Epistaxis is the medical term for "nasal bleeding". This ppt is more of use for medical students ....a compilation of all the required knowledge about epistaxis.

1. Epistaxis
Dr. Sushmita Pal
theAurals:your ENT
destination

2. From a Greek term “epistazo” which means “to bleed
from nose”.

3. Anatomy

6. Why nose?
• Situated in a vulnerable position as it protrudes
on the face
• Has a very rich blood supply
• Vasculature runs just under the mucosa
• Exposed to the drying effect of inspiratory
current

7. Epidemiology
• Lifelong incidence of epistaxis in general
population is about 60%
• Fewer than 60% seek medical attention
• Peaks in young children (2 – 10 y) and older
individuals (50 – 80 y)
• Males 58%, females 42%

8. Blood Supply
• Superior part of the nose (Internal carotid artery)
▫ Ophthalmic artery
 Anterior ethmoidal artery
 Posterior ethmoidal artery
• Inferior part of the nose (External carotid artery)
▫ Maxillary artery
 Greater palatine artery
 Sphenopalatine artery
▫ Facial artery
 Superior labial artery  vestibule of the nose

10. Kiesselbach’s Plexus
• Little’s area
• Anteroinferior part of the nasal septum
• Anastomosis between upper and lower arteries
▫ Anterior ethmoidal artery
▫ Posterior ethmoidal artery
▫ Sphenopalatine artery
▫ Greater palatine artery
▫ Septal branch of superior labial artery

11. Woodruff’s Plexus
• Lateral wall of inferior meatus
• Blood vessels have very little muscle tissue
within their walls, therefore hemostasis is poor
• Anastomosis between:
▫ Pharyngeal artery
▫ Posterior nasal artery
▫ Sphenopalatine artery
▫ Posterior septal artery

13. Pathophysiology
• Occurs when mucosa is eroded
• Vessels become exposed and subsequently break

14. Classification
• Anterior
▫ 90% of all cases of epistaxis
▫ Kiesselbach’s plexus
▫ Younger population
▫ Typically less severe
▫ A constant ooze, rather than profuse pumping of
blood

15. • Posterior
▫ Woodruff’s plexus
▫ Older population
▫ Profuse, prolonged and more difficult to control
▫ Associated with bleeding from both nostrils
▫ Greater flow of blood into the mouth
▫ Greater risk of airway compromise and aspiration
of blood

16. Etiology
• Most are idiopathic
• Local causes
▫ Spontaneous
▫ Trauma
 Nose picking/blowing, sneezing, fractures, barotraumas
▫ Foreign bodies
▫ Iatrogenic
 FESS, rhinoplasty, nasal cannula
▫ Inflammation/infection
▫ Tumors
 Polyps, nasopharyngeal carcinoma/angiofibroma
▫ Hereditary telengiectasia
▫ Leech infestation

17. • Systemic causes
▫ Cardiovascular conditions
 Hypertension
 Increased venous pressure
 Mitral valve stenosis, heart failure, mediastinal tumors
▫ Coagulopathies
 Hemophilia, von Willebrand’s disease
 Hepatic cirrhosis
 Anticoagulant therapy
 Thrombocytopenia
▫ Fever (rare)
 Influenza
▫ Drugs
 NSAIDs, aspirin, coumadin, warfarin, isotretinoin, etc

18. ▫ Infection
 Tuberculosis, syphilis
▫ Alcohol
▫ Anemia
▫ Uremia
▫ Connective tissue disorders
 SLE
▫ Hematological malignancy
▫ Vasculitis
 Wegener’s granulomatosis
▫ Vitamin C or K deficiencies
▫ Osler-Weber-Rendu syndrome
▫ Pregnancy
▫ Vicarious menstruation

19. History
• Age
• Onset, duration, severity, frequency
• Bilateral or unilateral
• Preceding factors: exercise, sleep, migraine, trauma
• Bleeding from other sites
• Aggravating and relieving factors
• Nasal discharge
• Medical conditions
• Current medications
• Smoking and drinking habits
• Previous epistaxis, recurrent bleeding, easy bruising
• Family history of bleeding disorders

