EPISTAXIS

Dr.ASHLY ALEXANDER
DEPT OF ENT
GMC,BHOPAL
“ Acute Hemorrhage from the Nostril,
Nasal Cavity or Nasopharynx”
 Vascular anatomy of the nose
External Carotid Artery Internal Carotid Artery
FacialArtery Anterior Ethmoidal
Superior Labial
Lateral Nasal Posterior Ethmoidal
Ascending Palatine
Maxillary Artery
Greater Palatine
Sphenopalatine
Lateral Nasal
Posterior Septal
 KIESSELBACH’S PLEXUS
(Little’s area)
• In anterior inferior
part of nasal septum
• Most common site for
Epistaxis
• Mainly anterior
epistaxis
1. septal br. Of
sphenopalatine
2. Anterior ethmoidal
3. Septal br. Of superior
labial
4. greater palatine
arteries
 WOODRUFF’S PLEXUS
• Posterior end of inferior Turbinate
• Venous plexus
• Most common site for posterior
epistaxis
 CLASSIFICATION
• Primary – no proven causal factor
• Secondary- proven causal factor
present
 CLASSIFICATION
Adult Vs Childhood Epistaxis
1. Childhood Epistaxis <16yrs
2. Adult Epistaxis >16yrs
• There is a pronounced bimodal
distribution in onset of Epistaxis
• More common in childhood, becomes
less common in early adulthood and
peaks again in 6th decade
 CLASSIFICATION
Anterior Posterior
Incidence More common Less common
Site Little’s Area Posterosuperior
or anterior part of nasal cavity
part of lateral
wall
Age Children and >40yrs
young Adults
Cause Traumatic Spontaneous
Bleeding Mild Severe
 LOCAL CAUSES
1. Congenital : unilateral choanal atresia, meningocoele,
encephalocoele, hemangioma etc..
2. Acquired :
 INFECTIONS-
 Acute – Viral, Bacterial, Fungal
 Chronic Specific – tuberculosis, Syphylis, Leprosy,
Rhinoscleroma
 Chronic Non specific – Ozoaena

• Inflammatory – Rhinosinusitis, Nasal Polyposis

• Trauma/ Foreign Body(Living/Non-Living)
• Idiopathic
• Neoplastic – Juvenile angiofibroma, etc..
• Drug Induced – Rhinitis Medicamentosa
• Inhalants- tobacco, cannabis, mercury, wood dust,
heroin, chrome, phosphorus
 SYSTEMIC CAUSES
Hypertension- commonest
Cardiac –CCF, Mitral stenosis
Pulmonary –COPD
Cirrhosis – Vitamin K
deficiency
Renal –Nephritis
Drugs – Excessive use of
salicylates , anticoagulants
Hormonal – Vicarious
Menstruation,
Endometriosis,granuloma
gravidarum
Coagulopathies –
• Clotting disorders
• bleeding disorders
• Agranulocytosis
• Leukemia
• Vitamin K deficiency
• Exanthematous fevers
Idiopathic Causes
 PATIENT HISTORY
• Previous bleeding episodes
• Onset, duration, frequency, amount of
blood loss
• h/o trauma
• Family history of bleeding
• Hypertension
• Hepatic diseases
• Drug history
• Any other medical ailment
 MANAGEMENT
• Locate the bleeding site
• Anterior and Posterior rhinoscopy
• Diagnostic Nasal Endoscopy
• INVESTIGATIONS :
Hematological investigations – Hb%, TLC, DLC,
BT, CT,
Platelet count, prothrombin time
Blood urea, liver function tests
Radiology – x-ray and CT scan of nose, PNS and
Nasopharynx
Other investigations depending upon the possible
cause
 Trotter’s method
• Old fashioned method of controlling
epistaxis
• Pt is made to sit upright with cork
between the teeth and allowing the pt
to bleed till he becomes hypotensive
• Complication – Coronary Artery
Thrombosis
Hippocratic Method
 Direct & indirect therapies
• Treatment may be divided into direct
and indirect therapies
• Direct treatment is logically and
theoretically superior
• Indirect therapy should be resorted
when bleeding point cannot be identified
or bleeding is uncontrolled/profuse
 Direct therapy
• Anterior Epistaxis can be easily controlled
with identification of the bleeder and
cauterizing it with silver nitrate cautery or
cautery with Trichloraceticacid(TCA)
• Posterior Epistaxis can be identified by
nasal endoscopy and cauterized with
bipolar cautery
• Direct method is more cost-effective as it
facilitates outpatient management and
significantly reduce inpatient stay
Cauterization
1. Electrical – with bipolar, Unipolar is
contraindicated as it can cause optic
nerve damage
2. Chemical
a) Silver Nitrate 10%
b) Tricholoroacetic acid 40%
c) Carbolic Acid
3. Thermal
4. Cryotherapy
 Indirect therapy
• Failure to find bleeding point is an
indication
Various methods are
1. Hot water irrigation – irrigation with
water heated to 500C
2. Systemic medical therapy – Tranexamic
Acid and Epsilon aminocaproic acid
3. Nasal Packing
Anterior nasal packing
• For this, a ribbon gauze soaked with
liquid paraffin is used.
• About 1 metre gauze (2.5 cm wide in
adults and 12 mm in children) is required
for each nasal cavity.
• Pack can be removed after 24 hours if
bleeding has stopped.
 POSTERIOR NASAL PACKING
• If bleeding does not stop after anterior
packing-Posterior epistaxis
 COMPLICATIONS OF NASAL
PACKING
• SEPTAL HAEMATOMA
/ ABSCESS
• SINUSITIS
• PRESSURE NECROSIS
• TOXIC SHOCK
SYNDROME
 Other methods
• Merocel – A sponge like material placed in nasal cavity. It
helps stop bleeding by providing pressure against the
mucosa and by providing a surface against which the blood
can clot. Pack is introduced in dehydrated state and
expanded by instilling normal saline. It has to be removed

