Dr. T. Balasubramanian M.S.
Definition: Epistaxis is defined as bleeding
from the nasal cavity. This is a Greek word meaning nose bleed.
Since it is a very common problem its true incidence is very
difficult to predict.
History: Hippocrates said that pinching the
nose for sometime and asking the patient to breath through the mouth
stopped bleeding from the nose. Carl Michel and James Little were
the first to identify the vascular plexus in the anterior part of
the nasal septum as the common area from which nasal bleeding
occurs. Pilz was the first person to treat epistaxis by surgically
ligating the external carotid artery, seiffert ligated the internal
maxillary artery through the maxillary antrum via caldwelluc
The nose has a rich supply of blood vessels
with good contribution from both external and internal carotid
systems. The general rule of the thumb is that the area of nasal
cavity below the level of middle turbinate has rich blood supply
from the external carotid system, where as the area above the middle
turbinate receives extensive supply from the internal carotid
artery. Anastomosis occur between the external and internal carotid
system throughout the nasal cavity.
External carotid system: Blood from the
external carotid system reaches the nasal cavity via the facial and
the internal maxillary arteries which are branches of the external
carotid artery. The artery of epistaxis is the sphenopalatine branch
of internal maxillary artery. This is called so because this vessels
supplies the major portion of the nasal cavity. It enters the nasal
cavity at the posterior end of the middle turbinate to supply the
lateral nasal wall, it also gives off a septal branch which supplies
the nasal septum.
Facial artery: the superior labial branch of
the facial artery is one of its terminal branches. It supplies the
anterior nasal floor and anterior portion of the nasal septum
through its septal branch.
Internal maxillary artery: after entering into
the pterygopalatine fossa this vessel gives rise to 6 branches.
These branches are posterior superior aleveolar artery, descending
palatine artery, infra orbital artery, sphenopalatine artery,
pterygoid artery, and pharyngeal artery. The descending palatine
artery enters the nasal cavity through the greater palatine canal to
supply the lateral wall of the nose, it also contributes blood
supply to the nasal septum through its septal branch.
Internal carotid system: the internal carotid
artery supplies the nasal cavity via its ophthalmic artery. It
enters the orbit via the superior orbital fissure and divides into
many branches. The posterior ethmoiod artery one of the branches of
ophthalmic artery exits the orbit via the posterior ethmoidal
foramen located 2-9 mm anterior to the optic canal. The anterior
ethmoidal artery which is larger leaves the orbit through the
anterior ethmoidal foramen. Both these vessels cross the roof of the
ethmoid and descends into the nasal cavity through the cribriform
plate. It is here that these vessels divide into lateral and septal
branches to supply the nose.
supply of lateral nasal wall
Little's area: This
area is located in the anterior part of the cartilagenous portion of
the nasal septum. Here there is extensive submucous anastomosis of
blood vessels both from the external and the internal carotid
systems. Bleeding commonly occurs from this area since it is highly
vascular and is also exposed to the exterior. Anastomosis occur
between the septal branches of sphenopalatine artery, greater
palatine artery, superior labial artery and the anterior ethmoidal
artery. This plexus is also known as Keisselbach's plexus. Bleeding
from this area is common because mucosal drying occurs commonly here
and this area is easily accessible to nose picking. Among the
vessels taking part in the anastomosis the anterior ethmoidal artery
is from the internal carotid system while the other vessels are from
the external carotid system. Bleeding from this area is clearly seen
and easily accessible and flows through the anterior nasal cavity
hence it is known as anterior
area of nose
Woodruff's plexus: is responsible for
posterior bleeds. This area is located over the posterior end of the
middle turbinate. The anastomosis here is made up of branches from
the internal maxillary artery namely its sphenopalatine and
ascending pharyngeal branches. The maxillary sinus ostium forms the
dividing line between the anterior and posterior nasal bleeds.
Posterior nasal bleeds are difficult to treat because bleeding area
is not easily accessible. Bleeding from Woodruff's plexus commonly
occur in patients with extremely high blood pressure. Infact this
plexus acts as a safety valve in reducing the blood pressure in
these patients, lest they will bleed intracranially causing more
problems. In patients with posterior bleeds it is difficult to
access the amount of blood loss because most of the blood is
swallowed by the patient.
