Epistaxis

EPISTAXIS
BLOOD SUPPLY OF NOSE
  • INTERNAL CAROTID SYSTEM
  1. Anterior ethmoidal artery
  2. Posterior ethmoidal artery
  • EXTERNAL CAROTID SYSTEM
  1. Sphenopalatine Artery-Also known as artery of epistaxis.
  2. Greater palatine artey
  3. Superior Labial branch of the facial artery
COMMON SITES OF EPISTAXIS
  • LITTLE'S AREA OR KIESSELBACH'S PLEXUS
  1. Situated in the anteroinferior part of nasal septum, just above the vestibule
  2. Most common site of epistaxis in children
  3. Site of origin of bleeding polypus (hemangioma) of nasal septum
  4. Four arteries anastomose here
  • Anterior ethmoidal artery
  • Septal branch of sphenopalatine artery
  • Septal branch of greater palatine artery
  • Septal branch of superior labial artery
  • Retrocolumellar vein — common site of venous bleeding in young people
WOODRUFF'S PLEXUS
  1. Site of epistaxis in elderly
  2. Posterior epistaxis occurs from Woodruff's plexus.
  3. Located posterior to middle turbinate
  4. 3 arteries anastomose here
  • Sphenopalatine artery
  • Ascending pharyngeal artery
  • Posterior nasal artery
CAUSES OF EPISTAXIS A. Local
  • Congenital-Multiple Telangiectases
  • Traumatic-head or facial trauma,postoperative,picking the nose,Nasal Hematoma
  • Inflammatory-Rhinitis/Sinusitis,Vestibulitis,Diphtheria,Atrophic Rhinitis,Rhinitis Sicca,Rhinosporidiosis,Tuberculosis,Syphilis,Leprosy,Wegener's Granulomatosis
  1. M/C cause of epistaxis in 3 years old child is Upper respiratory catarrh.
  2. Wegener's Granulomatosis is characterized by vasculitis of the upper respiratory tract (serious otitis media and epistaxis), vasculitis of the lower respiratory tract (hemoptysis) and vasculitis of the kidney (proteinuria) ,with or without presence of ANCA and rheumatoid factor .
  • Neoplasms-Angioma From Nasal Septum,Nasopharyngeal Angiofibroma/Carcinoma,Malignancy in Maxillary sinus/ethmoidal sinus.
  1. In ulcerative form of nasopharyngeal carcinoma, epistaxis is the common symptom.
  2. Squamous cell carcinoma is the commonest nasopharyngeal malignancy in a middle aged man presenting with epistaxis, serous otitis media with hearing loss,otalgia and a history of infectious 
  3. mononucleosis few weeks earlier.
  4. Diagnosis in a 15 year old child with unilateral nasal obstruction along with a mass in cheek and profuse and recurrent epistaxis is Juvenile Nasopharyngeal Angiofibroma
  5. Miscellaneous-Foreign bodies,Rhinolith,Maggots in nose
  6. In a 5-year-old child, most common cause of unilateral epistaxis is Foreign Body
B. Systemic
  • Hypertension
  • Epistaxis in elderly person is common in Hypertension.Posterior epistaxis is commonly seen in Hypertension.
  • Bleeding disorders-Leukemia,Hemophilia,Purpura, Vitamin C deficiency,Hereditary telengiectasia
  • Recurrent epistaxis in a 15-year-old female, the most common cause is Hematopoietic Disorder.
  1. Epistaxis can be a feature of Henoch Schonlein Purpura along with tetrad of palpable purpura, arthritis, glomerulonephritis and abdominal pain.
  2. Individuals with a positive bleeding history(Recurrent Epistaxis,Hematuria,Hematochezia), particularly with features such as delayed bleeding, umbilical stump bleeding or miscarriages and in whom the initial panel of screening test is negative, should be tested for Factor XIII deficiency.
  3. Increased pressure in Superior vena cava due to Mitral stenosis or Superior Mediastinal Tumours
  • Infections-Viral fever,Enteric fever,Rheumatic fever
  • Drugs-Salicylates,Anticoagulants
  • Chronic renal failure,liver disease
TYPES OF EPISTAXIS
  • ANTERIOR EPISTAXIS
  • More common
  • Mostly from Little's area
  • Usually in children or young adults
  • Usually due to trauma
  • Bleeding is usually mild, can be controlled by local pressure or anterior pack
POSTERIOR EPISTAXIS
  • Less common
  • Mostly from Woodruff's area
  • Usually > 40 years
  • Usually spontaneous, due to hypertension or arteriosclerosis
  • Bleeding is severe, requires hospitalization, postnasal pack often required
  • TREATMENT OF EPISTAXIS
A.Specific cause
B.First-Aid-

  • Bleeding from Little's area can be easily controlled by pinching the nose with thumb and index finger for about 5 mins
  • Trotter's method: patient made to sit, leaning a little forward over a basin to spit any blood and breathe quietly from the mouth.
