Epistaxis

EPISTAXIS

INTRODUCTION

Bleeding from inside the nose is called epistaxis

Fairly common and is seen in all age groups.

BLOOD SUPPLY OF NOSE

Nasal septum

• Internal carotid system Anterior ethmoidal artery Posterior ethmoidal artery• External carotid system Sphenopalatine artery (branch of maxillary artery)

gives nasopalatine and posterior medial nasal branches

Septal branch of greater palatine artery (branch of maxillary artery)

Septal branch of superior labial artery (branch of facial artery)

Lateral wall

• Internal carotid system Anterior ethmoidal artery Posterior ethmoidal artery• External carotid system Posterior lateral nasal branches- from

Sphenopalatine artery Greater palatine artery- from maxillary artery Nasal branch of anterior superior dental- from

infraorbital branch of maxillary artery Branches of facial artery to nasal vestibule

Little’s area

It is situated in the anterior part of nasal septum, just above the vestibule.

Four arteries- anterior ethmoidal, septal branch of superior labial, septal branch of sphenopalatine and the greater palatine, anastomose here to form a vascular plexus called “Kiesselbach’s plexus”.

Usual site for epistaxis in children and young adults. Retrocolumellar vein runs vertically downwards just

behind the columella, crosses the floor of nose and joins venous plexus on the lateral nasal wall. This is a common site of venous bleeding in young people.

Woodruff’s area

This vascular area is situated under the posterior end of inferior turbinate where sphenopalatine artery anastomoses with posterior pharyngeal artery.

Posterior epistaxis may occur in this area.

CAUSES OF EPISTAXIS

Local, in the nose or nasopharynxGeneralIdiopathic

Local causes

Nose

1. Trauma- Finger nail trauma, injuries of nose, intranasal surgery, fractures of middle third of face and base of skull, hard-blowing of nose, violent sneeze.

2. Infections

Acute: viral rhinitis, nasal diphtheria, acute sinusitis.

Chronic: all crust-forming diseases, e.g. atrophic rhinitis, rhinitis sicca, tuberculosis, syphilis septal perforation, granulomatous lesion of the nose, e.g. rhinosporidosis.

Local causes…

3. Foreign bodies Non-living: any neglected foreign body,

rhinolith. Living: maggots, leeches.4. Neoplasm of nose and paranasal sinuses. Benign: haemangioma, papilloma. Malignant: carcinoma or sarcoma.5. Atmospheric changes. High altitudes, sudden

decompression (Caisson’s disease).6. Deviated nasal septum.

Local causes…

Nasopharynx

1. Adenoiditis

2. Juvenile angiofibroma

3. Malignant tumours

General causes

1. Cardiovascular system- hypertension, arteriosclerosis, mitral stenosis, pregnancy (hypertension and hormonal).

2. Disorders of blood and blood vessels- Aplastic anaemia, leukemia, thrombocytopenic and vascular purpura, haemophilia, Christmas disease, scurvy, vitamin K deficiency, hereditary haemorrhagic telangectasia.

3. Liver disease- hepatic cirrhosis (deficiency of factor

General causes…

4. Kidney disease- chronic nephritis

5. Drugs- excessive use of salicylates and other analgesics, anticoagulant therapy.

6. Mediastinal compression

7. Acute general infection- influenza, measles, chickenpox, whooping cough, rheumatic fever, infectious mononucleosis, typhoid, pneumonia, malaria, dengue fever.

8. Vicarious menstruation.

Sites of epistaxis

Little’s areaAbove the level of middle turbinateBelow the level of middle turbinatePosterior part of nasal cavityDiffuse- both from septum and

lateral nasal wall.Nasopharynx

Classification

Anterior epistaxis More common Mostly from Little’s area or

anterior part of lateral wall Mostly occurs in children

or young adults Mostly trauma Usually mild, can be easily

controlled by local pressure or anterior pack

Posterior epistaxis Less common Mostly from

posterosuperior part of nasal cavity

After 40 years of age Spontaneous; often due

to hypertension or arteriosclerosis

Bleeding is severe, requires hospitalization; postnasal pack often required

ManagementIn any case of epistaxis, it is important to know: Mode of onset. Spontaneous or finger nail trauma. Duration and frequency of bleeding. Amount of blood loss. Side of nose from where bleeding is occurring. Whether bleeding is of anterior or posterior type. Any known bleeding tendency in the patient or family. History of known medical ailment (hypertension,

leukemias, mitral valve disease, cirrhosis, nephritis). History of drug intake (analgesics, anticoagulants,

etc.).

First aid

Little’s area- pinching the nose with thumb and index finger for about 5 minutes- compression of vessels.

Trotter’s method- patient is made to sit, leaning a little forward over a basin to spit any blood, and breathe quietly from mouth- cold compresses should be applied to nose to cause reflex vasoconstriction.

Cauterisation

Useful in anterior epistaxis.The area is first anaesthetised and the

bleeding point cauterised with a bead of silver nitrate or coagulated with electrocautery.

Anterior nasal packing

If bleeding is profuse and/or the site of bleeding is difficult to localise, anterior packing is done.

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

It is required for patients bleeding posteriorly into the throat.

A postnasal pack is first prepared by tying three silk ties to a piece of gauze rolled into the shape of a cone.

Endoscopic cautery

Posterior bleeding point can sometimes be better located with an endoscope.

It can be coagulated with suction cautery.Local anaesthesia with sedation may be

required.

Elevation of Mucoperichondrial flap and 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.

Ligation of vessels

a) External carotid- above the origin of superior thyroid artery.

b) Maxillary artery- approach is via Caldwell-Luc operation.

c) Ethmoidal arteries- in anterosuperior bleeding above the middle turbinate.

General measures in epistaxis

Make the patient sit up with a back rest and record any blood loss taking place through spitting or vomiting.

Reassure the patient. Mild sedation should be given. Keep check on pulse, BP and respiration. Antibiotics may be given to prevent sinusitis, if pack is to

be kept beyond 24 hours. Intermittent oxygen may be required in patients with

bilateral packs because of increased pulmonary resistance from nasopulmonary reflex.

Investigate and treat the patient for any underlying local or general cause.

Hereditary Haemorrhagic Telangectasia

It occurs on the anterior part of nasal septum and is the cause of recurrent bleeding.

It can be treated by using Argon, KTP or Nd: YAG laser.

Some cases require septodermoplasty where anterior part of septal mucosa is excised and replaced by a split skin graft.