Etiology: The etiology of epistaxis is not
just simple or straight forward. It is commonly multifactorial,
needing careful history taking and physical examination skill to
identify the cause. For purposes of clear understanding the etiology
of epistaxis can be classified under two broad heads, i.e. local and
Local factors causing
epistaxis: include vascular anamolies, infections and
inflammatory states of the nasal cavity, trauma, iatrogenic
injuries, neoplasms and foreign bodies. Among these causes the
commonest local factors involved in epistaxis is infection and
inflammation. Infections and inflammation of the nasal mucous
membrane may damage the mucosa leading on to bleeding from the
underlying exposed plexus of blood vessels. Chronic granulomatous
lesions like rhinosporidiosis can cause extensive epistaxis.
the internal carotid artery may occur following head injury, injury
sustained during surgical procedures. These extradural aneuryms and
aneurysms involving the cavernous sinus may extend into the sphenoid
sinus wait for the opportune moment to rupture. It can cause sudden
fatal epistaxis, or blindness. Urgent embolisation is the preferred
mode of management of this condition.
Trauma is one of the
common local causes of epistaxis. It is commonly caused by the act
of nose picking in the Little's area of the nose. This is commonly
seen in young children. Acute facial trauma may also lead to
epistaxis. Patients undergoing nasal surgeries may have temporary
episodes of epistaxis.
Irritation of the nasal
mucous membrane: any disruption of normal nasal physiology
can cause intense drying and irritation to the nasal mucosa causing
epistaxis. These episodes are common during extremes of temperature
when the nasal mucosa is stressed to perform its airconditioning
role of the inspired air. In these conditions there is extensive
drying of nasal mucosa causes oedema of the nasal mucous membrane.
This oedema is caused due to venous stasis. Ultimately the mucosa
breaches exposing the underlying plexus of blood vessels casuing
Common anatomical abnormality causing epistaxis is gross
septal deviation. Gross deviations of nasal septum causes disruption
to the normal nasal airflow. This disruption leads to dessication /
drying of the local mucosa. The dry mucosa cracks and bleeds.
Chronic non healing septal perforations can cause bleeding from the
granulation tissue around the perforation.
the nose and paranasal sinuses can cause epistaxis. Neoplasms
include benign vascular tumors like hemangioma, juvenile
nasopharyngeal angiofibroma, and malignant neoplasms like squamous
cell carcinoma. If epistaxis occurs along with secretory otitis
media then nasopharyngeal carcinoma should be the prime suspect.
Systemic causes for epistaxis:
Hypertension is one
of the common systemic causes of epistaxis. Accumulation of
atheroscerotic plaques in the blood vessels of these patients
replaces the muscular wall. This replacement of muscular wall
reduces the ability of the blood vessels to constrict facilitating
epistaxis. This is one of the common causes of posterior nasal
bleeds. It commonly arises from the Woodruff's plexus found close
the posterior end of the middle turbinate.
telengectasia is another systemic disorder known to affect
the blood vessels of the nose. This disease causes loss of
contractile elements within the blood vessels causing dilated
venules, capillaries and small arteriovenous malformations known as
telengectasia. These changes can occur in the skin, mucosal lining
the whole of the respiratory passage and urogenital passage.
Bleeding from these telengectasia is difficult to control. Bleeding
invariably starts when the patient reaches puberty. Common cause of
mortality in these patients is gastrointestinal bleed.
Systemic diseases like syphilis, tuberculosis
& wegner's granulomatosis cause epistaxis because of their
propensity to cause ulceration of the nasal mucous membrane.
Blood dyscrasias can
also cause epistaxis. A low platelet count is one common cause of
nasal bleed in this category. In thrombocytopenia the platelet count
is less than 1 lakh. Epistaxis can start when the platelet count
reduces to 50,000. Platelet deficiency can be caused by ingestion of
drugs like aspirin, indomethacin etc. Hyperspenism can cause
thrombocytopenia in idiopathic thrombocytopenic purpura. These
patients need to be transfused fresh blood in adequate quantities.
Only when thee platelet count increases will the nasal bleed stop.
Incidence: The incidence of epistaxis is known
to be slightly higher in males. It also has a bimodal distribution
affecting young children and old people.
Evaluation: While evaluating a patient with
epistaxis it is absolutely necessary to assess the quantum of blood
loss. The blood pressure and pulse rate of these patients must be
constantly monitored. These patients will have tachycardia. Infusion
of fluid must be started immediatly. Initially ringer lactate
solution will suffice. If the patient has suffered blood loss of
more than 30% of their blood volume (about 1.5 liters) then blood
transfusion becomes a must. Further examination should be started
only after the patient's general condition stabilises.
History: Careful history taking is a must.
History taking should cover the following points:
1. History regarding the freqency, severity
and side of the nasal bleed.
2. Aggravating and relieving factors must be
3. History of drug intaken must be
4. History of systemic disorders like
hypertension and diabetes mellitus must be sought.
The nasal pack if any must be removed.
Anterior nasal examination should be done, first attempted without
the use of nasal decongestants. If visualisation is difficult due to
oedema of the nasal mucosa then nasal decongestants can be used to
shrink the nasal mucosa. The solution used for anesthetising the
decongesting the nose is a mixture of 4% xylocaine and
Nasal endoscopy can be performed under local
anesthesia to localise posterior bleeds.
