4. Little’s Area
• Anterior inferior part of nasal septum, above vestibule
• Four arteries
• Anterior ethmoidal artery
• Septal branch of superior labial artery
• Septal branch of sphenopalatine
• Greater palatine artery
• Exposed to drying effect of inspiratory current
Forms vascular
Plexus
“Kiesselbach’s
plexus”
5. Reterocolumellar Veins
• Runs vertically downwards just behind columella
• Crosses the floor of nose and joints venus plexus on lateral nasal wall
• Common site for venous bleed in young patient
6. Woodruff’s plexus
• Plexus of veins situated inferior to posterior end of inferior turbinate
• Site for posterior epistaxis in adult
7. Introduction to Epistaxis
• Definition
• Bleeding from inside the nose
• About 50% population experience nosebleed in their life but severity
to seek medical consultation in <10%
• Some patients present as an emergency
• Occurs at any age group
• Children usually have mild anterior nasal bleeding while elderly have
profuse posterior nose bleeding
• Males affected more than females but after 50 years both the sexes
affected equally
9. Local causes
• Trauma
• Finger nail trauma
• Injury of nose
• Intranasal surgery
• Fracture of middle third of face and base of skull
• Hard blowing of nose
• Violent sneeze
• Infection
• Acute: viral rhinitis, acute sinusitis, nasal diphtheria
• Chronic: Crust forming Disease(rhinitis sicca, tuberculosis); Granulamatous
lesion of nose(rhinosporidosis)
10. Local cause
• Foreign bodies
• Nonliving: any neglected foreign body
• Living: Maggots, leeches
• Neoplasms of nose and paranasal sinus
• Benign: Hemangioma, papilloma
• Malignant: Carcinoma, sarcoma
• Atmospheric changes(high altitudes, sudden decompression Casisson
disease)
• Deviation of nasal septum
11. General Cause
• Cardiovascular system:
• Hypertension
• Arteriosclerosis
• Mitral stenosis
• Pregnancy(hypertension and hormonal)
• Disorders of blood and blood vessels
• Aplastic anaemia
• Leukemia
• Thrombocytopenia
• Vascular purpura
12. General Cause
• Liver disease
• Hepatic cirrhosis(deficiency of factor II,VII,, IX, and X)
• Kidney disease(Chronic nephritis)
• Drugs
• Saslicylates and other analgesic
• Anticoagulant therapy
• Mediastinal compression(tumor causing raised venous pressure)
• Acute general infection(influenza, measules, whooping cough)
• Vicarious menstruation
13. Sites of Epistaxis
• Little’s area(90% of cases)
• Above level of middle turbinate(anterior and posterior ethmoidal
artery)
• Below level of middle turbinate(from branch of sphenopalatine
artery)
• Posterior part of nasal cavity(blood to pharynx)
• Diffuse(from septum and lateral nasal wall)
• Nosopharynx
14. Classification of Epistaxis
• Anterior Epistaxis
• Blood flow out from front nose with patient in sitting position
• Posterior Epistaxis
• Blood flow back into the throat
16. Management
• First aid
• Cauterization
• Anterior Nasal packing
• Posterior Nasal Packing
• Endoscopic Cauterization
• Elevation of Mucoperichondrial flap and submucous resetion(SMR)
Operation
• Ligation of vessels
17. First aid
• Bleeding from Little’s area can be stopped by pinching the nose for 5
min
• Trotter’s method
• Patient is made to sit
• Leaning a little forward
• Breath quietly from the mouth
• Cold compression is applied(vasoconstriction)
18. Cauterization
• Useful in anterior epistaxis when bleeding point has been located
• Topically anaesthetized
• Bleeding point cauterization with bead of silver nitrate or coagulated
with electrocautery
19. Anterior Nasal Packing
• Done if localized bleeding is profuse or bleeding
point is not localize
• Use of a ribbon gauze soaked with liquid
paraffin(1 m gauze; 2.5 cm gauze in adult and 12
mm in children)
• Can be done with vertical layer and horizontal
layer
• Can be removed with 24 hour and can be kept
upto 2-3 days
• Systemic antibiotic should be given to prevent
sinus infection and toxic shock syndrome
20. Posterior Nasal Packing
• For posterior nasal bleed
• Can be carried through different instrument
• Gauze
• Foley’s Catheterization
• Nasal balloon
Nasal pack by Gauze
Nasal packing by Foley’s catheter
21. Endoscopic Cauterization
• Topical or general anesthesia, bleeding point is localized with rigid
endoscopy and cauterized
• Procedure is effective with less morbidity and decreased stay
• With profuse bleeding it is very difficult to localize so this procedure
can’t be carried out
22. Elevation of Mucoperichondrial Flap and
Submucous Resection(SMR) Operation
• For persistant or recurrent bleeds from septum
• Elevation of mucoperichondrial flap
• Reposining flap back help to cause fibrosis and constrict blood vessel
23. Ligation of Vessels
• Ligation can be done to
• External Carotid(ligation on origin of superior thyroid artery)
• Maxillary artery
• Ethmoidal artery
25. General Measures in Epistaxis
• Making patient sit up with back rest and record any blood loss taking place
through spitting or vomiting
• Mild sedation should be given
• Checking pulse, BP and respiration
• Maintenance of hemodynamics (Blood transfusion may required)
• Antibiotics can be given to prevent sinusitis, if pack is to be kept beyond 24
hours
• Intermittent oxygen may be required in patients with bilateral packs
because of increased pulmonary resistance from nasopharynx reflex
• Investigation and treatment for any underlying local or general cause
26. References
• Disease of Ear, Nose and Throat and head and neck surgery. Dhingra
PL, Dhingra S. 6th ed. Epistaxis. 176-80.
• Disease of Ear, Nose and Throat. Bhansal M. 1st ed. Nose and
Paranasal Sinuses. 295-7.
