EPISTAXIS

BY
 Introduction
 Epistaxis is a greek word meaning nose bleed.
has been a part of the human experience from
earliest times
 Hippocrates commented that holding pressure
on the nose helped to abate bleeding.
Kiesselbach and Little(1879) were the first to
identify the nasal septum’s anterior plexus as a
source of nasal bleeding.
 Pilz(1869) was the first to surgically treat
epistaxis with arterial ligation
 Incidence
 Epistaxis, has been reported to occur in up to 60
percent of the general population. It has a
bimodal distribution, with peaks at ages younger
than 10 years and older than 50 years.
 Affected persons usually do not seek medical
attention, particularly if the bleeding is minor or
self-limited. In rare cases, however, massive
nasal bleeding can lead to death.
 The incidence increases with advancing age,
during the winter months, and is more common
in males
 Anatomy

 The rich vascular supply of the nose

originates from the ethmoidal branches of
the internal carotid arteries and the facial
and internal maxillary divisions of the
external carotid arteries. Although nasal
circulation is complex epistaxis usually is
described as either anterior or posterior
bleeding. This simple distinction provides
a useful basis for management.
Blood supply of nose
 Common bleeding Sites
 Kiesselbachs plexus Littles area
 Woodruffs Area
 Retrocolumellar vein
 Middle turbinate
 Local causes

Epistaxis digitorum (nose picking) &Trauma

Foreign bodies
 Intranasal neoplasm or polyps
 Irritants (e.g., cigarette smoke)
 Medications (e.g., topical corticosteroids)
 Rhinitis, Sinusitis acute and chronic
 Septal deviation , Septal perforation
 Adenoids
Vascular malformation or telangiectasia
 Systemic causes

 Haemophilia
 Hypertension
 Leukemia
 Liver disease (e.g., cirrhosis,Factor defeciency)
 Medications e.g., aspirin, anticoagulants, nonsteroidal anti-
inflammatory drugs
 Platelet dysfunction & Thrombocytopenia
 Others
 Diffuse oozing, multiple bleeding sites, or recurrent bleeding
may indicate a systemic process
 Idiopathic
 Vastmajority of cases come under this
category
 Bleeding patterns
 Septum littles area
 Above the middle turb ethmoidal vessels
 Below the middle turb sphenopalatine A
 Posterior woodruffs area
 Generalized bleeding disorder
 Site and age relationship
 Anterior
1/3 bleeds in adults
Commonest from littles area
Posterior 2/3 bleeds in old age
At the juntion of floor and lateral wall
 Examination
 Every attempt should be made to locate the
source of bleeding that does not respond to
simple compression and nasal plugging.
 The examination should be performed in a well-
lighted room, with the patient seated and
clothing protected by a sheet or gown.
 The doctor should wear gloves and other
appropriate protective equipment (e.g., surgical
mask, safety glasses).
 A headlamp /head mirror and a nasal speculum
should be used for optimal visualization
 Examination contd

 Clotsand foreign bodies in the anterior

nasal cavity can be removed with a small
suction tip, irrigation, forceps, and cotton-
tipped applicators.
 Initial Management
 Application of direct pressure to the septal area
and plugging of the affected cavity with gauze
or cotton that has been soaked in a topical
decongestant.
 Direct pressure should be applied continuously
for at least five minutes, and for up to 20
minutes.
 Tilting the head forward prevents blood from
pooling in the posterior pharynx, thereby
avoiding nausea and airway obstruction.
 Hemodynamic stability and airway patency
 Management Principles
 Although most patients with epistaxis can
be treated as out patients, hospital
admission and close observation should
be considered for elderly and patients with
posterior bleeding or coagulopathy.
Admission also may be prudent for
patients with complicating comorbid
conditions such as IHD, severe
hypertension or significant anemia
 ANTERIOR EPISTAXIS

