Epistaxis & its management- Dr.Ashly Alexaander

1. EPISTAXIS
Dr.ASHLY ALEXANDER
DEPT OF ENT
GMC,BHOPAL

2. “ Acute Hemorrhage from the Nostril,
Nasal Cavity or Nasopharynx”

3. Vascular anatomy of the nose
External Carotid Artery
FacialArtery
Superior Labial
Lateral Nasal
Ascending Palatine
Maxillary Artery
Greater Palatine
Sphenopalatine
Lateral Nasal
Posterior Septal
Internal Carotid Artery
Anterior Ethmoidal
Posterior Ethmoidal

4. KIESSELBACH’S PLEXUS
(Little’s area)
• In anterior inferior
part of nasal septum
• Most common site for
Epistaxis
• Mainly anterior
epistaxis
1. septal br. Of
sphenopalatine
2. Anterior ethmoidal
3. Septal br. Of superior
labial
4. greater palatine
arteries

5. WOODRUFF’S PLEXUS
• Posterior end of inferior Turbinate
• Venous plexus
• Most common site for posterior
epistaxis

6. CLASSIFICATION
• Primary – no proven causal factor
• Secondary- proven causal factor
present

7. CLASSIFICATION
Adult Vs Childhood Epistaxis
1. Childhood Epistaxis <16yrs
2. Adult Epistaxis >16yrs
• There is a pronounced bimodal
distribution in onset of Epistaxis
• More common in childhood, becomes
less common in early adulthood and
peaks again in 6th decade

8. CLASSIFICATION
Anterior Posterior
Incidence More common Less common
Site Little’s Area
or anterior
part of nasal
septum
Posterosuperior
part of nasal cavity
Age Children and
young Adults
>40yrs
Cause Traumatic Spontaneous
Bleeding Mild Severe

9. LOCAL CAUSES
1. Congenital : unilateral choanal atresia, meningocoele,
encephalocoele, hemangioma etc..
2. Acquired :
 INFECTIONS-
 Acute – Viral, Bacterial, Fungal
 Chronic Specific – tuberculosis, Syphylis, Leprosy,
Rhinoscleroma
 Chronic Non specific – Ozoaena
• Inflammatory – Rhinosinusitis, Nasal Polyposis
• Trauma/ Foreign Body(Living/Non-Living)
• Idiopathic
• Neoplastic – Juvenile angiofibroma, etc..
• Drug Induced – Rhinitis Medicamentosa
• Inhalants- tobacco, cannabis, mercury, wood dust,
heroin, chrome, phosphorus

10. SYSTEMIC CAUSES
Hypertension- commonest
Cardiac –CCF, Mitral stenosis
Pulmonary –COPD
Cirrhosis – Vitamin K
deficiency
Renal –Nephritis
Drugs – Excessive use of
salicylates , anticoagulants
Hormonal – Vicarious
Menstruation,
Endometriosis,granuloma
gravidarum
Coagulopathies –
• Clotting disorders
• bleeding disorders
• Agranulocytosis
• Leukemia
• Vitamin K deficiency
• Exanthematous fevers
Idiopathic Causes

11. PATIENT HISTORY
• Previous bleeding episodes
• Onset, duration, frequency, amount of
blood loss
• h/o trauma
• Family history of bleeding
• Hypertension
• Hepatic diseases
• Drug history
• Any other medical ailment

12. MANAGEMENT
• Locate the bleeding site
• Anterior and Posterior rhinoscopy
• Diagnostic Nasal Endoscopy
• INVESTIGATIONS :
Hematological investigations – Hb%, TLC, DLC,
BT, CT,
Platelet count, prothrombin time
Blood urea, liver function tests
Radiology – x-ray and CT scan of nose, PNS and
Nasopharynx
Other investigations depending upon the possible
cause

13. Trotter’s method
• Old fashioned method of controlling
epistaxis
• Pt is made to sit upright with cork
between the teeth and allowing the pt
to bleed till he becomes hypotensive
• Complication – Coronary Artery
Thrombosis

14. Hippocratic Method

15. Direct & indirect therapies
• Treatment may be divided into direct
and indirect therapies
• Direct treatment is logically and
theoretically superior
• Indirect therapy should be resorted
when bleeding point cannot be identified
or bleeding is uncontrolled/profuse

