Epistaxis

Question 1

Describe the blood supply to the nasal septum

Answer 1

Blood supply to the nose can be divided into:

1. Branches of the internal carotid
2. Branches of the external carotid

Question 2

What are the branches of the internal carotid?

Answer 2

• opthalmic artery
• anterior ethmoidal
• posterior ethmoidal

Question 3

What are the branches of the external carotid?

Answer 3

• Facial artery ->
  
  • superior labial artery, angular artery
• Maxillary artery ->
  
  • sphenopalatine artery
  • greater palatine artery

Question 4

What is ‘Little’s area’?

Which 4 arteries are involved?

Answer 4

• AKA Kiesselbach’s plexus
• region in the anterioinferior part of the nasal septum
• where 4 arteries anastamose to form a plexus:
  
  • anterior ethmoidal artery
  • sphenopalatine artery
  • greater palatine artery
  • septal branches of superior labial artery
• 90% of nosebleeds occur here

Question 5

Epistaxis can be divided into anterior or posterior. What is anterior?

Answer 5

• 90%
• bleeding almost always occurs from Little’s area
• source of bleeding is obvious

Question 6

What is posterior epistaxis?

Answer 6

usually arises in the posterior nasal cavity at the following sites:

• behind posterior part of middle turbinate
• posterior suprior part of the roof of nasal cavity
• involves branches of sphenopalatine artery and mayr esult in sudden massive bleeding

Question 7

What are the local causes of epistaxis?

Answer 7

• idiopathic
• trauma (nose picking, fracture, foreign body, sneezing)
• nasal allergy
• infection eg. sinusitis
• tumours (angiofibroma, hemangioma, malignancy)
• hereditary telangiectasia

Question 8

What are the systemic causes of epistaxis?

Answer 8

• hypertension
• cardiac -> CCF, mitral stenosis
• pulmonary -> COPD
• cirrhosis -> vit K def
• coagulopathies -> haemophilia, leukaemia, agranulocytosis
• exanthematous fevers
• hormonal -> vicarious menstruation, endometriosis
• drugs -> XS salicylates, anticoagulant therapy

Question 9

Generally, resuscitation is not required in most people presenting with epistaxis, but is required in the rare instance of haemodynamic compromise.

When is it likely required?

Answer 9

• there is severe bleeding
• patient is older
• patient is unwell or frail

These patients need ABC approach, look out for symptoms of haemodynamic instability

Question 10

What are the initial conservative measures for acute active bleeding?

Answer 10

• entire lower compressible cartilage of nose is pinched
• to apply pressure to possible anterior bleeding sites
• ice pack
• bed rest

Question 11

For initial measures, what topical agent can be applied to help stop bleeding?

Answer 11

oxymetazoline (vasoconstrictor)

can be diagnostic + therepeautic

help visualise epistaxis site and encourage haemostasis

can then also apply topical anaesthetic

if bleeding continues, can soak cotton wool in above agents and apply to nose

Question 12

What should the patient do to remove possible blood clots?

Answer 12

• blows nose to clear blood + clots
• suction may be used

Question 13

What can be done to stop any obvious, visible bleeding?

Answer 13

• silver nitrate cautery
• uncomfortable
• use petroleum jelly after for moisturisation
• important to avoid cautery at same location on both sides of septum -> can result in septal perforation
• electrocautery indicated for brisker bleeding resistant to silver nitrate cautery (done by ENT consultant)

Question 14

If cautery fails to control bleeding, what can be done next, surgically?

Answer 14

• anterior nasal packing
  
  • traditional packing vs expanding nasal sponges
• anterior-posterior nasal packing if above fails
• posterior packing:
  
  • double-balloon epistaxis device
  • traditional gauze anterior pack w/ foley urinary catheter placed posteriorly
• endoscopic management of epistaxis sites
• angiography and embolisation w/ interventional radiology
• open surgical ligation