20. Physical Examination
• Vital signs
• Nasal cavity
• Fiberoptic endoscopy (rigid or flexible)
• Skin examination

21. Management
• Control significant bleeding or hemodynamic
instability before obtaining a lengthy history
• Steps:
▫ First aid and resuscitation
▫ Assess blood loss
▫ Localize bleeding
▫ Control bleeding
▫ Prevention

22. First Aid & Resuscitation
• Address ABC
• Neck should not be hyperextended to prevent
blood flow into the stomach or possible
aspiration
• Trotter’s triad
@ Blood in mouth should not be swallowed
@ Mouth breathing
@ Direct pressure over the cartilaginous part of
the nose
@ 5 – 10 minutes is usually sufficient
• Gauze moistened with epinephrine may be
placed to promote vasoconstriction

23. • Vital signs and signs of shock
• Patient with significant hemorrhage should
receive an IV line and crystalloid infusion and
reptilase/ethamsylate in bolus or infusion
• Cross match for 2 units packed RBC
• Continuous cardiac monitoring and pulse
oximetry

24. Localization of Bleeding
• Pledgets soaked with anesthetic-vasoconstrictor
solution are inserted into the nasal cavity to
anesthetize and shrink nasal mucosa
• Allow them to remain for 10 – 15 minutes
• Visualize cavity with speculum + good light
source
• Aspirate excess blood and clots
• If the bleeding originated from Little’s area, it is
clearly visible

26. • Rigid endoscope is used to localize posterior
bleeding
▫ Superior optics
▫ Allow endoscopic suction and cauterization
• Points suggesting posterior source:
▫ Anterior surface cannot be visualized
▫ Bilateral bleeding
▫ Constant dripping of blood in the posterior
pharynx
▫ Bleeding in the pharynx with the anterior nasal
packing in place

28. Control of Bleeding
• Topical vasoconstrictors
▫ Otrivin (xylomethazoline)
▫ Cocaine
• Chemical cauterization with silver nitrate stick
▫ Rolled over mucosa until a grey eschar forms
▫ Only one side should be cauterized to prevent
septal necrosis or perforation
• Thermal cauterization with an electrocautery
device for more aggressive bleeding under LA or
GA

30. Anterior Nasal Packing
• Roller gauze soaked with petroleum jelly and
an antibiotic ointment
• Success rate 85%

33. Posterior Nasal Packing
• Indications:
▫ Failure of anterior packing
▫ High suspicion of posterior bleeding
▫ Older patient with atherosclerosis
▫ Patient with bleeding diathesis
• Contraindications
▫ Facial trauma
▫ Shock
▫ Altered mental status

34. • Uncomfortable and difficulty in breathing
• Risk of hypoventilation and hypoxia
• Admission, bed rest, sedation
• Supplemental oxygen:
▫ Elderly patients
▫ Cardiac disorders
▫ COPD
• Monitor blood pressure and hemoglobin level
• Control coexistent hypertension

35. • Foley catheter

36. • Double-balloon catheter

37. • Gauze method

38. Surgical Intervention
• Indications:
▫ Bleeding continues despite adequate packing and
resuscitation
▫ Nasal anomaly (septal deviation)
▫ Patient’s refusal or intolerance to packing

39. • Arterial ligation
▫ External carotid artery
▫ Internal maxillary artery transorally or
transnasally
▫ Ethmoidal arteries
▫ Most commonly ligated vessel is
SPHENOPALATINE ARTERY
• Angiography and vessel embolization

40. Prevention
Control of hypertension
Correction of bleeding disorders
Humidifier or vaporizers
Nasal saline sprays, ointment, vaseline
• Avoid hard nose blowing or sneezing
• Sneeze with mouth open
• Avoid nose picking
• Control the use of medications

41. Complications of Epistaxis $ Nasal
packing
• Rhinosinusitis
• Cardiovascular compromise
• Septal perforation
• Toxic shock syndrome
• Hypoxia
• Aspiration pneumonia
• CVA associated with embolization
• Recurrent epistaxis
• Re-bleeding on nasal pack removal

42. Thank You