EPISTAXIS

Maj Dr BB Khatri
Dept of ENT & HNS
SBH and NAIHS
EPISTAXIS
 Clinical Case
60/f
Spontaneous nose bleed
ER management
Endoscopy
Packing
Removal of pack: rebleed
Cauterised
 EPISTAXIS

BLEEDING FROM INSIDE THE NOSE.

VERY COMMON 60-70% OF POPULATION.

SEVERITY VARIES FEW DROPS TO

TORRENTIAL.

BE MENTALLY PREPARED TO DEAL WITH

SEVERE EPISTAXIS.

Symptom, not a disease

 NOSE

TENT POLE SEPTUM

FLANGES FRAMEWORK

ROOM CAVITY

SCROLLS
 BLOOD SUPPLY
Medial wall Lateral wall

Spheno
palatine
A Br
Facial A
 BLOOD SUPPLY
ANT ETHMOID ARTERY
PECULIARITIES
POST ETHMOID ART
DUAL BLOOD
SUPPLY
SPHENO
LITTLES AREA
PALATINE ERECTILE TISSUE
ART
LITTLES AREA
KEISSELBACHS
PLEXUS
GREATER
PALATINE Woodrofs area
SUPERIOR ART
LABIAL ART
BLOOD SUPPLY

Both ECA AND ICA systems.

Predominantly- ECA.

Middle turbinate virtually

acts as a rough dividing line
between ECA/ ICA systems.

Arterio- arterial anastamoses

- failure of ligation of ECA.

Retrocollumellar venous
bleeding can be significant.
TYPES OF EPISTAXIS
ANTERIOR POSTERIOR
More common Less common
Site generally Littles Postero- superior, difficult
area or antero-lat wall. to localise
Age generally > 40 yrs
children/ young
Cause commonly Spontaneous
trauma. hypertension/
Bleeding mild, local arteriosclerosis
pressure/ ant pack Severe, both ant/ post
suffice packs may be reqd.
APPROACH TO EPISTAXIS
Quick evaluation

Resuscitate

Arrest Bleeding

Find & treat the cause

EVALUATION - HISTORY

How frequent? Last episode?

How much? Quantify in equivalents.
Which side? Anterior / posterior?
How does it stop?
Colour of blood? Does it drip drop by drop or is it
brown and vomited out?
Any drugs being taken?
Any recent or current infection?
Any recent RTA / Head injury?
Any bleeding from other sites ?
EVALUATION - EXAMINATION

General look
Air Hunger - Tachypnoea
Pulse Tachycardia
BP Hypotension/ Hypertension
Active Bleeding?
Anterior
Posterior
Any evidence of a generalized bleed?
RESUSCITATION
Anxiolytics
IV Lifeline
Blood for grouping
& PCV
IV Fluids
Blood transfusion
STOP BLEEDING

ER ROOM

ENT CENTRE

ADVANCED CENTRES
STOP BLEEDING MI ROOM

REASSURE THE PATIENT

RESUCUITATE
POSITION
PINCHING THE NOSE
ICE PACKS
NO ADRENALIN
NO MANIPULATION
STOP BLEEDING

ER ROOM

ENT CENTRE

ADVANCED CENTRES
STOP BLEEDING ENT CENTRE

VISUALISE THE
SITE OF BLEED
Ant & Post
Rhinoscopy
Nasal Endoscopy

ARREST BLEEDING
CAUTERISATION
ANTERIOR NASAL
PACKING
POSTERIOR NASAL
PACKING
 MANAGEMENT
ANTERIOR NASAL PACKING

Topical Anaesthesia

1.25 cm gauze strip

Liquid paraffin
Neosporin

Nasal Speculum
Tilleys Forceps

Illumination
Suction
ANTERIOR NASAL PACKING

Respect nasal mucosas

integrity
Antibiotic cover, Sedation
Removal 24-48 hours
Severe bleeding on removal
Re-pack
Anterior
Posterior
POSTERIOR NASAL PACKING

Topical / General
Anaesthesia

Posterior Nasal Pack

Liquid paraffin
Neosporin

Nasal Speculum
Tilleys Forceps
Red Rubber Catheters

Illumination
Suction
POSTERIOR NASAL PACKING
ALTERNATIVES TO PACKING

Merocel

Foleys catheter
12/14Fr

Epistaxis catheters
STOP BLEEDING

ER ROOM

ENT CENTRE

ADVANCED CENTRES
STOP BLEEDING ADVANCED
CENTRES
Angiography & DSA
Arterial Ligation
Ethmoidal vessels medial orbital incision
Maxillary artery Caldwell Lucs approach
ECA ligation if required
Embolisation
Gel sponge/beads/desiccated dura
In severe recurrent bleeds
Embolisation of ICA branches dangerous
Embolise and then ligate
Rare treatments for haemorrhagic telangiectasia
FIND & TREAT THE CAUSE
- LOCAL CAUSES
Trauma
Hard blowing/ sneezing.
Nose picking
#s of nose/ maxillo-facial region
Infections
Acute
URTIs
Sinusitis
Vestibulitis
Chroniconic
Atrophic rhinitis
Rh sicca
Granulomata - TB, Syphilis, Rhinosporiodiosis.
Foreign Bodies
DNS, Polypi.
Tumours
Juvenile nasopharyngeal angiofibroma (JNA)
Others papilloma,haemangioma,Carcinoma
 FIND & TREAT THE CAUSE
- GENERAL CAUSES
HYPERTENSION
BLEEDING DISORDERS Coagulopathies/ Thrombopathies
SYSTEMIC DISORDERS Renal/ Liver
DRUG INDUCED
ENVIRONMENTAL High altitude, dry weather.
IDIOPATHIC
CONGENITAL- Oslers disease
BLOOD STAINED RHINORRHEA IN HEAD
INJURY

Lean patient forward for many minutes

Presence of sugar
Halo sign
Beta-2 Transferrin analysis*
THANK YOU
MCQz
Nose is supplied by
External carotid system
Internal carotid system
Both
none
Most common cause of
epistaxis in children
Bleeding disorder
DNS
Nose picking
tumours
Epistaxis due to this occurs
exclusively in adolescent males
ITP
Aplastic anaemia
JNA
Hereditary telangiectasia
Kiesselbachs plexus is formed
by all except
Anterior ethmoidal
Posterior ethmoidal
Septal branch of sphenopalatine
Greater palatine