Do you know about epistaxis?

What is epistaxis?

Epistaxis is the medical term for a nosebleed. It can occur in one or both nostrils. It
is usually harmless but may be life-threatening.
Epistaxis is common about 60% of people will have at least one nosebleed in their
lifetime. Only about 10% of cases are severe enough to require medical treatment.

Types of epistaxis

There are two main types:
Anterior epistaxis

• Bleeding from the anterior septum (the wall that separate the two sides of the
  nose). This is the most common type and usually isn’t serious. It is more
  common in children.
  Posterior epistaxis
• Bleeding from a vessel situated posterior to the pyriform aperture (back part
  of the nose). It can result in heavy bleeding, which may flow down the back
  of your throat. This type is more common in adult.

Causes of epistaxis

1. Local causes
   Idiopathic (85%)
   Traumatic (fracture, foreign body, nose picking)
   Inflammatory (rhinitis, sinusitis)
   Tumors of the nose, sinuses and nasopharynx
   Bleeding polyp
   Environmental (high attitude, air conditioning)
   Endocrine (menstruation, pregnancy)
   Iatrogenic (surgery, steroid nasal spray)
   Recreational drugs (Cocain and other drugs)
   Anatomical ireegularities (Septal spur, Septal deviation)
2. Systemic (General) causes
   Aniticoagulants (warfarin, aspirin)
   • Diseases of the blood (haemophilia, leukaemia)
   • Hypertension
   • Familial haemorrhagic telangiectasia (HHT, Osler-Weber-Rendu disease)
   • Raised venous pressure (whooping cough, pneumonia)
   • Alcohol use

Blood vessels involved

The upper part of the nose are supplied by branches from the internal carotid artery
(anterior and posterior ethamoid arteries) and the rest from branches of the external
carotid artery (greater palatine, sphenopalatine, superior labial). Little’s area
(Kiesselbach’s plexus) is the commonest site of bleeding.

Management

• The aims are to arrest the bleeding and to treat the underlying cause.
• The bleeding is usually stopped by one of the following methods:
•  Pressure on the nostrils (can be supplement with ice-cold packs and sucking
• ice tubes)
•  Local cautery ( chemical or electrocoagulation).
•  Anterior nasal packing (paraffin gauze, BIPP, merocel).
•  Packing of the postnasal space (gauze, Foley’s catheter, Brighton balloon).

Further surgery is indicated only on the rare occasion when bleeding is not
controlled by packing and cautery, or if a severe epistaxis recurs. Vascular ligation
under a general anaesthesia is possible, and the following arteries may be ligated:
Sphenopalatine artery, Internal maxillary artery, Anterior and posterior ethmoidal
arteries, External carotid artery.
Patients with HHT may required treatment by split-skin grafts, laser therapy or
radiotherapy to reduce the incidence of bleeding.

Aftercare

After stabilization, any contributing factors such as warfarin overdose or
hypertension should be treated.
Moisturisation of the nasal mucosa with aqueous gel may be helpful in preventing
recurrences.
Use of a posterior balloon or pack requires coverage with antibiotics due to the
consequent obstruction of the eustachian tube.

Author: Dr. NSTDA
Refference: Key Topics in Otolaryngology and Head and Neck Surgery (second
edition)
Total Revision: Ear, Nose and Throat (First edition)
Figure source: Internet

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