artery
superior labial artery
Septum & alae nasi
facial artery
external carotid artery
anterior ethmoidal arteries
Posterior ethmoidal arteries
ophthalmic artery
internal carotid artery
Lateral •sphenopalatine artery
•Woodruff's area
nasal wall
Medial •anterior region
•Little's area / Kiesselbach's plexus
•majority of nose bleeds
(septal)
• easily accessed and be treated with simple
measures.
ETIOLOGY OF EPISTAXIS
Local Systemic
•Trauma: digital, fractures •Hypertension
•Nasal sprays (local trauma effect)
•Vascular disorders
•Inflammatory reactions
•Anatomic deformities (e.g., septal •Blood dyscrasias
spur/deflection) •Hematologic malignancies
•Foreign bodies •Allergies
•Intranasal tumors •Malnutrition
•Chemical irritants
•Nasal prong O2, CPAP (continuous
•Alcohol
positive airway pressure)
•Drugs
•Surgery •Infections
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TREATMENT EPISTAXIS
Observation (especially in pediatric patients)
Antiseptic cream
Barrier ointment (petroleum jelly)
Cauterization
Nasal packing: anterior pack, posterior nasal pack,
nasopharyngeal balloon
Pterygopalatine fossa block
Laser photocoagulation
Pharmacologic
Surgical arterial ligation
Angiographic embolization
Surgical reconstruction
Minor Hemorrhage
Most episodes of epistaxis are minor and stop
spontaneously
Optimal management of recurrent nosebleeds in the
pediatric population remains unknown
Antiseptic creams reducing vestibulitis and mucosal
inflammation moistening the mucosa and
preventing drying and crusting.
Barrier ointments preventing crusting of the septal
mucosa reduce mucosal friability decrease the
frequency of minor epistaxis
silver nitrate cautery Little's area
nasal pack
Exsanguinating Hemorrhage
usually occurs after major trauma
Anterior skull base fractures anterior and posterior
ethmoidal arteries
fractures of the maxilla internal maxillary artery or
one of its branches
sphenoid is involved traversing the internal carotid
artery catastrophic bleeding
Management
A-B-C-D
postnasal space balloon catheter + 15 mL saline
packed with ribbon gauze (soaked in bismuth
iodoform paraffin paste petroleum gauze coated with
antibiotic ointment, boorzalf)
sphenopalatine artery ligation
external carotid ligation
ligation of the anterior and the posterior ethmoidal
artery
Massive hemorrhage from the sphenoid region
internal carotid injury
Sagittal section through the nose demonstrating the techniques for layering
ribbon gauze in the nose for tamponade of the bleeding blood vessel
EMERGENCIES EXSANGUINATING EPISTAXIS
COMPLICATIONS EPISTAXIS MANAGEMENT
TERIMA
KASIH
