Epistaxis ent

Definition: Bleeding from inside the nose. It is a sign, not a disease per se. Seen in all age groups.

Anatomy: Blood Supply

1. Nasal Septum Supply

• Internal Carotid System:
  • Anterior Ethmoidal Artery.
  • Posterior Ethmoidal Artery.
• External Carotid System:
  • Sphenopalatine A. (Branch of Maxillary) → gives Nasopalatine & Posterior Medial Nasal branches.
  • Greater Palatine A. (Septal branch).
  • Superior Labial A. (Septal branch of Facial artery).

2. Lateral Wall Supply

• Internal Carotid System: Anterior & Posterior Ethmoidal Arteries.
• External Carotid System:
  • Sphenopalatine A. (gives Posterior Lateral Nasal branches).
  • Greater Palatine A. (Branch of Maxillary).
  • Ant. Superior Dental A. (Nasal branch from Infraorbital).
  • Facial A. (Branches to vestibule).

3. Key Landmarks

A. Little's Area (Kiesselbach's Plexus)
Situated in the Anterior Inferior part of septum. Major site (90%) of bleeding in children/young adults. Formed by anastomosis of:

• Anterior Ethmoidal A.
• Septal br. of Superior Labial A.
• Septal br. of Sphenopalatine A.
• Greater Palatine A.

B. Retrocolumellar Vein: Vertical vein behind columella; common venous bleed site in young people.

C. Woodruff's Plexus: Venous plexus inferior to posterior end of Inferior Turbinate. Site of posterior epistaxis in adults.

Aetiology (Causes)

A. Local Causes

• Trauma: Finger nail (most common), surgery, hard blowing, violent sneeze.
• Infections: Viral rhinitis, sinusitis, granulomas (Rhinosporidiosis).
• Foreign Bodies: Non-living or Living (maggots/leeches).
• Neoplasms: Haemangioma, Angiofibroma, Carcinoma.
• Atmospheric: High altitude, sudden decompression.
• Septum: DNS (Deviated Nasal Septum) / Spurs.

B. General Causes

• CVS: Hypertension, Mitral stenosis, Pregnancy.
• Blood: Leukemia, Haemophilia, Purpura, Vit K deficiency.
• Organ Failure: Cirrhosis (Liver), Chronic Nephritis (Kidney).
• Drugs: Salicylates (Aspirin), Anticoagulants.
• Infections: Dengue, Malaria, Typhoid, Measles.
• Vicarious Menstruation.

Classification: Ant vs. Post

Feature	Anterior Epistaxis	Posterior Epistaxis
Incidence	More common.	Less common.
Site	Little's Area / Anterior lateral wall.	Posterosuperior nasal cavity (often Woodruff's).
Age	Children / Young adults.	> 40 years.
Cause	Trauma.	Spontaneous (HTN/Arteriosclerosis).
Presentation	Flows out from front.	Flows into throat ("Coffee-coloured" vomitus).

Management

1. First Aid (Trotter's Method)

• Position: Sit up, lean forward (spit blood, don't swallow).
• Compression: Pinch nose (Little's area) for 5 mins.
• Adjunct: Cold compresses (reflex vasoconstriction).

2. Cauterization

• Useful for anterior bleeds where point is visible.
• Method: Topical anaesthesia → Silver nitrate bead OR Electrocautery.

3. Anterior Nasal Packing

Indications: Profuse bleeding or site not localized.

• Material: Ribbon gauze soaked in liquid paraffin.
• Size: 1 meter long. Width: 2.5cm (Adults), 12mm (Children).
• Technique: Layered from floor to roof and before backwards.
• Duration: 24-72 hours. *Systemic antibiotics required to prevent Toxic Shock Syndrome.

4. Posterior Nasal Packing

Indications: Blood flowing into throat. Hospitalization mandatory.

• Method A (Gauze Cone): Cone with 3 silk ties. Guided via catheter through nose into nasopharynx.
• Method B (Foley's): Size 12-14F. Balloon inflated with 5-10 mL saline. Pulled forward to block choana.
• Method C: Nasal balloons (double bulb).
• *Note: Always accompanied by anterior packing.

5. Surgical Interventions

• Endoscopic Cautery: Rigid endoscope used to localize and cauterize.
• SMR / Mucosal Flap: Elevation of flap causes fibrosis/constriction. Removes spurs.
• Ligation:
  • Ext. Carotid: Above sup. thyroid artery (rarely done now).
  • Maxillary: Caldwell-Luc approach.
  • Ethmoidals: External ethmoid (Lynch) incision.
• TESPAL: Transnasal Endoscopic Sphenopalatine Artery Ligation. High success for refractory posterior bleeds.

6. Embolization

• Interventional radiology (femoral cath).
• Uses Gelfoam/coils.
• Risk: Cerebral thromboembolism.
• *Ethmoidal arteries cannot be embolized.