Epistaxis

DEFINITION
• Any bleeding from the nasal cavity & nasopharynx is
called epistaxis.
• It is a symptom as well as a sign.
• It is itself not a disease, but is the result of some LOCAL OR
SYSTEMIC DISEASES.

• Importance
•Epistaxis is a common reason of attending Emergency dept.
•Some are quite frightening, while a few are even Life
threatening.
•Sometimes it may be a manifestation of very bad
diseases like malignancy.
How common ?
•Approximately 60% of population has at least one episode
of epistaxis over the course of a life time.
•In cold countries, 7 -14% of population suffer each year.
•10% of which seek medical advice.

Demography
•Males > females
•Children > adults
•Adults epistaxis more severe
•For children it is mostly idiopathic and self improving
• An a t o m i c a l factors nose is situated on the most vulnerable
place of face. In fact it is the anteriormost structure of the body.
Any injury to face can easily in nose, thereby resulting in bleeding
nose- very rich in blood supply
- can be due to injury to sinuses as well
PARANASAL SINUSES: all are lined with mucous
membrane continuous with that of nasal fossa
 Medial wall of nasal cavity
•Formed by
•Nasal Septum (most bleeding occurs at here)
• Bony cartilaginous
Partition covered with
Mucous membrane.
Little’s area- Common place of bleeding, easily
accessible area- pick nose- causes bleeding
Platelet/ clotting factors Vessel wall integrity Extravascular protective layer
Deficiency/abnormality Pathology/ disruption Breach
(nose blockage and u try to blow forcefully- bleeding can occur)
•Pathology of vessel wall
*Failure of vessel to contract as in atherosclerosis & in old age.
* Dissecting aneurism causing localised weakness
* Microaneurism as in HPT

•INFECTION > Mucositis & HGE

•Deficiency diseases
Vit- C : Lack of cementing material of capillary wall.
•Haemostatic disorders:
Platelet factors Vascular factors
•Coagulation disorders affecting
Clotting factors e.g.
Etiology Haemophilia
•Any alteration in normal nasal physiology can lead to nasal
bleeding.
•Epistaxis increases in frequency during winter months. The
decreased humidity along with decreased temperature inhibits
nasal humidification. The nasal mucosa is subject to poor local
wound healing and is therefore more susceptible to bleeding.
•The most common local causes of epistaxis are trauma, anatomic
deformities, inflammatory reactions, and intranasal tumors.
•The most common systemic causes of epistaxis are
hypertension, aberrations in clotting ability, inherited bleeding
diatheses, and vascular/cardiovascular diseases.
ETIOLOGY
Local
• Idiopathic
• traumatic
• inflammatory
• neoplastic
• Environmental

General
• Raised arterial pressure.
• (Hypertension)
• Diseases of blood and blood vessels
• Raised venous pressure
• Etiology
1. IDIOPATHIC

Spontaneous arterial bleeding from nasal septum especially in

Little’s area ( COMMONEST SITE 90%)-is the commonest cause.

Venous bleeding from retro-columellar vein is frequent,

especially in young people.

Slight trauma or atmospheric drying leading to crusting may be

the initiative factors but not clearly known yet. (eg: stayed in
aircon room for long time)

2. Trauma: direct blow to nose, abrasion of nasal mucosa often

trivial
• Compound # of bones/ cartilages of face, nasal cavity/sinuses
• Fracture Base of skull – CSF fluid may be mixed with blood
 •Bleeding can be post-op: If
any post-operative bleeding
Please inform the surgical team as
soon as possible and take the
immediate measures.

Trauma
•Digital trauma from nose-picking is a frequent cause
especially in children and older people.
• Septal spur or deviated nasal septum (deviated septum)
is not an uncommon cause→ disruption of air flow→
desiccation of adjacent tissue
•Chronic nasal perforation rimmed by granulation tissue
(rich in blood supply)
 I N F LA M M A T O R Y / I N F E CT I V E
• Any form of Rhinitis or Sinusitis Bacterial / viral ,
Fungal or Allergy . Atrophic
Forceful blowing of nose sometimes may cause bleeding from a
weak , inflamed & ulcerated mucosa.
-Juvenile: male, young adults,presents with easy bleeding- can be life threatening
Eg: young kid with nasal bleeding at he morning due to sleeping in air con room for too long

Eg: Tobacco powder

Other local causes
Septal perforation

5. Chemical
- cocaine abuse
- Nasal sprays (both steroids and decongestants)
- Ammonia
- Others: Gasoline, phosphorus, chromium salts,
sulfuric acid, etc