  • Ice or Cold pack application on the bridge of nose may arrest the bleeding by relefx vasoconstriction
C. ocal management
  • Cauterization — in anterior epistaxis, when bleeding point has been located
  • Nasal packing-Anterior or posterior.
D.
  • Correction of Hypertension,Blood loss.
  • In case of epistaxis due to Hypertension, management is Observation and control of hypertension
  • Coagulants in case of coagulation disorder
  • Aminocaproic acid would be recommended for a hemophilic child with Epistaxis and oral bleeding.
E. Surgical management
  • SMR for persistent or recurrent bleeds
  • Treatment of choice in recurrent epistaxis in a patient with hereditary hemotelangiectasis is Septal dermatoplasty.
  • Management of Septal Hematoma in a child presenting with recurrent epistaxis after fall injury is Incision and Drainage
  • Endoscopic cautery — if posterior bleeding point is located
  • Ligation of vessels
  1. External carotid — when conservative measures have failed, external carotid artery is ligated above the origin of superior thyroid artery. Avoided these days in favor of embolization or ligation of more peripheral branches
  2. Maxillary artery — in uncontrolled posterior epistaxis
  3. In case of uncontrolled epistaxis, ligation of internal maxillary artery is to be done in the Pterygopalatine fossa.
  4. Ethmoidal arteries — in anterosuperior bleeding above middle turbinate
  5. Ethmoidal artery may be responsible for epistaxis after ligation of external carotid artery.
  6. Transnasal Endoscopic Sphenopalatine artery ligation (TESPAL)
  7. If posterior epistaxis cannot be controlled, Sphenopalatine artery artery is ligated
Exam Question
  • In ulcerative form of nasopharyngeal carcinoma, epistaxis is the common symptom.
  • Ethmoidal artery is responsible for epistaxis after ligation of external carotid artery..
  • Management of Septal Hematoma in a child presenting with recurrent epistaxis after fall injury is Incision and Drainage
  • An 70 yrs aged patient with epistaxis , patient is hypertensive with B.P = 200/110 mmHg. On examination no active bleeding noted, next step of management is Observation and control of hypertension.
  • Squamous cell carcinoma is the commonest nasopharyngeal malignancy in a middle aged man presenting with epistaxis, serous otitis media with hearing loss,otalgia and a history of infectious mononucleosis few weeks earlier.
  • Epistaxis can be a manifestation of Vitamin C deficiency.
  • Epistaxis can be a feature of Henoch Schonlein Purpura along with tetrad of palpable purpura, arthritis, glomerulonephritis and abdominal pain.
  • Individuals with a positive bleeding history(Recurrent Epistaxis,Hematuria,Hematochezia), particularly with features such as delayed bleeding, umbilical stump bleeding or 
  • miscarriages and in whom the initial panel of screening test is negative, should be tested for Factor XIII deficiency.
  • Aminocaproic acid would be recommended for a hemophilic child with Epistaxis and oral bleeding.
  • M/C cause of epistaxis in 3 years old child is Upper respiratory catarrh.
  • In a 5-year-old child, most common cause of unilateral epistaxis is Foreign Body.
  • Recurrent epistaxis in a 15-year-old female, the most common cause is Hematopoietic Disorder.
  • Epistaxis in elderly person is common in Hypertension.
  • Systemic causes of epistaxis are Hypertension ,Anticoagulant treatment and Hereditary telangiectasia.
  • If posterior epistaxis cannot be controlled, Sphenopalatine artery artery is ligated.
  • In case of uncontrolled epistaxis, ligation of internal maxillary artery is to be done in the Pterygopalatine fossa.
  • Treatment of choice in recurrent epistaxis in a patient with hereditary hemotelangiectasis is Septal dermatoplasty.
  • Allergic rhinitis does not cause epistaxis.
  • Posterior epistaxis is commonly seen in Hypertension.
  • Posterior epistaxis occurs from Woodruff's plexus.
  • Diagnosis in a 15 year old child with unilateral nasal obstruction along with a mass in cheek and profuse and recurrent epistaxis is Juvenile Nasopharyngeal Angiofibroma.
  • Sphenopalatine Artery is known as artery of epistaxis.
  • Wegener's Granulomatosis is characterized by vasculitis of the upper respiratory tract (serious otitis media and epistaxis), vasculitis of the lower respiratory tract 
  • (hemoptysis) and vasculitis of the kidney (proteinuria) ,with or without presence of ANCA and rheumatoid factor .
  • Rhinolith can cause Epistaxis.
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