Epistaxis

Question 1

What is the blood supply of the nose

Answer 1

Usually from Kiesselbach’s plexus, in Little’s area in anterior nasal septum (formed by anastomoses between ICA and ECA)

ICA (via ophthalmic artery):

• Anterior ethmoidal artery
• Posterior ethmoidal artery

ECA:

• Sphenopalatine artery (terminal branch of maxillary artery)
• Greater palatine artery (from maxillary artery)
• Superior labial artery (from facial artery)

Question 2

What are the causes of epistaxis?

Answer 2

1) Local
- Trauma e.g. punch, nose-picking (digital trauma)
- Foreign body
- Infection
- Iatrogenic
- Neoplasm
- Chemical toxins. e.g. heavy metals (mercury), acid

Systemic

• HTN w/ atherosclerosis (usually in elderly)
• Hereditary haemorrhagic telangiectasia (HHT)
• Haematological disorders, e.g. haemophilia, multiple myeloma (MM), ITP, leukaemia
• Liver impairment causing coagulopathy
• Drugs e.g. aspirin, warfarin

Question 3

What are the complications of epistaxis?

Answer 3

Hypotension
Anaemia
Hypoxia
Aspiration
Death (uncommon)

Question 4

How would you manage epistaxis?

Answer 4

Assess and secure ABC (airway, breathing, circulation) + resus (and IV access)

First aid

• Sit patient upright, lean forward slightly w/mouth open, look downward (prevent flow of blood down throat)
• Firm pressure to alar/front/soft part of nose (where Little’s area is and not the bridge which is bone/hard part, to promote stasis and clotting), breathe via mouth.

Refer to ENT if active severe bleed (otherwise just TCU)

Topical vasoconstrictors, e.g. Cophenylcaine, Oxymetazolin, adrenaline, – can be applied on nose packing

If small, localised bleed (source can be identified): chemical cautery (AgNO3) or electrical cautery (diathermy)
Ant and post nasal packing (nasal sponge pack)

If severe bleed:

• Interventional radiology, i.e. angiography KIV angioembolization.
• Surgical: examination under anesthesia and hemostasis (endoscopic or open)/ Ligation of sphenopalatine, internal maxillary, anterior ethmoid and posterior ethmoid arteries.