If bleeding is minimal no investigation is
If bleeding is more then a complete blood work
up to rule out blood dyscrasias is a must. It includes bleeding
time, clotting time, platelet count and partial thromboplastin time.
Imaging studies like CT scan of the para nasal
sinuses must be done to rule out local nasal conditions of
epistaxis. Imaging must be done only after 24 hours of removing the
nasal packing. Scans done with the nasal pack or immediatly after
removing the nasal pack may not be informative.
In diffiucult and intractable cases
angiography can be done and the internal maxillary artery can be
embolised in the same sitting. This procedure should be reserved
only for cases of intractable nasal bleeding.
Anterior nasal packing using roller gauze impregnated with liquid
paraffin is sufficient to manage a majority of anterior nasal
bleeds. The liquid paraffin acts as a lubricant, and as a moistoning
agent. The tamponoding effect of a nasal pack is sufficient to stop
nasal bleeding. This type of roller gauzes can be kept inside the
nasal cavity only up to 48 hours after which it has to be removed
and changed. The newer packs like the BIPP (Bismuth Iodine paraffin
paste) packs can be left safely in place for more than a week.
To manage post nasal bleed a post nasal pack
is a must. Post nasal packing can be done in 2 ways:
Post nasal packing
(conventional): A gauze roll about the size of the patient's
naso pharynx is used here. Three silk threads must be tied to the
gauze roll. One at each end and the other one at the middle. The
patient should be in a recumbent position. After anesthetising the
nasal cavity with 4% xylocaine the mouth is held open. Two nasal
catheters are passed through the nasal cavities till they reach just
below the soft palate. These lower ends of the catheters are grasped
with forceps and pulled out through the mouth. The silk tied to the
ends of the gauze is tied to the nasal catheters. The post nasal
pack is introduced through the mouth and gradually pushed into the
nasopharynx, at the same time the nasal catheters on both sides of
the nose must be pulled out. When the pack snugly sits inside the
nasopharynx, the two silk threads tied to its end would have reached
the anaterior nares along with the free end of the nasal suction
The two silk threads tied to the suction
catheters are untied. The catheters are removed from the nose. The
silk thread is used to secure the pack in place by tying both the
ends to the columella of the nose. The silk tied to the middle
portion of the gauze pack is delivered out through the oral cavity
and taped to the angle of the cheek. This middle portion silk will
help in removal of the nasal pack. In addition to the postnasal pack
anterior nasal packing must also be done in these patients.
Postnasal pack using baloon
catheters: Specially designed baloon catheters are available.
This can be used to perform the post nasal pack. Foleys catheter can
be used to pack the post nasal space. Foley's catheter is introduced
through the nose and slid up to the nasopharynx. The bulb of the
catheter is inflated using air through the side portal of the
catheter. Air is used to inflate the bulb because even if the bulb
ruptures accidentally there is absolutely no danger of aspiration
into the lungs. After the foleys catheter is inflated the free end
is knotted and anchored at the level of the anterior
Problems of nasal packing:
1. Epiphora (watering of eyes) occur due to blocking of
the nasal end of the nasolacrimal duct.
2. Heaviness /headache due to blocking of the normal
3. Prolonged post nasal pack can cause eustachean tube
block and secretory otitis media.
4. Prolonged nasal packing can cause secondary sinusitis
due to blockage of sinus ostium.
Newer packing materials: Newer packing materials made of
silicone are available. The advantages of these material are that
they are not irritating, patient can breath through the nose with
the pack on through the vent provided, these packs can be retained
inside the nasal cavity for more than 2 weeks. They can be removed
and repositioned if necessory. The only disadvantage is that they
Endoscopic cauterisation can be tried if the bleeders are
localised and accessible. If not accessible, ligation of the
internal maxillary artery can be done through caldwelluc approach.
Spenopalatine artery clipping can be done endoscopically. It is
accessible close to the posterior end of the middle turbinate. In
rare cases external carotid artery ligation at the neck can be
resorted to. External carotid artery is differentiated from the
internal carotid in the neck by the fact that internal carotid
artery does not give rise to branches in the neck, while the
external carotid artery does so.
Ethmoidal artery ligation: If epistaxis occur high in the
nasal vault, anterior and posterior ethmoidal arteries may be
ligated using ligaclips. These arteries can be accessed using an
external ethmoidectomy incision. The anterior ethmoidal artery is
usually found 22mm from the anterior lacrimal crest. If ligation of
the anterior ethmoidal artery does not stop bleeding then posterior
ethmoidal artery should also be ligated. The posterior ethmoidal
artery can be found 12mm posterior to the anterior ethmoidal
Epistaxis caused by the presence of tumors both benign
and malignant calls for definitive treatment of the tumor
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