The document summarizes the causes, evaluation, and management of epistaxis (nosebleeds). Key points include: - The most common causes are local trauma, dry air, and hypertension. Weather has a proven association with incidence. - Evaluation involves examination of the nasal cavity to identify the bleeding site. Imaging and labs may be needed to investigate underlying causes. - Management begins with first aid and may involve cautery, nasal packing, medications, or surgery to control active bleeding and address its cause. Continued or severe bleeding may require embolization or ligation of arteries supplying the nasal cavity.

1. INTRODUCTION:
Synonyms: nasal hemorrhage, nose bleed, bosebleed, bloody nose.
Definition: acute hemorrhage from the nostril, nasal cavity, nasopharynx.
majority bleeding is in small quantities and self-limited
sometimes very intense and life-threatening.
Incidence: peak in aged 2-10 years and 50-80 years.
No sex predilection.
Climates factor: most common occurs during colder month and in dry colder climates.
Why bleeding from the nose ?
Vascularity of nose
Both external and internal carotids.
Anastomsis between arteries and veins.
Blood vessels run just under the mucosa-unprotected.
Larger vessels on the turbinate run in bony canals- cannot contract

2. Historical aspect:
Carl Michel (1871), James Little (1879) , and Wilhelm Kiesselbach
First to identify nasal septum anterior plexus
Pilz : (1869) first to surgically treat epistaxis
Ligation of common carotid artery.
Seiffert: (1928) via maxillary sinus
ligated internal maxillary artery
Henry Goodyear: First anterior ethmoid artery ligation.
Hippocratic technique : pinching the ala nasi
Vascular anatomy of nasal cavity:
Respiratory mucosa with its underlying vascular supply serve to regulate heat
exchange and humidification during respiration.

3. Blood supply:
1.External Carotid Artery
-Sphenopalatine artery
-Greater palatine artery
-Ascending pharyngeal artery
-Posterior nasal artery
-Superior Labial artery
2.Internal Carotid Artery
-Anterior Ethmoid artery
-Posterior Ethmoid artery
Arteries intercommunicate in rich plexuses
Kisselbach,s plexus(anterior bleed)
Woodruff,s plexus(posterior bleed)

4. Kesselbach’s Plexus/Little’s Area:
1/2 inch from the caudal border of the septum antero-inferiorly.
Vessels anastomosing are
-Anterior Ethmoid (Opth)
-Superior Labial A (Facial)
-Sphenopalatine A (IMAX)
-Greater Palatine (IMAX)
Bleeding may be arterial or venous.
Commonest site of bleeding
Exposed to drying of inspiratory current & finger nail trauma

5. Woodruff’s Plexus:
Lying just inferior to posterior end of inferior turbinate
Pharyngeal & Post. Nasal AA of Sphenopalatine A (IMAX)
? venous plexu

6. Retrocolluellar vein :
Run vertically downwards just behind the collumella
Crosses floor of nose and joins venous plexus on lateral nasal wall.
Common site of venous bleeding in young people
Classification of Epistaxis
According to Age:
Childhood <16 years
Adult >16 years
Common in childhood, less common in early adult life,peaks in 6th decade
According to causal factor:
Primary no proven causal factor.
Secondary proven causal factor
According to area:
Anterior bleeding point anterior to piriform aperture
Posterior bleeding point posterior to piriform aperture
Anterior epistaxis Posterior epistaxis
Incidence More common Less common
Site Mostly from little,s area Posteriosuperior part of nasal
cavity
Age In children and young adults After 40 yrs of age
Cause Mostly trauma Spontaneous(HTN,arteriosclerosis)
Bleeding Mild,ctrl by local pressure or anterior Severe,hospitalization,post nasal
pack pack often required

7. Etiology of epistaxis
Local
General
Idiopathic
Local causes
Congenital Hereditary telengectesia (osler- weber – rendu syndrome)
Trauma
Microtrauma by nose picking
Facial and skull bone fractures
Foreign body in nose
Iatrogenic trauma
Barotraumas
Inflammatory
Infective rhinitis
Specific
Acute infection life diphtheria
Chronic granulomatous conditions
Tuberculosis
leprosy
syphilis
rhinosporidiosis
Rhinoscleroma
Wegener,s granulomatous

8. Non specific
Viral –common cold ,influenza
Bacterial-Secondoary bacterial rhinitis sinusitis
Fungal rhinosinusitis
Atrophic rhinitis
Neoplastic
Benign
Juvenile angiofibroma,angioma of septum,capillary and
cavernous hemangioma,inverted papilloma
Malignant
Squamous cell carcinoma,olfactory neuroblastoma,
nasopharyngeal carcinoma
Miscellaneous causes
Deviated nasal septum and spur
Rhinitis sicca
Spontaneous rupture of tortuous arteriosclerotic vessels
Rhinolith

