EPISTAXIS (Nakseer)

Aisha Anwer, roll no. 4

Student, BUMS final proff

senior
Epistaxis commonly known as nosebleed or rua’af in Unani medicine is a symptom
that occurs as a result of localised trauma to the nose or systemic diseases like
hypertension and diabetes. It may present as an active bleeding or complaints of
nosebleed. Management of nosebleed is done according to the cause and the
amount of blood lost. The bleeding usually occurs from Little’s area/ kisselbache’s
plexus, wooruff’s plexus or retrocolumellar vein. Anterior epistaxis usually occurs in
children due to trauma by nose picking. Posterior epistaxis is a more dangerous
condition resulting from systemic involvement. Pseudoepistaxis is a condition
where blood appear to come from nose but nose is not the source of blood.
Management of epistaxis is easy in most of the cases but some may need
sohenopalatine artery ligation and posterior nasal packing.

Keywords: Little’s area, Kisselbache’s plexus, wooruff’s plexus, Retrocolumellar

INTRODUCTION: It is also known as nosebleed and is considered a symptom

rather than a disease. It is one of the most commonly seen emergency in ENT.
(1). It can be unilateral or bilateral (3)

(2) copied from springer

link
DIVE INTO PHYSIOLOGY: the bleeding in a nosebleed is mostly arterial . It mostly tends
to occur from an area present near the antero inferior part of the nasal septum called the
Little’s area. (1). In 90% cases Little’s area is the site of bleeding (3)

Little’s Area. Little’s area (also known as Kiesselbach’s plexus) is found on the anterior
nasal septum (Fig. 1) and is an anastomosis of 5 arteries: anterior ethmoidal artery,
posterior ethmoidal artery, sphenopalatine artery, greater palatine artery, and the septal
branch of the superior labial artery. (2).

External and internal carotid artery Supply the Little’s area of which ECA supplies 80% and
ICA 20% respectively. The internal carotid artery gives rise to ophthalmic artery which in
turn branches into anterior and posterior ethmoidal artery.

Similarly the maxillary artery ( branch of external carotid artery) gives rise to
sphenopalatine artery terminally which majorly supplies the Little’s area and is also known
as the ‘Artery of epistaxis’ (1).

Retrocolumellar vein which lies behind columella joins the venous plexus and maybe a
source of epistaxis in young people.(1,3)

The plexus described by Woodruff’s states the following sites: The posterior 1 cm of nasal
floor, inferior meatus, inferior turbinate posterior end, middle meatus, the vertical strip of
mucosa anterior to the Eustachian tube, the mucosa lateral and superior to the posterior
choana, covering adjacent sphenoid rostrum. Although earlier thought to be an arterial
plexus, recent studies suggest it to be a venous plexus with thin walled sinusoids.(3).

Anterior Epistaxis Posterior Epistaxis

 More common Less common

 Mostly from little’s  Mostly from postero

area or anterior part of superior part of the
lateral wall nasal cavity.
 Mostly occur in  After 40 years of age
children or young
adults

 Mostly traumatic  Spontaneous (due to

HTN or
arteriosclerosis,)
 Causes of Epistaxis

LOCAL SYSTEMIC

1. Traumatic –
1. Blood disorders – severe anaemia,
a) physical trauma like blows, aplastic anaemia, Leukemia,
accidents or nose picking purpura, Haemophilia,
Thrombocytopenia,
Facial or skull fracture (3)
Arteriosclerosis, Hypertension,
b) operative trauma scurvy (6)

c) chemical or thermal trauma

2. Congenital- osler weber rendu
d) Barotrauma syndrome (aka hereditary
haemorrhagic telangiectasia) is a
condition in which there is
2. Infection – congenital vascular anomaly on
mucosal surface especially of
Hummiyàt damwi wa safrawi (7)
nose, lips and tongue. It is usually
managed by estrogen therapy or
Saunder’s dermoplasty (1)
ACUTE CHRONIC

 Influenza  Chr rhinitis

 Ac. Rhinitis  Sinusitis 3. Systemic disorders – congestive
 Typhoid  Adenoiditis cardiac failure and mitral stenosis,
 Measles  Atrophic rhinitis Hypertension (usually in older)
 Diptheria  Rhinosporidiosis (4)., jaundice, hepatic cirrhosis,
 Chikenpox  Tuberculosis, cyanosis, uremia, Toxemia
syphilis
4. Drugs- Tetracycline,
chloramphenicol, ampicillin,
3. Neoplasm of nose, paranasal sinusis aspirin, phenylbutazone, quinine,
(PNS) and nasopharynx anticoagulants,
immunosuppressants (1)
A. Benign- angioma, papilloma, fibroma

B. Malignant- carcinoma, sarcoma

4. Ulceration (4) 5. Endocrine disorders: Diabetes
mellitus – usually a cause in old people
5. Tumors of mediastinum (6)
(4), pregnancy, vicarious
6. Miscellaneous – Deviated Nasal septum, menstruation, hypothyroidism
spur, localised dryness and crusting,
6. Idiopathic: 10% cases
spontaneous rupture of tortuous
arteriosclerotic vessels and rhinolith (2)

Types of epistaxis (1)

PSEUDOEPISTAXIS (1)

1. Spontaneous epistaxis- occur in Seen in-

children and young adults usually
 Pulmonary haemoptysis
due to trauma of Little’s area. It is
 Bleeding esophageal varices
easy to stop but tends to recur
 Hematemesis
2. Hypertensive epistaxis- occur in  Bleeding from lumens of nasopharynx and
older age group and arises from far trachea
back or high up in the nose. It is
difficult to stop and tends to recur

EVALUATION (4)

The initial evaluation of nosebleed patients includes assessment of hemodynamic stability,

airway compromise and vital parameters.

