Etiology, evaluation and management of epistaxis

1. EPISTAXIS
Dr. AVINASH MALEKAR
GMC Nagpur

2. Epistaxis, derived from the Greek term
epistazein, is defined as bleeding from the
nose

3. HISTORY
Hippocratic technique
Pilz (1869)= 1st surgically
treated epistaxis (Ligation of CCA)
James Little (1879)
Wilhem Kisselbach

4. Saiffert (1928)= via maxillary sinus ligated
internal maxillary artery
Woodruff (1949)
Sokoloff= first undertook angiographic
embolisation for epistaxis in 1972

5. Vascular supply of nasal cavity
Various anastomoses on the ipsilateral side between
the internal and external carotid systems exist as well
as crossover to the contralateral side
Knowledge of these anastomosis is important in
addressing most distal site of bleeding

6. Vascular supply of nasal cavity

7. Anterior and Posterior ethmoidal arteries

8. Sphenopalatine artery

9. Common bleeding sites
1. Little’s area
2. Woodruff’s plexus
3. Retrocolumellar vein

10. Little’s area

11. Woodruff plexus

12. Retrocolumellar vein
Run 2mm behind and parallel to columella
Common cause of venous epistaxis in children

13. Classification of epistaxis

14. Anterior epistaxis Posterior epistaxis
More common Less common
Mostly occurs in children
and young adults
After age of 40 years
Mostly from Little’s area or
anterior part of lateral wall
Mostly from
posterosuperior part of
nasal cavity
Cause= Mostly trauma Cause= Spontaneous
Bleeding is mild and
controlled by local pressure
or anterior pack
Bleeding is severe
Require hospitalization
Postnasal pack often
required

15. Epistaxis
Anterior epistaxis Posterior epistaxis

16. Local causes

17. Systemic causes
Hypertension: No direct causal relationship
Altered clotting abilities= Drugs (NSAIDs, apsirin,
clopidogrel), Liver disease
Inherited blood diatheses= Hemophilia (Factor VIII
deficiency), Von Willebrand’s disease
Hereditary hemorrhagic telengiectasia (HHT)
- Autosomal dominant
- widespread cutaneous, mucosal and visceral
telengiectasia

18. Approach to a patient with epistaxis
A} History of epistaxis
- Onset - Frequency
- Duration - Quantity
- Uni/Bilateral - Previous episodes
- Hematemesis/Hemoptysis
B} History of
- Trauma - Exanthematous fever
- Foreign body - Bleeding disorders
- Hypertension - Drug intake

19. C} Examination of nose and PNS
D} Systemic examination
E} Blood investigations= BT,CT, Coagulation
profile
F} Radiological investigations= X ray, CT scan
G} Biopsy
E} Endoscopy

20. Management of epistaxis
1. Establish the site of bleeding
2. Stop the bleeding
3. Treat the cause

21. Management of epistaxis
• Epistaxis
• First aid
• Pinch nose with index and thumb for 5 min
• Trotter’s maneuver

23. If bleeding
continues
• Allay anxiety
• Ice packs over nose
• Quick examination of nose nasopharynx
• Systemic examination
• Exclude general causes
• Anterior/Posterior rhinoscopy/ endoscopy
If bleeding
size
localised
• Cauterization
Silver nitrate
Bipolar diathermy

24. Cauterization
Chemical
Silver nitrate
Thermal
Bipolar suction dithermy

25. If bleeding
still continues
• Anterior nasal packing

27. Merocel nasal tampon

28. • Send blood for Hb, blood counts,
BT, CT, PT, aPTT, Blood group
Bleeding
continues
• Posterior nasal packing

30. Posterior nasal packs
Bivona nasal pack Foley’s catheter

31. Posterior nasal packs
Rapid rhino

32. Complications of nasal packing
Septal hematoma/ abscess
Sinusitis
Pressure necrosis
Toxic shock syndrome

33. Bleeding
continues
• Blood transfusion
• Surgical Mx
• Ligation of arteries (Sphenopalatine artery,
Anterior and posterior ethmoid artery, maxillary
artery ligation, ECA ligation)
• Septal surgeries
• Embolization

34. Endoscopic ligation of sphenopalatine artery

35. Anterior and posterior ethmoidal artery
ligation
Lynch incision (curvilinear
incision halfway between
medial canthus and tip of
the nasal dorsum

36. Maxillary artery ligation
Sublabial approach -
Antrostomy formed
Mucosa of posterior wall
of antrum elevated
Window made through
pterygopalatine fossa
Ligation of maxillary
artery done

37. External carotid artery ligation
Horizontal skin incision is made between the hyoid
bone and the superior border of the thyroid cartilage
Subplatysmal skin flaps are then raised, and the
sternocleidomastoid muscle is retracted posteriorly.
Carotid sheath is opened and its contents exposed
Usually ligated just distal to the superior thyroid
artery

38. Bleeding
continues
• Angiographic
embolization

39. Epistaxis in children
Causes
Common Less common
Idiopathic
Infection
Trauma: Nose
picking
Vestibulitis
Nasal allergy
Local= septal
deformity, tumors
Systemic=
coagulopathies
HHT

40. Guidelines for Management of epistaxis in
children
Expectant treatment in mild cases= Pinching nose, allay
anxiety of child and parents
Petrolium jelly used as primary treatment= forms water
resistant film over affected area
Nasal barrier cream (Chlorhexidine, neomycin)offer
limited benefit
If cautery is considered: Silver nitrate is optimum method
Electrocautery should rarely considered

41. Laser therapy, fibrin glue and septoplasty have limited
role based on individual basis
Neither systemic or local tranexamic acid has any
place in treatment of childhood epistaxis
Endoscopic ligation of arteries have limited role in
children

42. References
Scott-Brown's Otorhinolaryngology: Head
and Neck Surgery 7Ed
Cummings otolaryngology, Head and neck
surgery 5th Ed
Ballenger’s otorhinolaryngology, Head and
neck suregry

43. Thank you