9. Physiological causes
High altitude
Extreme cold or hot climate
Systemic causes
Hypertension
Cardiac – CCF,mitral stenosis
Pulmonary – COPD
Cirrhosis – vit K deficiency
Renal - nephritis
Hormonal – vicarious menstruation,endometiosis,granuloma gravidarum
Coagulopathies
Clotting disorders like Christmas diseases Von willebrand diseases
,hemophilia
Bleeding disorders like thrombocytopenic purpura
Agranulocytosis
Leukemia
Vit K deficiency
Exanthematous fevers like measles,mumps,typhoid
Idiopathic
No obvious cause detected clinically and after investigations
Summary of etiology evidence :
Factor
Weather proven association
NSAID proven association
Alcohol proven association
Hypertension no association
Septal deviation no association

10. Evaluation of epistaxis:
Priority to ctrl bleed before invest
FIRST AID
ABC of emergency management is followed (Airway ,Breathing and Circulation).
Make pt. sit up , pinch the nose for 5-10 min,open mouth and breath
Ice pack on nose
Sedatory /sublingual antihtn in case of hypertensive epistaxis
In profuse bleed, aspiration is prevented by (#facial bones) lateral position/intubation with
inflated cuff.
Injection or topical use of hemocoagulase
Vital sign regularly monitored and concerntration is given on the following:
Volume status
BP
Adequacy of airway
Oral and nasal examination
Detailed medical and treatment history simultaneously with bleeding ctrl

11. Patient history
Physical examination equipments
• Protective equipment - gloves, safety goggles
• Headlight if available
• Nasal Speculum
• Suction with Frazier tip
• Bayonet forceps
• Tongue depressor
• Vasoconstricting agent (such as oxymetazoline)
• Topical anesthetic
Physical examination:
Anterior rhinoscopy
Posterior rhinoscopy
Nasal endoscopy
Radiological evaluation
Xray PNS r/o infective, traumatic and neoplastic condition
CT scan
Digital subtraction angiography –identification of bleeding vessel

12. Hematological investigations
CBC with platelet count
Clotting and bleeding profiles
Blood grp and cross matching

13. Management of epistaxiS EPISTAXIS
ASSESSEMENT & FIRST AID /RESUSCITATION
NASAL PREPARATION
IDENTIFY SITE OF BLEEDING
ANTERIOR NOT IDENTIFIED POSTERIOR
CAUTERY
(chemical,electocautery,
endoscopiccwutery
Antibiotic anterior nasal pack ANP+PNP
ointment FOLEYS WITH TAMPONADE
WITH ANP
Ctl unctrl
CTRL UNCTRL
UNCTRL CTRL
Consider bld transfusion
VESSEL LIGATION
LOW BLEEDING UIDENTIFIED HIGH BLEEDING
SITE SITE
IMA LIGATION/ ANT & POST ETHMOIDAL
TESPAL LIGATION
CTRL UNCTRL CTRL
ARTERIOGRAPHY & EMBOLISATION

14. Preventive measures:
• Keep allergic rhinitis under control. Use saline nasal spray frequently to cleanse and
moisturize the nose.
• Avoid forceful nose blowing
• Avoid digital manipulation of the nose with fingers or other objects
• Use saline-based gel intranasally for mucosal dryness
• Consider using a humidifier in the bedroom
• Keep vasoconstricting spray at home to use only prn epistaxis
Direct therapy
Silver nitrate cautery - avoid cautery of bilateral nasal septum as this may lead to
necrosis and perforation of the septum
Collagen Absorbable Hemostat or other topical coagulant
Endoscopic control – enables targetted hemostasis using insulated hot wire
cautery or modern single fibre bipolar electrodes.
Monopolar diathermy should not be used in nasal cavity –blindness
Indirect therapies
Nasal packing
Anterior nasal packing for refractory epistaxis - may use expandable sponge packing
or gauze packing
Posterior nasal packs

15. Usually, 1/2 inch Iodiform or NuGauze is used.
Coat the gauze with a topical antibiotic ointment prior to placement
Formed expandable
sponges are very
effective
Available in many
shapes, sizes and
some are
impregnated with
antibacterial
properties

16. Correct direction for placement of nasal packing
Actual duration will vary according to the patient’s particular needs.
Typically, anterior pack at least 24-48 hours, sometimes longer.
Best to place patient on a p.o. antibiotic to decrease risk of sinusitis and Toxic Shock
Syndrome
Advise pt to avoid straining, bending forward or removing packing early
If other nostril is unpacked, advise topical saline spray and saline gel to moisturize
nasal mucosa
Admission may also be prudent for those with CAD, severe HTN or significant anemia.
Give supplemental oxygen via humidified face tent.
Hot water irrigation - reflex vasodilation and reduction in nasal lumen dimension
Cold water irrigation
Systemic medical therapy

