Assaignment Title: Causes, Work Up & Management of Epistaxis Discipline: MBBS

ASSAIGNMENT TITLE
Causes, Work Up & Management Of Epistaxis

Discipline: MBBS
Class: 4th Year
Subject: Otorhinolaryngologist
Name: Jahanzaib Saeed
Roll No: 286
FAISALABAD MEDICAL UNIVERSITY,

FAISALABAD
Introduction
Epistaxis is defined as acute hemorrhage from the nostril, nasal cavity,
or nasopharynx. It is a frequent emergency department (ED) complaint
and often causes significant anxiety in patients and clinicians.
Sometimes in more severe cases, the blood can come up the
nasolacrimal duct and out from the eye. Fresh blood and clotted blood
can also flow down into the stomach and cause nausea and vomiting.
Types:
There are two types of epistaxis.
1) anterior (the most common)

2) posterior (less common & more likely to require medical attention)
Pathophysiology:
The nasal mucosa contains a rich blood supply that
can be easily ruptured and cause bleeding. Rupture may be
spontaneous or initiated by trauma. Nosebleeds are reported in up to
60% of the population with peak incidences in those under the age of
ten and over the age of 50 and appear to occur in males more than
females. An increase in blood pressure (e.g. due to general
hypertension) tends to increase the duration of spontaneous epistaxis.
Anticoagulant medication and disorders of blood clotting can promote
and prolong bleeding. Spontaneous epistaxis is more common in the
elderly as the nasal mucosa becomes dry and thin and blood pressure
tends to be higher. The elderly are also more prone to prolonged nose
bleeds as their blood vessels are less able to constrict and control the
bleeding.
The vast majority of nose bleeds occur in the anterior part of the
nose from the nasal septum. This area is richly endowed with blood
vessels (Kiesselbach's plexus). This region is also known as Little's area.
Bleeding farther back in the nose is known as a posterior

bleed and is usually due to bleeding from Woodruff's plexus, a venous
plexus situated in the posterior part of inferior meatus. Posterior bleeds
are often prolonged and difficult to control. They can be associated
with bleeding from both nostrils and with a greater flow of blood into
the mouth.
Sometimes blood flowing from other sources of bleeding

passes through the nasal cavity and exits the nostrils. It is thus blood
coming from the nose but is not a true nose bleed i.e not truly
originating from the nasal cavity. Such bleeding is called
pseudoepistaxis. Examples include blood coughed up through the
airway and ending up in the nasal cavity, then dripping out.
Causes
A. LOCAL CAUSES
Nose
1. Trauma
Finger nail trauma, injuries of nose, intrananasal surgery, fractures
of middle third of face and base of skull, hard-blowing of nose,
violent sneeze.
2. Infections
Acute: Viral rhinitis, nasal diphtheria, acute sinusitis.
Chronic: All crust-forming diseases, e.g. atrophic rhinitis, rhinitis
sicca, tuberculosis, syphilis septal perforation, granulomatous
lesion of the nose, e.g. rhinosporidiosis.
3. Foreign bodies
Nonliving: Any neglected foreign body, rhinolith.
Living: Maggots, leeches.
4. Neoplasms of nose and paranasal sinuses.
Benign: Haemangioma, papilloma.
Malignant: Carcinoma or sarcoma.
Atmospheric changes. High altitudes, sudden decompression
(Caisson disease).
5. Deviated nasal septum.
Nasopharynx
1. Adenoiditis.
2. Juvenile angiofibroma
3. Malignant tumours.
B. GENERAL CAUSES
1. Cardiovascular system
Hypertension, arteriosclerosis, mitral stenosis, pregnancy.
2. Coagulopathy
Thrombocytopenia (thrombotic thrombocytopenic purpura,
idiopathic thrombocytopenic purpura, Von Willebrand's disease,
Hemophilia, Leukemia, HIV
3. Chronic liver disease
Cirrhosis causes deficiency of factor II, VII, IX,& X
4. Inflammatory:
Granulomatosis with polyangiitis
Systemic lupus erythematosus
5. Medications/Drugs
Anticoagulation (warfarin, heparin, etc)
Insufflated drugs (particularly cocaine)
Nasal sprays (particularly prolonged or improper use of nasal
Steroids.
C. Ideopathic
Many times the cause of epistaxis is not clear.
Sites of epistaxis
1. Little’s area
In 90% cases of epistaxis, bleeding occurs from this site.
2. Above the level of middle turbinate
Bleeding from above the middle turbinate and corresponding area
on the septum is often from the anterior and posterior ethmoidal
vessels (internal carotid system).
3. Below the level of middle turbinate
Here bleeding is from the branches of sphenopalatine artery. It may
be hidden, lying lateral to middle or inferior turbinate and may
require infrastructure of these turbinates for localization of the
bleeding site and placement of packing to control it.
4. Posterior part of nasal cavity
Here blood flows directly into the pharynx.
5. Diffuse
Both from septum and lateral nasal wall. This is often seen in
general systemic disorders and blood dyscrasias
6. Nasopharynx
Work Up
If a history of persistent heavy bleeding is present, obtain a
hematocrit count and type and cross match. If a history of recurrent
epistaxis, a platelet disorder, or neoplasia is present, obtain a
complete blood count (CBC) with differential. The bleeding time is
an excellent screening test if suspicion of a bleeding disorder is
present. Obtain the INR/PT if the patient is taking warfarin or if liver
disease is suspected. Obtain the activated partial thromboplastin
time (aPTT) as necessary.
With regard to visual evaluation, direct visualization with a good
directed light source, a nasal speculum, and nasal suction should be
sufficient in most patients. However, computed tomography (CT)
scanning, magnetic resonance imaging (MRI) , or both may be
indicated to evaluate the surgical anatomy and to determine the
presence and extent of rhinosinusitis, foreign bodies, and
neoplasms. Nasopharyngoscopy may also be performed if a tumor is
the suspected cause of bleeding.
Management
FIRST AID:
Most of the time bleeding occurs from the Little’s area and
can be easily controlled by pinching the nose with thumb and index
finger for about 5 min. This compresses the vessels of the Little’s area.
In Trotter’s method patient is made to sit, leaning a little forward over a
basin to spit any blood and breathe quietly from the mouth. Cold
compresses should be applied to the nose to cause reflex
vasoconstriction.
CAUTERIZATION:
This is useful in anterior epistaxis when bleeding point
has been located. The area is first topically anaesthetized and the
bleeding point cauterized with a bead of silver nitrate or coagulated
with electrocautery.
ANTERIOR NASAL PACKING:

In cases of active anterior epistaxis, nose
is cleared of blood clots by suction and attempt is made to localize the
bleeding site. In minor bleeds, from the accessible sites, cauterization
of the bleeding area can be done. If bleeding is profuse and/or the site
of bleeding is difficult to localize, anterior packing should be done. For
this, use a ribbon gauze soaked with liquid paraffin. About 1 m gauze
(2.5 cm wide in adults and 12 mm in children) is required for each nasal
cavity. First, few centimetres of gauze are folded upon itself and
inserted along the floor and then the whole nasal cavity is packed
tightly by layering the gauze from floor to the roof and from before
backwards.
Packing can also be done in vertical layers from back to the front. One
or both cavities may need to be packed. Pack can be removed after
24h, if bleeding has stopped. Sometimes, it has to be kept for 2-3 days;
in that case, systemic antibiotics should be given to prevent sinus
infection and toxic shock syndrome.
POSTERIOR NASAL PACKING:
It is required for patients bleeding
posteriorly into the throat.A post nasal pack is first prepared by tying
three silk ties to a piece of gauze rolled into the shape of a cone. A
rubber catheter is passed through the nose and its end brought out
from the mouth. Ends of the silk threads are tied to it and catheter
withdrawn from nose. Pack, which follows the silk thread, is now
guided into the nasopharynx with the index finger. Anterior nasal cavity
is now packed and silk threads tied over a dental roll. The third silk
thread is cut short and allowed to hang in the oropharynx. It helps in
easy removal of the pack later. Patients requiring postnasal pack should
always be hospitalized. Instead of postnasal pack, a Foley’s catheter
size 12-14 F can also be used. After insertion balloon is inflated with 5-
10 mL of saline. The bulb is inflated with saline and pulled forward so
that choana is blocked and then an anterior nasal pack is kept in the
usual manner. These days nasal balloons are also available. A nasal
balloon has two bulbs, one for the postnasal space and the other for
nasal cavity.
Transnasal Endoscopic Sphenopalatine Artery Ligation

(TESPAL):
The procedure can be done with rigid endoscopes under
topical anaesthesia with sedation or under a general anaesthesia. A
mucosal flap is lifted in posterior part of lateral nasal wall,
sphenopalatine artery (SPA)is localized as it exits the foramen and
closed with a vascular clip. Distal branches of the artery can be
additionally cauterized and the flap then reposited. Anterior ethmoidal
artery can also be ligated by Lynch incision as an adjunctive procedure.
SPA ligation gives high success in control of refractory posterior bleed.
Embolization:
It is done by an interventional radiologist through
femoral artery catheterization. Internal maxillary artery is localized and
the embolization is performed with absorbable gelfoam and/or
polyvinyl alcohol or coils. Both ipsilateral or bilateral embolizations may
be required for unilateral epistaxis because of cross circulation.
Embolization is generally a safe procedure but may have potential risks
like cerebral thromboembolism, haematoma at local site. Ethmoidal
arteries cannot be embolized.

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ASSAIGNMENT TITLE

Causes, Work Up & Management Of Epistaxis

FAISALABAD MEDICAL UNIVERSITY,

1) anterior (the most common)

Bleeding farther back in the nose is known as a posterior

Sometimes blood flowing from other sources of bleeding

Hypertension, arteriosclerosis, mitral stenosis, pregnancy.

Thrombocytopenia (thrombotic thrombocytopenic purpura,

idiopathic thrombocytopenic purpura, Von Willebrand's disease,

Hemophilia, Leukemia, HIV

3. Chronic liver disease

Cirrhosis causes deficiency of factor II, VII, IX,& X

Granulomatosis with polyangiitis

Systemic lupus erythematosus

Anticoagulation (warfarin, heparin, etc)

Insufflated drugs (particularly cocaine)

Nasal sprays (particularly prolonged or improper use of nasal

ANTERIOR NASAL PACKING:

Transnasal Endoscopic Sphenopalatine Artery Ligation

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