Nanang Mardiraharjo, dr., Sp.

THT-KL
 Epistaxis
 a common condition
 presenting in 7% to 14% of the general population
each year.
 Most patients: bleed is minor and usually stops quickly
do not seek medical attention.
 Incidence : higher in males than females, more
frequent in the winter months than the summer
months.
Vascular Anatomy of the Nose
blood supply of the nose:
 The major portion : the external carotid system
 smaller component : the internal carotid system.
 greater palatine artery

internal
maxillary
artery the sphenopalatine artery

external
carotid artery
pharyngeal
artery

superior Septum &

facial artery labial artery alae nasi
 anterior
ethmoidal
arteries

internal carotid ophthalmic

artery artery

Posterior
ethmoidal
arteries
 • sphenopalatine artery
Lateral • Woodruff's area

nasal wall

• anterior region

Medial • Little's area / Kiesselbach's

plexus
• majority of nose bleeds

(septal) • easily accessed and be treated

with simple measures.
ETIOLOGY OF EPISTAXIS
Local Systemic

• Trauma: digital, fractures • Hypertension

• Nasal sprays (local trauma effect) • Vascular disorders
• Inflammatory reactions • Blood dyscrasias
• Anatomic deformities (e.g., septal • Hematologic malignancies
spur/deflection) • Allergies
• Foreign bodies • Malnutrition
• Intranasal tumors • Alcohol
• Chemical irritants • Drugs
• Nasal prong O2, CPAP (continuous • Infections
positive airway pressure)
• Surgery
Epistaxis can vary

mild intermittent
blood-stained discharge

full blown life-threatening

major hemorrhage
TREATMENT EPISTAXIS
 Observation (especially in pediatric patients)
 Antiseptic cream
 Barrier ointment (petroleum jelly)
 Cauterization
 Nasal packing: anterior pack, posterior nasal pack,
nasopharyngeal balloon
 Pterygopalatine fossa block
 Laser photocoagulation
 Pharmacologic
 Surgical arterial ligation
 Angiographic embolization
 Surgical reconstruction
Minor Hemorrhage
 Most episodes of epistaxis are minor and stop
spontaneously
 Optimal management of recurrent nosebleeds in the
pediatric population remains unknown
 Antiseptic creams reducing vestibulitis and mucosal
inflammation moistening the mucosa and
preventing drying and crusting.
 Barrier ointments preventing crusting of the septal
mucosa reduce mucosal friability  decrease the
frequency of minor epistaxis
 silver nitrate cautery  Little's area
 nasal pack
Exsanguinating Hemorrhage
 usually occurs after major trauma
 Anterior skull base fractures anterior and posterior
ethmoidal arteries
 fractures of the maxilla internal maxillary artery or
one of its branches
 sphenoid is involved traversing the internal carotid
artery catastrophic bleeding
Management
 A-B-C-D
 postnasal space balloon catheter + 15 mL saline
 packed with ribbon gauze (soaked in bismuth
iodoform paraffin paste petroleum gauze coated with
antibiotic ointment, boorzalf)
 sphenopalatine artery ligation
 external carotid ligation
 ligation of the anterior and the posterior ethmoidal
artery
 Massive hemorrhage from the sphenoid region
internal carotid injury
Sagittal section through the nose demonstrating the techniques for layering
ribbon gauze in the nose for tamponade of the bleeding blood vessel
EMERGENCIES EXSANGUINATING EPISTAXIS
COMPLICATIONS EPISTAXIS MANAGEMENT