16. Direct therapy
• Anterior Epistaxis can be easily controlled
with identification of the bleeder and
cauterizing it with silver nitrate cautery or
cautery with Trichloraceticacid(TCA)
• Posterior Epistaxis can be identified by
nasal endoscopy and cauterized with
bipolar cautery
• Direct method is more cost-effective as it
facilitates outpatient management and
significantly reduce inpatient stay

17. Cauterization
1. Electrical – with bipolar, Unipolar is
contraindicated as it can cause optic
nerve damage
2. Chemical
a) Silver Nitrate 10%
b) Tricholoroacetic acid 40%
c) Carbolic Acid
3. Thermal
4. Cryotherapy

18. Indirect therapy
• Failure to find bleeding point is an
indication
Various methods are
1. Hot water irrigation – irrigation with
water heated to 500C
2. Systemic medical therapy – Tranexamic
Acid and Epsilon aminocaproic acid
3. Nasal Packing

19. Anterior nasal packing

20. • For this, a ribbon gauze soaked with
liquid paraffin is used.
• About 1 metre gauze (2.5 cm wide in
adults and 12 mm in children) is required
for each nasal cavity.
• Pack can be removed after 24 hours if
bleeding has stopped.

22. POSTERIOR NASAL PACKING
• If bleeding does not stop after anterior
packing-Posterior epistaxis

24. COMPLICATIONS OF NASAL
PACKING
• SEPTAL HAEMATOMA
/ ABSCESS
• SINUSITIS
• PRESSURE NECROSIS
• TOXIC SHOCK
SYNDROME

25. Other methods
• Merocel – A sponge like material placed in nasal cavity. It
helps stop bleeding by providing pressure against the
mucosa and by providing a surface against which the blood
can clot. Pack is introduced in dehydrated state and
expanded by instilling normal saline. It has to be removed
• Gel Foam – An absorbable material with pro-coagulant
properties. Contrary to Merocel it shrinks when it gets
wet and dissolves in matter of weeks. It helps prevent the
bleeding site from desiccation.
• Kaltostat – Sodium-Calcium Alginate containing material
(80:20 ratio). It swells up on absorbing water and it has to
be removed. It controls bleed by providing pressure
• Bivona – double balloon nasal catheter. Provides the effect
of both anterior and posterior packing. Disadvantage –
Balloons tend to inflate towards the path of least
resistance and may fail to provide tamponade at the
affected site.

26. Ligation methods
Ligation is reserved for intractable bleeding
where the source cannot be located or
controlled by techniques mentioned above.
Ligation should be performed as close to the
bleeding point as possible. Thus the
heirarchy of ligation is
• Sphenopalatine artery- ESPAL
• Internal maxillary artery- IMAL
• External carotid artery- ECAL
• Anterior/Posterior Ethmoidal artery

27. Elevation of Mucoperichondrial flap &
SMR operation
• In case of persistent or recurrent
bleeds from the septum, just elevation
of mucoperichondrial flap and then
repositioning it back helps to cause
fibrosis and constrict blood vessels.
• SMR operation can be done to achieve
the same result or remove any septal
spur which is sometimes the cause of
epistaxis.

28. Resuscitation
Initial
Examination
Vessel NOT located
Endoscopy
Indirect Therapy
Eg : Anterior Packs
Continued
Bleeding
Posterior Pack
Septal Surgery
Ligation
(ESPAL)
Continued Bleeding
- Angiography and embolization
- Repeat above steps
Check for secondary factors
Vessel Located
Direct
Therapy
Eg: BipolarBleeding
Controlled
-packs
48hrs
minimum
- Direct,
same day
discharge

29. QUESTIONS
??? ARTERY OF EPISTAXIS
??? MC ARTERY TO BLEED IN
ENDOSCOPIC SURGERIES
??? MCC OF EPISTAXIS IN CHILDREN
??? MCC OF EPISTAXIS IN ELDERLY

30. ??? U/L EPISTAXIS IN ELDERLY MAY
BE THE FIRST SYMPTOM OF--
??? MAIN D/D OF EPISTAXIS IN
ADOLESCENT MALE
??? ARTERY NOT TAKING PART IN
KEISSELBACH’S PLEXUS
??? DIVIDING LINE BETWEEN ANT &
POST BLEED

31. ??? MC SITE OF BLEEDING IN NASAL
CAVITY