 Ifa single anterior bleeding site is found,

vasoconstriction should be attempted with
topical application of oxymetazoline or
phenylephrine solution. For bleeding that
is likely to require more aggressive
treatment, a local anesthetic, such as a
 4% Xylocaine solution, should be used.
Adequate anesthesia should be obtained
before treatment proceeds.
 Cautrization
 Larger vessels generally respond more readily
to electrocautery. However, it must be performed
cautiously to avoid excessive destruction of
healthy surrounding tissues.
 Use of electrocautery on both sides of the
septum may increase the risk of septal
perforation.
 Some studies found no difference in efficacy or
complication rate between chemical cautery
(silver nitrate ) and electrocautery
 Anterior nasal packing
 anterior nasal cavity should be packed, from posterior to
anterior, with ribbon gauze impregnated with petroleum
jelly or polymyxin B-bacitracin zinc-neomycin .
Nonadherent gauze impregnated with petroleum jelly
and Bipp also works well .Bayonet forceps and a nasal
speculum are used to approximate the layers of the
gauze, which should extend as far back into the nose as
possible. Each layer should be pressed down firmly
before the next layer is inserted .Once the cavity has
been packed as completely as possible, a gauze "drip
pad” may be taped over the nostrils and changed
periodically.
Anterior nasal packing
Complications of nasal packing
 Procedures include septal hematomas and
abscesses from traumatic packing,
sinusitis, syncope during packing, and
pressure necrosis secondary to
excessively tight packing.
 possibility of toxic shock syndrome with
prolonged nasal packing
 POSTERIOR EPISTAXIS
 Much less common than anterior bleeding . Posterior
packing may be accomplished by passing a catheter
through one nostril (or both nostrils), through the
nasopharynx, and out the mouth . A gauze pack then is
secured to the end of the catheter and positioned in the
posterior nasopharynx by pulling back on the catheter
until the pack is seated in the posterior choana, sealing
the posterior nasal passage and applying pressure to the
site of the posterior bleeding.
 It requires special training and usually is performed by
an otolaryngologist
Post nasal packing
 Foleys catheter
 A Foley catheter (10 to 14 French) with a 30-mL balloon
may be used. The catheter is inserted through the
bleeding nostril and visualized in the oropharynx before
inflation of the balloon. The balloon then is inflated with
approximately 10 mL of saline, and the catheter is
withdrawn gently through the nostril, pulling the balloon
up and forward. The balloon should seat in the posterior
nasal cavity and tamponade a posterior bleed. With
traction maintained on the catheter, the anterior nasal
cavity then is packed as previously described. Traction is
maintained by placing an clamp on the catheter beyond
the nostrils, which should be padded to prevent soft
tissue damage. As with anterior epistaxis, topical
antistaphylococcal antibiotic ointment may be used to
prevent toxic shock syndrome. However, use of oral or
intravenous antibiotics for posterior nasal packing is
documented
 PERSISTENT BLEEDING

 Patients with anterior or posterior bleeding that

continues despite packing or balloon procedures
may require treatment by an otolaryngologist.
Endoscopy may be used to locate the exact site
of bleeding for direct cauterization.
 Hot water irrigation, a technique described more
than 100 years ago, has been reexamined
recently. This technique has shown promise in
reducing discomfort and length of hospitalization
in patients with posterior epistaxis.
 Danger signals in a severe nosebleed

 Heavy bleeding.

 Palpitation, shortness of breath and turning pale.

 Swallowing large amounts of blood, which will

cause you to vomit.
Indications for surgical intervention
 have been widely debated, but usually include
failure of medical treatment after 72 hours,
 nasal anatomy that precludes local treatments,
patient refusal of medical management,
 initial hematocrit of <38% (males),
 and the need for transfusion.
 Many authors have argued that a posterior
bleed that will necessitate a posterior pack is
indication enough to pursue surgical treatment.
 Surgical measures
 Arterialligation
 maxillary artery
 anterior ethmoidal artery
 posterior ethmoidal artery
 external carotid artery
 Embolization
 Septal surgery
 lasers
 How to avoid nosebleeds

 Avoid damaging the nose and excessive nose-picking.

 Seek medical treatment for any disease causing the

nosebleeds.

 Get a humidifier if you live in a dry climate or at high

altitude.
 summary
 The medical community’s understanding
of epistaxis has increased dramatically.
Our treatment, though somewhat modified
over the years, has continued to include
techniques first noted several thousand
years ago.
 Summary
 Epistaxis is the manifestation of many different
disease processes.
Its treatment is as varied as its etiologies.
Treatment will be most effective when underlying
medical problems are understood, nasal
anatomy is appreciated, and the patient’s
response to treatment and general medical
status are taken into account.
The otolaryngologist should be familiar with
treatment options and be able to offer surgical
intervention, if necessary.