17. Surgical management
Continued epistaxis consists of:
Posterior packing
Ligation techniques
Septal surgery techniques
Embolisation techniques
Posterior nasal packs

18. • Always test before
placing in patient
• Fill “balloons” with
water, not air
• Orient in direction
shown
• Fill posterior balloon
first, then anterior
• Document volumes
used to fill balloons
Posterior pack- rolling 4 *4 inch gauze sponge into
A 1 inch dameter pack secured with 3 heavy silk suture
10 french Foleys used

19. Potential complications of PNP
Hypovolemic shock Naso-vagal reflux
Hypoxia Hypoventilation
Respiratory obstruction Local infection
Bacteremia TSS
Obstuctve sleep apnoea Cardiac arrhythmia
Indications for surgery/embolization
Continued bleeding despite nasal packing
Pt requires transfusion/admit hct of <38% (barlow)
Nasal anomaly precluding packing
Patient refusal/intolerance of packing
Posterior bleed vs. failed medical mgmt after >72hrs
Selective Angiography/embolization
Helps identify location of bleeding
Embolization most effective in patients who
Still bleeding after surgical arterial ligation
Bleeding site difficult to reach surgically
Comorbidities prohibit general anesthetic
Effective only when bleeding is >.5 ml/min
90+% success rate, complication rate of 0.1%
Only able to embolize external carotid & branches
Complications: minor (18-45%)/major (0-2%)
Contraindicated in bad atherosclerosis, Ethmoid bleed

20. Ligation techniques
Transantral IMA ligation
Intraoral IMA ligation
Anterior/Posterior Ethmoidal ligation
Transnasal Sphenopalatine ligation
External carotid artery ligation
Septodermoplasty/Laser ablation
Transatral IMA ligation(SEIFFERT,s operation)
Under LA/GA
After Caldwell-Luc maxillary antrotomy,posterior maxillary sinus wall
identified & removed
Periosteum opened via cruciate incision
IMA & its 3 major branches explored
Vascular clips applied to IMA ,
Recurrence rate (failure rate) of 10-15%
Complication rate of 25-30% -sinusitis , damage to infraorbital nerve,oroantral
fistula, dental damage , anaesthesia , rare opthalmoplegia, blindness

23. Intraoral IMA ligation
Posterior gingivobuccal incision beginning at second molar
Temporalis mm split and partially dissected
IMAX visualized, clipped and divided
Advantages: children/facial fractures
Disadvantages: more proximal ligation
Complications: trismus, damage to infraorbital n
Ant./Post. Ethmoidal ligation
Patients s/p IMAX ligation still bleeding, superior nasal cavity epistaxis, or in
conjunction when source unclear
Lynch incision
Fronto-ethmoid
suture line

24. Transnasal Endoscopic Sphenopalatine Artery ligation
Follow Middle Turbinate to posteriormost aspect
Vertical mucoperiosteal incision 7-8mm anterior to post middle turb (between mid.
and inf. turbs)
Elevation of flap—ID neurovascular bundle at foramen
Ligation with titanium clip
Reapproximate flap
Complications –few, Failures—0-13%
ECA ligation
Effectiveness
Anterior border of SCM
ID ECA/ICA
Ligation after clear that surrounding structures are safe.
Septodermoplasty/Laser
Remove mucosa from anterior ½ septum, floor of nose, lateral wall
STSG vs. cutaneous, myocutaneous, microvascular free flaps vs. Autografts
Neodymium-yttrium-garnet (Nd-YAG) laser or Argon laser + topical steroid best
nonsurg rx for mild/mod disease
Still bleed, but not as bad
Definitive treatment (severe disease)—closure of nose

25. Special cases:
Hereditary hemorrhagic telangiectasia
Also called Rendu-Osler-Weber diseaseargon
Autosomal dominant
Affecting blood vessels in skin , mucous membranes and viscera.
Genetic abnormality located to chromosome 9q(HHT1) & 12q(HHT2).
Features telengiactias,av malformationsand aneurysms.

26. Recurrent epistaxis in HHT
No bld transfusions bld transfusion
Mild moderate severe
Septodermoplasty
hormones
antifibrinolytics agents
arterial ligation
selective embolisation
Coagulating laser Nasal closure
eg.argon

27. Haemophilia:
– Replace factor VIII, or fresh blood.
Other clotting deficiency:
– FFP.
Purpura:
-Platelets
Anticoagulants:
– Stop drug, or titrate.
– Heparin is reversed with protamine sulphate,
– warfarin with vitamin K
Unconscious head injury;
– Dangerous to pack in suspected skull #.