SILAR KHAN MAYANA

Introduction and History

Acute hemorrhage from the nostril, nasal

cavity, or nasopharynx is called epistaxis

60% of people have a nosebleed at some
point in their life.
About 10 % of nose bleeds are serious and
require specialist care.

REASONS FOR
EXCESSIVE BLEEDING
Vascularity of nose
Both external and internal carotids.
Anastomosis between arteries and veins.
Blood vessels run just under the

mucosa-unprotected.
Larger vessels on the turbinate run in
bony canals- cannot contract.

Frank Netter. Ciba

Frank Netter. Ciba

Kiesselbachs Plexus
a.k.a
Littles
area
1/2 inch
from the caudal border of
the septum antero-inferiorly.
Vessels anastomosing are; Anterior
ethmoid, greater palatine, and
sphenopalatine, and septal branch
of superior labial.

Kisselbachs Plexus

Underlying Causes
Local irritation
Use of ASA or NSAIDS
Hypertension
Coagulapathies / Bleeding disorders
Platelet dysfunction

Underlying Causes
Allergies
Malignancy
Systemic disease such as granulomatous

disease(Wegeners sarcoidosis)
Hereditary hemorrhagic
telangiectasia(Osler-Weber-Rendu
syndrome)
Cirrhosis, Renal Failure

Underlying Causes Trauma

Nose picking
Nose blowing/sneezing
Nasal fracture
Nasogastric/nasotracheal intubation
Trauma to sinuses, orbits, middle ear, base of

skull
Barotrauma

Underlying causes Iatrogenic nasal injury

Functional endoscopic sinus surgery
Rhinoplasty
Nasal reconstruction

Local Factors
Cold, dry airmore common in wintertime
Dry heat
Nasal oxygen
Anatomic abnormalities
Atrophic rhinitis
Nasal septal deviation
Nasal septal perforation

Initial Management
ABCs
Medical history/Medications
Vital signsneed IV?
Physical exam
Anterior rhinoscopy
Endoscopic rhinoscopy

Laboratory exam
Radiologic studies

Laboratory Studies
CBC
PT / PTT
Bleeding Time

14

Treatment
IV Access
IV Fluids
Blood or Blood product transfusion
Control of hypertension
Correct coagulapathy
FFP, Vit. K, Protamine

Basic Treatment
Make the patient sit up, pinch nose,

open mouth and breath.

Ice on fore head and or gargle ice

water

16

Ask the Patient

Patients will almost always tell you the

side of bleeding
Which side did it start on
Was in coming out the front or draining
down the throat
Nosebleeds rarely have bilateral sources

Anterior or Posterior
Anterior
Bright

red blood from front of nose

Posterior
Nausea, hematemesis, anemia,
hemoptysis or melena.
No visualized anterior source of
bleeding
Post nasal drip of blood

Treatment
Be Prepared
Adequate equipment to the bedside
Headlight
Nasal

Speculum
Suction
Packs
Cautery
Anesthetic

19

Treatment
Locate the point after packing the nose

with 4% xylocaine and oxymetazoline

Suction the Nose
Have patient blow clots out of the nose

CAUTERIZATION
Chemicals
Silver Nitrate stick

Electrical
Bovie
Bipolar

Avoid bilateral or excessive

cautery

22

Nasal packs
Anterior nasal packs
Merocel Nasal Tampon
Vaseline Gauze
Inflatable Packs
Surgicel or Gelfoam

Posterior Epistaxis
Packing

Posterior Epistaxis
Packing

Epistaxis - Complications
Sinusitis
Possibility of airway obstruction
Toxic shock syndrome
Septal hematoma or abscess
Septal perforation
Loose pack obstructing the airway
Nasal scarring or stenosis
Alar necrosis

Treatment after Packing

Removed as soon as possible
Typically 3-5 days
Antibiotics

Posterior or bilateral packing requires admission

Transfuse
Continue treatment of underlying condtions
Oxygen

ICU Admit

Other Treatments
Surgery / embolization
Indications
Continued bleeding with packing
Required transfusion
Nasal anomaly precluding packing
Patient intolerance to packing
Posterior bleed vs. failed medical

mgmt after >72hrs

Surgery
Ligation of vessels
Maxillary artery
Ethmoid arteries
External Carotid artery

Transmaxillary artery
ligation
Electrocautery of posterior wall before

removal
Microscopic dissection and ligation of IMA
--descending palatine & sphenopalantine most
important
Recurrence rate (failure rate) of 10-15%
Complication rate of 25-30% (oa
fistula,dental, n)
Imax ligation now done commonly through
endoscopic approach

Transnasal Endoscopic
Sphenopalatine
Artery
Follow Middle Turbinate to posteriormost
aspect
ligation
Vertical mucoperiosteal incision 7-8mm

anterior to post middle turb (between mid.

and inf. turbs)
Elevation of flap neurovascular bundle at
foramen
Ligation with titanium clip
Reapproximate flap
Complications few, Failures0-13%

ECA ligation
Effectiveness
Anterior border of SCM
ID ECA/ICA
Ligation after clear that surrounding

structures are safe.

Selective
Angiography/embolization
Helps identify location of bleeding
Embolization most effective in patients who
Still bleeding after surgical arterial ligation
Bleeding site difficult to reach surgically
Comorbidities prohibit general anesthetic

Effective only when bleeding is >.5 ml/min

90+% success rate, complication rate of 0.1%
Only able to embolize external carotid & branches
Complications: minor (18-45%)/major (0-2%)
Contraindicated in bad atherosclerosis, Ethmoid

bleed

Treatment after
Discharge
Humidity/emolients
Discontinue offending meds
Nasal saline sprays
Avoidance of nose picking/blowing
Sneeze with mouth open
Avoid straining/bedrest

Refrences
Textbook of E.N.T by Dr. Dhingra
Essentials of E.N.T by Dr. Hazarika
Textbook of E.N.T by Dr. Mohan Bansal
Self Assesment AIPGME by Dr. Arvind Arora