Epistaxis, or nosebleed, is bleeding from inside the nose. The nose is richly supplied by blood vessels. Common causes of epistaxis include local trauma, infections, tumors, high blood pressure, bleeding disorders, and medications like anticoagulants. Symptoms are nasal bleeding and blood draining from the nose or throat. Treatment depends on severity but may include pinching the nose, nasal packs, cauterization, surgery, or embolization to stop bleeding vessels. Proper diagnosis involves history, exam, and tests to identify underlying causes and guide management.
6. Nasal septum
1.Internal carotid system
a) Anterior ethmoidal artery branches of ophthalmic artery
b) Posterior ethmoidal artery
7. Nasal septum
2. External carotid system
a) Sphenopalatine artery(branch of maxillary artery) gives
nasopalatine and posterior medial nasal branches.
b) Septal branch of the greater palatine artery (branch of
maxillary artery)
c) Septal branch of superior labial artery( Branch Of facial
artery)
8. Lateral walls of the nose
1. Internal carotid system
a) Anterior ethmoidal artery branches of ophtalmic artery
b) Posterior ethmoidal artery
9. Lateral walls of the nose
2. External carotid system
a) Posterior lateral nasal branches From
Sphenopalatine artery .
b) Greater palatine artery From maxillary artery
c) Nasal branch of anterior superior dental from
infraobital branch of maxillary artery
d) Branches of facial artery to nasal vestibule
10. BLOOD SUPLY OF NOSE
LATERAL
NOSE
SEPTUM
LATERAL NOSE
INTERNAL
CARROTID
EXTERNAL
CAROTID
Maxillary
artery
Ophthalmic
artery
Facial
artery
SUPERIOR
LABIAL
ANTERIOR
ETHMOIDAL
SEPTAL
BRANCH
greater
palatine
artery
Sphenop
alatine
artery
Posteri
or
lateral
nasal
branch
es
POSTERIOR
ETHMOIDAL
11. Little’s Area/“Kiesselbach’s
plexus”
• Is formed by anastomoses 4 arteries
–Anterior ethmoidal artery ,
–septal branch of superior labial,
–Septal branch of sphenopalatine and
–greater palatine artery,
• and situated in anterior inferior part of the
nasal septum just above the vestibule.
13. Retrocolumellar vein
• Runs vertically down behind the columella ,
crosses the floor of the nose and join the
venous plexus on the lateral nasal wall.
• This is a common site of venous bleeding in
young people
14. Woodruff’s Area
• Is a vascular area situated under the posterior
end of the inferior turbinate where
sphenopalatine artery anastomoses with
posterior pharyngeal artery . Posterior
epistaxis may occur at this area
16. A. Local causes
• Nose
1. Trauma ;
E.g
– finger nail trauma(nose
picking),
– injuries to the nose(blow
to the nose,pen or pencil
in,stick ,knife ect
– fracture of middle 3rd of
the face and base of
skull,
– hard blowing of the
nose,
– voilent sneezing
17. 2. Infections
acute; viral or allergic rhinitis , nasal diphtheria , acute sinusitis.
chronic; all crust forming disease e.g. atrophic rhinitis, rhinitis sicca,
tuberclosis , syphilis septal perfuration , rhinosporidiosis
(granulomatous lesion of the nose)
18. 3. Foreign bodies
non living;
•any neglected foreign
body,
• rhinolith .
Living ;
•maggots,
•leeches
19. 4. Neoplasms of the nose and paranasal
sinuses
Benign; haemangioma, papiloma.
Malignant; carcinoma or sarcoma.
24. 1. Cardiovascular system
• Hypertension ,
• arteriosclerosis,
• mitral stenosis ,
• pregnancy {hypertension and hormonal},
• heart failure{due to venous pressure}
25. 2. Disorders of blood and blood vessels
• Aplastic anemia,
• leukemia,
• thrombocytopenic and vascular purpura,
• hemophilia,
• Christmas disease,
• scurvy,
• vitamin K deficiency,
• hereditary hemorrhagic telangectasia,
• von-willebrand’s disease
26. 3. Liver disease;
hepatic cirrhosis{deficiency in factor II,
VII , IX , and X}
4. Kidney disease;
Chronic nephritis
27. 5. Drugs
•Excessive use of salicylates and other
analgesics,anticoagulants,insufflared drugs e.g.
chronic cocain abuse
6. Mediastinal compression;
Mediastinal tumours raising venous pressure in
the nose
28. 7. Acute general infection
Influenza, measles, chicken-pox, whooping cough,
rheumatic fever, infectious mononucleosis, typhoid,
pneumonia, malaria, dangue fever
8.Evernomation(snake bites
By mambas , taipans , kraits and death adders
29. 9. Low relative humidity of inhaled air e.g. cold
winter,nasal cannuler in oxygen delivery
10. Nasal spray{prolong improper use of steroids}
11. Vicatrious menstration
32. PATHOPHYSIOLOGY
• Due to the rupture of a blood vessel within the richly
perfused nasal mucosa. May be
– spontaneous or
– initiated by trauma.
• Occurs in 60% population
• peak incidences…… <10yr olds and >50 and
• Male > females.
• Increase in BP(e.g. due to general hypertension)
tends to increase the duration of spontaneous
epistaxis..
33. PATHOPHYSIOLOGY
• Anticoagulant medication and disorders of blood clotting
can promote and prolong bleeding.
• Spontaneous epistaxis is more common in the elderly as
the nasal mucosa (lining) becomes dry and thin and blood
pressure tends to be higher.
