EPISTAXIS

© SWARNADEEP MANI
BLOOD SUPPLY OF NOSE

INTERNAL CAROTID SYSTEM

1. Anterior ethmoidal artery
2. Posterior ethmoidal artery
} Branches of ophthalmic
artery

EXTERNAL CAROTID SYSTEM

1. Sphenopalatine artery (branch of maxillary artery)
2. Greater palatine artery (branch of maxillary artery).
3. Superior labial artery
Blood supply of septum
Blood supply of walls
SITES OF EPISTAXIS
• Little’s area (Ant. & Post. Ethmoidal, Superior labial,
greater palatine arteries)
• Above middle turbinate (Sphenopalatine artery)
• Below middle turbinate (ant. & post. Ethmoidal artery)
• Posterior nasal cavity
• Diffuse
• Nasopharynx

 MC site of anterior epistaxis – Little’s area

 MC site of posterior epistaxis – Woodruff’s plexus
 MC site of venous bleeding – Retrocolumellar vein
 CAUSES OF EPISTAXIS

Epistaxis

Local Systemic Idiopathic

Nose Nasopharynx • CVS

• Kidney
• Liver
• Trauma • Adenoiditis
• Blood
• Foreign body • Angiofibroma
• ↑ CVP
• DNS • Papilloma
• Atmosphere
• Infection
• Tumour
 Epistaxis

Childhood Adult

<16 yrs >16 yrs

MC cause - Trauma MC cause - Hypertension

RELEVANT HISTORY TO BE TAKEN
• Mode of onset – spontaneous / traumatic
• Amount of bleeding
• Anterior / Posterior
• Which side – right / left
• Duration & frequency
• Δ? Blood dyscrasia
• Δ? Systemic disease
FIRST AID
 Pinch nose between index and thumb for 5 minutes
 Apply ice pack over dorsum of nose
 Trotter’s method (obsolete) – let the person bleed till he is
hypotensive with a cork between teeth drooping forwards.
 Breathe through mouth
 Keep check on pulse, BP and respiration
 Reassure the patient.
HOSPITAL MANAGEMENT
 Cauterisation under anaesthesia when source is anterior
 Anterior nasal packing
 Posterior nasal packing
 Endoscopic cauterisation
 SMR in cases of recurrent medial wall epistaxis
 Ligation of blood vessel
 External carotid above superior thyroid branch (obsolete)
 Maxillary artery in pterygopalatine fossa
 Ethmoidal arteries
 TESPAL
 Embolization of vessels
 Argon / KTP / Nd-YAG laser ablation of vessels in case of
Hereditary Haemorrhagic Telangiectasia (Osler Weber Rendu
syndrome)
ANTERIOR PACKING

Back to front packing Vertical packing

1. Indications: Active anterior epistaxis. Cauterization of the bleeding
area is tried first. But if bleeding is profuse and the site of bleeding
cannot be localized, anterior nasal packing is done.
2. Method:
 Nose must be cleared of blood clots by suction and forceps.
 One meter long ribbon gauze (width 2.5 cm in adults and 12 mm in
children), which is soaked in liquid paraffin, is packed tightly in each
nasal cavity by layering the gauze from floor to the roof and from
before backwards.
 The initial few centimetres of ribbon gauze are folded upon it and
introduced along the floor.
 If bleeding starts from another nose then posterior nasal bleeding must
be suspected. Either one or both nasal cavities may be packed.
3. Removal: Pack can be removed after 24 hours or after 2–3 days.
4. Packing materials:
 Ribbon gauze
 Merocel Pope
 Kennedy nasal sponges
 Prefashioned anterior nasal balloons
 Gel foam
 Oxidized cellulose (Surgicel).
5. Systemic antibiotics are started to prevent infection and toxic shock
syndrome.
POSTERIOR PACKING
1. Indications: Posterior nasal packing is done when cauterization fails
and bleeding site cannot be determined.
2. Methods:
a. Gauze:
 A piece of gauze is rolled into the shape of a cone. Then three silk
ties are tied to this cone-shaped gauze. A rubber catheter is passed
through the nose. Its pharyngeal end is brought out from the mouth
and the silk threads of postnasal pack are tied to it. The catheter
along with the silk threads is gradually withdrawn from nose and
postnasal pack tied with silk threads is guided into the nasopharynx
with the index finger. Anterior nasal cavity is now also packed. The
third silk thread, which is cut short, hangs in the oropharynx and
helps in easy removal of the postnasal packing.
b. Foley’s catheter:
 The bulb is inflated with saline. The catheter is pulled out and
choana is blocked by the inflated bulb. Then anterior nasal packing
is done.
c. Nasal balloon:
 The current variety of nasal balloon has two bulbs, one lies in
postnasal space while another remains in nasal cavity.
 TESPAL
Stands for Transnasal Endoscopic Spheno Palatine Artery Ligation