The lecture has been given on Nov. 29th, 2010 by Dr. Yousif Chalabi.

1. EPISTAXISEPISTAXIS

2. IntroductionIntroduction
Epistaxis is a Latin word means bleedingEpistaxis is a Latin word means bleeding
from the nose.from the nose.
Epistaxis is a common problem and affectsEpistaxis is a common problem and affects
all age groups , although it is common inall age groups , although it is common in
both extremes of life, 5-10% of theboth extremes of life, 5-10% of the
population experience an episode ofpopulation experience an episode of
epistaxis each year. 10% of those will see aepistaxis each year. 10% of those will see a
physician. 1% of those seeking medicalphysician. 1% of those seeking medical
care will need a specialist.care will need a specialist.

3. • The nasal fossa generally is
supplied by branches of:
• External Carotid Artery
-Sphenopalatine artery
-Greater palatine artery
- Superior Labial artery
-
-
• Internal Carotid Artery
-Anterior Ethmoid artery
-Posterior Ethmoid artery
Of maxillary artery
Of facial artery
Of ophthalmic artery

4. Arterial supply of nasal cavityArterial supply of nasal cavity

5. Vascular supply of the nasal cavity

6. Anatomy of the Nasal Cavity
and Vasculature

7. Kiesselbach’s
Plexus/Little’s Area:
-Sphenopalatine A
- -Greater
Palatine A
-Superior Labial A
-Anterior Ethmoid (Opth)
Woodruff’s Plexus:
-Pharyngeal & Post. Nasal
branches of

9. Sites of bleedingSites of bleeding
1.Nasal septum :1.Nasal septum :
75%-90%75%-90%
Little’s area ‘’Kiesselbach’s’’plexus.Little’s area ‘’Kiesselbach’s’’plexus.
often behind a spuroften behind a spur
‘bleeding polypus’ (an‘bleeding polypus’ (an
inflammatory granuloma) .inflammatory granuloma) .
2.Inferior turbinate and nasal floor .2.Inferior turbinate and nasal floor .
3.Above the middle turbinate.3.Above the middle turbinate.
anterior ethmoidal vessels, usually in hypertension.anterior ethmoidal vessels, usually in hypertension.
4.The middle meatus.4.The middle meatus.
5.sinuses.5.sinuses.

10. EtiologyEtiology
Local factorsLocal factors
-congenital (meningocele)-congenital (meningocele)
-acquired-acquired

IdiopathicIdiopathic

Trauma -F.B, facial trauma, iatrogenicTrauma -F.B, facial trauma, iatrogenic

Infectious/InflammatoryInfectious/Inflammatory

Neoplasm (benign , malignant)Neoplasm (benign , malignant)

Drug induced (rhinitis medica mentosa,local)Drug induced (rhinitis medica mentosa,local)

Inhalant (tobacco,wood dust)Inhalant (tobacco,wood dust)

DessicationDessication

11. EtiologyEtiology
Systemic factorsSystemic factors
1.Hypertension ,1.Hypertension , not cause epistaxis.not cause epistaxis.
2.Raised venous pressure2.Raised venous pressure , retrocolumelar vein., retrocolumelar vein.
3.Bleeding disorder:3.Bleeding disorder:
-coagulopathy (haemophilia ,Christmas disease…).-coagulopathy (haemophilia ,Christmas disease…).
-platelet disorder-platelet disorder
-blood vessel disorder-blood vessel disorder
-hyper fibrinolysis-hyper fibrinolysis
4. Drugs4. Drugs
(aspirin,NSAIDs,methotrexate,immunosupressive).(aspirin,NSAIDs,methotrexate,immunosupressive).
5.Neoplasm.5.Neoplasm.
6.Inflammatory disorder (SLE)6.Inflammatory disorder (SLE)
7.Others (liver failure, hypothyroidism)7.Others (liver failure, hypothyroidism)

12. Nasal Fracture with Septal Hematoma

13. Etiology and AgeEtiology and Age
Children—foreign body, nose pickingChildren—foreign body, nose picking
Adults—trauma, idiopathicAdults—trauma, idiopathic
Middle age—tumorsMiddle age—tumors
Old age--hypertensionOld age--hypertension