• The elderly are also more prone to prolonged nose bleeds
as their blood vessels are less able to constrict and control
the bleeding.
34. PATHOPHYSIOLOGY
• majority occur in ANTERIOR(front) part of the nose
from the nasal septum whichis richly endowed with
blood vessels (Kiesselbach's plexus/Little's area).
• POSTERIOR nasal bleed is usually due to rupture of
the sphenopalatine artery .Often prolonged and
difficult to control.
• associated with bilateral nasal bleeding with a greater flow of
blood into the mouth.
36. Signs
• General:
– pale, drowsy, unconscious or semiconscious, BP is high or low or
normal, high pulse or weak pulse, generalised lymph nodes
• Nose;
– nasal bleeding
– Deviated nasal bridge
– Blood in nasal cavity
– Enlarged and congested nasal turbinate
– Mass in nasal cavity
• Throat : post nasal drip. Blood on pharynx
• EAR: Normal/dull
• HEAD AND NECK : Asymmetry of head, cervical
lymph nodes
37. Management
History
• Controlling bleeding and or hemodynamic instability
should take precedence over obtaining a lengthy history.
• Note duration, severity and the side of initial bleeding.
• CVS : Palpitation, easy fatigability, dizziness
• PMHX; epistaxis, hypertension, hepatic or other systemic
disease,
• family HX:, easy bruising, or prolonged bleeding after
minor surgical procedures.
38. History
• Recurrent episodes of epistaxis, even if self-
limited, should raise suspicion for significant
nasal pathology.
• DRUG HX;
• aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs),
warfarin, heparin, ticlopidine, and dipyridamole should
be documented, as these not only predispose to
epistaxis but make treatment more difficult.
39. Physical examination
• Pale, pulse, BP, Temperature
• 90% of bleeding are visualized in the anterior portion of the nasal
cavity.
• Blood dripping from the posterior nasopharynx confirms a nasal
source.
• Perform a thorough and methodological examination of the nasal
cavity.
– Blowing the nose decreases the effects of local fibrinolysis and removes
clots, permitting a better examination.
– Application of a vasoconstrictor prior to the examination may reduce
hemorrhage and help to pinpoint the precise bleeding site.
– Topical application of a local anesthetic reduces pain associated with
the examination and nasal packing.
40. Physical examination
• Gently insert a nasal speculum and spread the
nares vertically. This permits visualization of most
anterior bleeding sources.
• A posterior source is suggested by failure to
visualize an anterior source, by hemorrhage from
both nares, and by visualization of blood draining
in the posterior pharynx
43. Treatment
• Epistaxis and other hemorrhages of the head and neck are
treated with first aid, cautery, packing, surgical procedures,
and embolization.
1. First aid : pinching the nose for about 5min, leaning
forward, and using a nasal sprays or ointments that keep
the area moist.[ TROTTER’S METHOD],ICE pack on nose
2. Cautery ; is the use of a caustic substance (silver nitrate)
or an electrical instrument to seal the site of the
hemorrhage and induce clotting.
44. Treatment
3. Packing is the insertion of gauze or an inflatable
balloon into the sinuses to keep the area moist and
apply pressure to the site of hemorrhage, but this
treatment can be uncomfortable and may lead to
infection.
45. Treatment
4. Surgical procedures,
• septoplasty
• arterial ligation, in which an artery, such as the external
carotid artery, the internal maxillary artery, or the ethmoid
artery, is constricted with either cautery or a small metal
clip.
5. Embolization :
• involves the insertion of a catheter, or tube, through an
artery in the groin. The tube is guided up through the blood
vessels to the site of the epistaxis, where it delivers small
particles of a spongy material that embolize, or clog up, the
artery. This material eventually will break down.
• Alternatively, small pieces of soft flexible platinum wire that
induce clotting may be used to embolize the artery.
49. Anterior nasal packing
• Packing of the anterior nasal cavity using gauze strip
impregnated with petroleum jelly.
– A. Gauze is gripped with bayonet forceps and inserted into
the anterior nasal cavity.
– B. With a nasal speculum (not shown) used for exposure,
the first packing layer is inserted along the floor of the
anterior nasal cavity. Forceps and speculum then are
withdrawn.
– C. Additional layers of packing are added in an accordion-
fold fashion, with the nasal speculum used to hold the
positioned layers down while a new layer is inserted.
Packing is continued until the anterior nasal cavity is filled.
51. Posterior nasal packing
• ILLUSTRATION BY CHRISTY KRAMES
• Posterior nasal packing.
• A. After adequate anesthesia has been obtained, a catheter is passed
through the affected nostril and through the nasopharynx, and drawn out
the mouth with the aid of ring forceps.
• B. A gauze pack is secured to the end of the catheter using umbilical tape or
suture material, with long tails left to protrude from the mouth.
• C. The gauze pack is guided through the mouth and around the soft palate
using a combination of careful traction on the catheter and pushing with a
gloved finger. This is the most uncomfortable (and most dangerous) part of
the procedure; it should be completed smoothly and with the aid of a bite
block (not shown) to protect the physician’s finger.
• D. The gauze pack should come to rest in the posterior nasal cavity. It is
secured in position by maintaining tension on the catheter with a padded
clamp or firm gauze roll placed anterior to the nostril. The ties protruding
from the mouth, which will be used to remove the pack, are taped to the
patient’s cheek.
52. conclusion
• Epistaxis most often is mild but can be life
threatening.
• Causes are many and can therefore a detailed
history,physical examination and investigations are
inportant in treating a patient
• Surgical Treatment depends or the surgical skill of
the doctor and options available to him
