Epistaxis is bleeding from inside the nose. It is a common ENT emergency that is seen in all age groups. Almost 90% of the population will have an episode of epistaxis.
Plexuses involved in epistaxis
| Plexus | Description |
|---|---|
| Kiesselbach’s plexus | Formed by 4 vessels (anterior ethmoidal, septal branch of the superior labial, septal branch of the sphenopalatine and greater palatine) at Little’s area – anterior-inferior part of the nasal septum just superior to the vestibule. This area is exposed to the drying effect of inspiratory current and finger nail trauma and is the usual site of epistaxis in children and adults. |
| Woodruff’s plexus | Woodruff’s plexus of veins is situated inferior to the posterior end of the inferior turbinate. It is a common site of posterior epistaxis in adults. |
Causes of epistaxis
| Causes of Epistaxis | Examples |
|---|---|
| Idiopathic | 80-85% |
| Local causes | Trauma, Inflammation, Foreign body, Tumors, Deviated nasal septum |
| Systemic causes | Salicylates, Anticoagulants, Mediastinal compression from tumors of the mediastinum, Haematologic disorders, Hypertension, Pregnancy, Chronic Kidney disease, Cirrhosis, Alcohol use |
Anterior vs Posterior Epistaxis
| Anterior epistaxis | Posterior epistaxis | |
|---|---|---|
| Site | Little’s area | Woodruff’s area |
| Bleed type | Arterial | Venous |
| Severity | Mild. Easily controlled by local pressure or packing | Severe. Requires admission and post-nasal pack |
| Age | Children and young adults | > 40 years |
| Cause | Mostly trauma | Spontaneous (often hypertension |
| Blood flow | Blood flows out from the front of the nose in sitting position | Blood flows back into the throat |
- Why does epistaxis happen so commonly?
- Presence of a rich blood supply- nose is supplied by branches of both internal and external carotid arteries
- Various anastomosis
- Blood vessels run unprotected in the nose
- Sites of epistaxis
- Little’s area (90%)
- Above the middle turbinate (anterior and posterior ethmoidal vessels)
- Below the middle turbinate (sphenopalatine artery)
- Posterior nasal cavity
- Diffuse (from both septum and lateral wall – seen in systemic and hematologic disorders)
- Nasopharynx
- Patient History
- Onset: spontaneous or fingernail trauma
- Duration and frequency of bleeding
- Amount of blood loss
- Side of nose where bleeding is occurring
- Whether bleeding is anterior or posterior
- Known bleeding tendency in patient or family
- Medical history (Hypertension, cirrhosis, leukemia, blood dyscrasias)
- History of drug intake (analgesics, anticoagulants)
- First Aid
- Pinch the lower third of the nose for about 5 minutes (to compress Little’s area)
- Irrigate or blow the nose (to remove clots)
- Spray with phenylephrine or oxymetzoline, or cold compress over the nose(to cause vasoconstriction)
- Alternatively, do Trotter’s method: sit and lean head forward over a basin, pinch the nares firmly closing the nostrills and hold the nose for 20 minutes without releasing pressure
- General measures for severe bleed and critically ill patients
- Airway, Breathing and Circulation
- IV access, IV fluids
- Blood for CBC and Group and Crossmatch for possible transfusion
- Monitor Blood Pressure, Pulse rate, and Respiratory rate
- Start with a good light source, nasal speculum, suction, and bayonet forceps
- Suction and Headlight to visualize bleed
- Try to determine the site of bleeding (anterior, superior, or posterior)
- Treatment of anterior epistaxis
- Local Anaesthesia and Cauterization w/ Silver nitrate or Electrocautery if the bleeding point has been localized (avoid deep cautery on both sides simultaneously as this may cause septal perforation)
- Anterior nasal packing with gauze soaked in BIPP (Bismuth Iodine Paraffin Paste) or paraffin oil or vaseline: Horizontal layering (floor to roof), Vertical layering (back to front)
- Remove pack in 24 hours if bleeding has stopped to prevent sinusitis and toxic shock syndrome
- Give systemic antibiotics if packs are to be kept for 2-3 days
- Treatment of posterior epistaxis (consider if anterior pack is not successful)
- Posterior nasal packing OR tamponade with foley catheter/nasal balloon: inflate balloon with saline and pack anteriorly for about 48-72 hours
- Deflate the ballon on day 3 or 4 before removing the anterior pack 1 – 2 days later
- Start with anterior pack
- If anterior pack is not successful place a posterior pack using a Foley with 5 mm balloon
- Leave the pack in place for 3-5 days
- Treatment of massive bleeds when anterior and posterior packs have failed
- Ligation of the vessels
- Maxillary artery (uncontrolled posterior epistaxis)
- Anterior and posterior ethmoidal arteries (via lynch incision for uncontrolled superior epistaxis)
- External carotid artery (uncontrolled anterior epistaxis)
- Endoscopic cauterization
- Embolization
- Elevation of mucoperichondrial flap and submucous resection (SMR – for persistent bleeds from the septum)
- Ligation of the vessels
- What additional measures should be done for patients with bilateral packs?
- Intermittent oxygen in patients with bilateral packs (avoid the nasopulmonary reflex → pulmonary vasoconstriction)
- Medical Treatment
- Vasoconstrictors: Xylometazoline (not for > 5 days)
- Tranexamic acid (5 days for anterior epistaxis)
- Paraffin oil drops (5- 10 days)
- Antibiotic ointment or petroleum jelly to both nostrils nightly and saline spray 3 – 4 times during the day to counter nasal dryness which can result in chronic, intermittent nose bleeds