14. Management of EpistaxisManagement of Epistaxis
HistoryHistory::
--quantity of blood lossquantity of blood loss
--side and site of bleedingside and site of bleeding
--durationduration
--co morbiditiesco morbidities
--family historyfamily history
ExaminationExamination::
locallocal
--anterior and posterior rhinoscopyanterior and posterior rhinoscopy
--flexible and rigid nasoendoscopyflexible and rigid nasoendoscopy
generalgeneral
--vital sign , general examination , systemicvital sign , general examination , systemic
Investigation( CBC, Coagulation studies,Investigation( CBC, Coagulation studies,
Blood group and cross matchBlood group and cross match((
Treatment ( initial , non surgical , surgicalTreatment ( initial , non surgical , surgical((

15. Immediate managementImmediate management
Pressure on the nostrilsPressure on the nostrils
(breath through the mouth and(breath through the mouth and
head leant forward)head leant forward)
Ice or cold pack (to bridge ofIce or cold pack (to bridge of
nose and roof of mouth)nose and roof of mouth)
mild sedativesmild sedatives

16. Epistaxis (active bleedingEpistaxis (active bleeding((
Admission, IV line , blood
group and cross match,
monitor pulse ,BP. Consider
blood transfusion .Treat
primary cause .
Identify site of
bleeding (anterior,
posterior, unclear)
Nasal cautery after
cocainization
successful
Naseptin
General advice
unsuccessful
Nasal packing (2-5)days
Anterior ,posterior, both
Still bleeding
Surgical intervention
Remove pack
Ephedrine drop,
cautery
Still bleedingSurgical
intervention

17. EpistaxisEpistaxis
Coagulopathy
Family history +ve
Osler Weber disease
Laser cautery Septodermoplasty
Recent bleeding
Bleeding site identified
Ant.Rhinoscopy
Nasal cautery after
cocainization
(L.A.)
Advise and Topical care
(naseptin cream)
monitoring underlying
cause
Previous treatmentRecurrent
Nasal cautery
(G.A.)

18. Non-surgical treatmentsNon-surgical treatments
General adviseGeneral advise
Avoidance of nose picking/blowingAvoidance of nose picking/blowing
Sneeze with mouth openSneeze with mouth open
Avoid strainingAvoid straining

19. Elderly and those with other chronicElderly and those with other chronic
diseases may need to be admitted todiseases may need to be admitted to
the ICUthe ICU
Continuous cardiopulmonary monitoringContinuous cardiopulmonary monitoring
AntibioticsAntibiotics
Oxygen supplementation may beOxygen supplementation may be
neededneeded
Mild sedation/analgesiaMild sedation/analgesia
IVFIVF

20. Indications for surgery/embolizationIndications for surgery/embolization
The patient who continues to bleed everyThe patient who continues to bleed every
time the pack is removed or the bleedingtime the pack is removed or the bleeding
continue with the pack in situ ,will generallycontinue with the pack in situ ,will generally
have to be transfused. if severe bleeding orhave to be transfused. if severe bleeding or
over 4-5 days bleeding has not stopped,over 4-5 days bleeding has not stopped,
surgical intervention should be considered.surgical intervention should be considered.
Posterior bleed vs. failed medicalPosterior bleed vs. failed medical
management after >72hrsmanagement after >72hrs
Nasal anomaly precluding packingNasal anomaly precluding packing

21. Surgical treatmentSurgical treatment
Transmaxillary IMA ligationTransmaxillary IMA ligation
Intraoral IMA ligationIntraoral IMA ligation
Transnasal Sphenopalatine ligationTransnasal Sphenopalatine ligation
External carotid artery ligationExternal carotid artery ligation
Anterior/Posterior Ethmoidal ligationAnterior/Posterior Ethmoidal ligation
Other method of treatmentOther method of treatment

22. SMRSMR
When bleeding behind prominent spurWhen bleeding behind prominent spur
To improve access for cauteryTo improve access for cautery
To interrupt blood supply from little’sTo interrupt blood supply from little’s
area ,hemorrhagic nodulearea ,hemorrhagic nodule

23. Anterior and posterior nasal
packing

24. Balloons
close

25. Thank youThank you