 History: Complete history includes following questions:

1. Side of bleeding; worst side if bleeding is bilateral.
2. Symptoms of posterior nasal bleeding such as expectora- tion of blood and
hematemesis.
3. Precipitating events such as trauma, acute infection, nasal drops and sprays and
surgery.
4. Duration and amount of bleeding.
5. Syncopal or near syncopal attacks
6. Risk factors such as hypertension, leukemia, hemophilia, purpura, congestive heart
failure, renal failure and liver dysfunction and their medications
7. Drugs such as aspirin, NSAIDs (ibuprofen), heparin, anti- platelet drugs, high doses of
vitamin E.

8.Past history of bleeding and its treatment

9.Family history of bleeding tendencies such as hemophilia.

 Examination :
1. Examination should include vital parameters, complete ear, nose and throat
examination, general features and systemic examination.
2. The examination is often treatment oriented and should try to locate the
cause and site of bleeding. Patient needs reassurance.
3. The local anesthesia (4% xylocaine) and decongestants (phenylephrine) and
mild sedation make the nasal exami nation as well as patient comfortable
4. Clots need evacuation by forceps and suction. Patient can be asked to blow
the nose, which helps in cleaning the nose and bringing out large clots.
Patient should be encouraged to cough out clots.
5. Vital signs and patient’s mental status need constant attention tion during the
physical examination.
6. Some patients may need examination under general anes- thesia.
7. Posterior nasal examination in postnasal bleeding needs nasal endoscope.
8. Loupe magnification helps in localizing the site of anterior nasal bleeding.

INVESTIGATIONS:

1. Haematological- haemoglobin, TLC, DLC, BT, CT, PT, PTT

2. Biochemical- Blood sugar, Blood urea, LFT
3. Complete urine R&M
4. Radiological- X-ray and CT nose, paranasal sinusis amd nasopharynx

Image by Geeky medics

(2)
MANAGEMENT OF
EPISTAXIS

Aim: 1. To assess general condition of the patient.

2. To control haemorrhage

3. To treat the underlying cause

 FIRST AID MEASURES:

1. pinching nostril for atleast 10 minutes (5)

 a. Anterior Nasal packing
(micocope.com)

b. Posterior Nasal Packing (specialist-ent.com)

 UNANI CONCEPT OF
EPISTAXIS

According to Unani medicine, Epistaxis occurs in people who have damwi mizaj
or hot temperament and symptoms include burning sensation in the nose and
excessive thirst (7)

TREATMENT- It is done by habis uddam (haemostyptic) drugs. Sedatives may

also be given. Following are the different formulations used in the treatment of
epistaxis.

1. Sheera tukhme bartang (seeds of Plantago ovata) 6 gm, sheera tukhme

khurfa siyah (seeds of Portulacea oleracea) 25gm, sheera tukhme kahu (Lettuce
seeds) 13gm. Mix sharbate nilofar 25mL and powdered samag arbi ( gum of
Acacia arabica)1gm and give in morning and evening (7)

2. Dam ul akhwain (liquid gum of Dracaena cinnabari), tabasheer (Bambusa

arundinaceae) each 1gm. Grind to make a powder and mix with sharbat injabar
12mL (7)

3. Grind Gile Armani (Armenian bole) in sirka (vinegar or 5-8% acetic acid) and
apply it as a zimaad (paste) (7)

4.Mix kafoor (camphor) in aab barg kishneez (leaf extract of coriander sativum)
and apply it as a zimaad (7)
 CONCLUSION: Epistaxis is a manageable symptom and a manifestation of
many systemic diseases therefore it is always advised to seek medical attention
if a person has an episode of bleeding through the nose. Through proper history
taking and examination it’s underlying cause can be evaluated and treated
permanently

 ACKNOWLEDGEMENT: I sincerely want to thank my teachers Dr. Zehra Zaidi

and Dr. Abdul Nasir to give me the opportunity to review an important clinical
aspect of the above topic. I am also thankful to my friends and parents for being
supportive.

(1) Textbook of Ear, Nose and Throat by BS Tuli ,

second edition (pg 185-189)

(2) Google .com

(3) Textbook of Ear, Nose and Throat and head & neck
surgery by P Hazarika, D.R. Nayak and R.
Balakrishnan; third edition (pg 272-278)
R
(4) Diseases of Ear, Nose and Throat by Mohan Bansal
E , 1st edition (pg 293-297)
F (5) Diseases of the Nose, Throat and Ear by Simson
E Hall and Bernard H. Colman, 13th edition (pg 49-54)

R (6) Diseases of Ear, Nose and Throat & head and neck
surgery, 7th edition (pg 197-201)
E
(7) Amraze uzn wa anf wa halq by Dr. Waseem Ahmad
N Aazmi (pg 79-83)
C (8) Kitaab ul tadabeer by Mohd. Arshad jamaal (pg
E 97)

S (9) Amraze Atfal by hakeem Waseem Ahmad Aazmi,

1989 edition (pg 137-141)

(10) Kitabul hawi hissa som (part 3) including

diseases of ear, nose and throat by Abu Bakr
Mohammad Bin Zakariya Raazi; 1998 edition (pg 62)

(11) Supportive study from Al Qanoon fil Tibb hissa

som (part 3) and moalijat sharahe Asbab.