• Gel Foam – An absorbable material with pro-coagulant

properties. Contrary to Merocel it shrinks when it gets
wet and dissolves in matter of weeks. It helps prevent the
bleeding site from desiccation.

• Kaltostat – Sodium-Calcium Alginate containing material

(80:20 ratio). It swells up on absorbing water and it has to
be removed. It controls bleed by providing pressure

• Bivona – double balloon nasal catheter. Provides the effect

of both anterior and posterior packing. Disadvantage –
Balloons tend to inflate towards the path of least
resistance and may fail to provide tamponade at the
affected site.
 Ligation methods
Ligation is reserved for intractable bleeding
where the source cannot be located or
controlled by techniques mentioned above.
Ligation should be performed as close to the
bleeding point as possible. Thus the
heirarchy of ligation is

• Sphenopalatine artery- ESPAL

• Internal maxillary artery- IMAL
• External carotid artery- ECAL
• Anterior/Posterior Ethmoidal artery
Elevation of Mucoperichondrial flap &
SMR operation

• In case of persistent or recurrent

bleeds from the septum, just elevation
of mucoperichondrial flap and then
repositioning it back helps to cause
fibrosis and constrict blood vessels.
• SMR operation can be done to achieve
the same result or remove any septal
spur which is sometimes the cause of
epistaxis.
 Resuscitation
Initial
Examination
Vessel NOT located Vessel Located

Endoscopy Direct
Therapy
Indirect Therapy
Bleeding Eg: Bipolar
Eg : Anterior Packs Controlled
Continued -packs
Bleeding 48hrs
Posterior Pack minimum

Septal Surgery - Direct,

same day
Ligation discharge
(ESPAL)

Continued Bleeding
- Angiography and embolization
- Repeat above steps
Check for secondary factors
 QUESTIONS
??? ARTERY OF EPISTAXIS

??? MC ARTERY TO BLEED IN

ENDOSCOPIC SURGERIES

??? MCC OF EPISTAXIS IN CHILDREN

??? MCC OF EPISTAXIS IN ELDERLY

??? U/L EPISTAXIS IN ELDERLY MAY
BE THE FIRST SYMPTOM OF--

??? MAIN D/D OF EPISTAXIS IN

ADOLESCENT MALE

??? ARTERY NOT TAKING PART IN

KEISSELBACH’S PLEXUS

??? DIVIDING LINE BETWEEN ANT &

POST BLEED
??? MC SITE OF BLEEDING IN NASAL
CAVITY