• Social/occupational history are important

SYSTEMIC /GENERA L C AUSE
• RAISED ARTERIAL PRESSURE (bleeding with HTN: must admit
patient, observe)
• HYPERTENSION / ARTERIOSCLEROSIS itself does not cause epistaxis.
But bleeding in these individuals is more severe & prolonged.
• USUALLY NEEDS HOSPITAL ADMISSION

Causes of Raised venous pressure

- may lead to uncontrolled bleeding episode
• Cardiac & pulmonary disorders
• Mitral stenosis
• Whooping cough, pneumonia
• Mediastinal tumour /
• Venacaval syndrome
• PERICARDIAL EFFUSION etc.
• Usually associated with venous bleeding from retrocolumellar
vein.
Diseases of
BLOOD AND BLOOD vessels
• Any pathology in blood or blood vessels affecting the mechanism
of our normal
• HEAMOSTASIS & coagulation
• Can lead to abnormal bleeding and thus Epistaxis.

•Congenital : Osler’s disease.

•Acquired : Severe infection
*Septicaemia
*Meningococcal infection
*Measles
*Typhoid etc.

Allergic conditions
*Heanoch purpura
*Connective tissue disease
e.g. Rheumatoid arthritis
Other Vascular conditions
• Senile Purpura
• Early Bruising Syndrome
• Scurvy
• Factitial purpura
• Effect of drugs: Steroids
• Sulphones

PLATELET DISORDERS
• Thrombocytopenia due to any cause
• e.g. ITP, Dengue
• Dysfunction : Myeloproliferative disorder Leukaemia
• Uraemia Liver disease
• Paraproteinaemia Drugs- Aspirin,
• Dipyridamol etc. # Massive BL. Transf. can affect both.
THROMBOCYTOPENIA
• Impaired production : in bone marrow failure as in
Leukaemia, myeloma etc
• Excessive destruction : as in ITP, virus (allergic), DIC,
hypersplenism,
• Dilutional loss after BL . Transf.

COAGULATION DISORDERS
• Congenital : Haemophillia - A
• Haemophilia - B
• ( Christmas disease)
• Von- willebrand disease- most common cong. Cause in
• females.
• Most common acquired cause is probably drugs particularly
associated with oral-anticoagulants which suppress the vit-k
dependent coagulation factors.
COAGULATION DISORDERS
• ACQUIRED:
• Disseminated intravascular coagulation (DIC)
• Vitamin K deficiency (dietary, antibiotics, warfarin)
• Liver disease - hepatocellular failure
• Circulating anticoagulants ( aspirin, warfarin)
• Massive transfusions (when it is given without sufficient fresh
plasma ) Miscellaneous disorders:
• Plasmapheresis
• Hemodialysis
• Extracorporeal circulation associated with cardiopulmonary
bypass surgery
SITE OF BLEEDING
• Nasal septum: up to 90% cases
• Inferior turbinate and nasal floor
• Above the middle turbinate usually in HPT from ant
ethmoidal vessels
• Middle meatus rarely
• The sinuses
• Nasopharynx

MANAGEMENT (try to stop the bleeding first, don’t panic)

• DIAGNOSIS : BY - C/F
• History
• Examination
• Investigation
TREATMENT :
• OF the symptom ‘Epistaxis
• Of the underlying cause/ disease
• Features of the causative disease
such as Infection, FB. Tumour etc
eg : FB: nose block; neck mass (any
tumor any site).
• Features of the complication from
bleeding such as shock etc.

Clinical Features
History
(from mother may be exaggerated because too worry about the child)
•Duration: How long ? How frequent ?
•Amount of bleeds.
•One side or both sides
•Any relation to URTI
•H/O trauma/injury/operation and Drugs
•Family history of bleeding tendency
•Any associated other symptoms such as fever, rashes etc.
•H/O easy bruises, prolong bleeding (eg: little trauma but bleed non
stop)

Exam of ear, nose and throat

• General exam-
• Anaemia, Jaundice, BP, pulse, respiration, neck glands, Skin rashes
• Systemic exam- Liver, spleen, heart, lungs etc.
Investigation:
• BLOOD : FBC and Film: No. and morphology of platelets,
Leukaemia, Hb% etc
• Bleeding Time (rarey use in hosp setting): measures platelet plug
formation,
• Clotting Time: for coagulation defects.
• PT, PTT (must do): for coagulation defects.
• TT: for Fibrinogen deficiency. 10-12 sec
• Blood grouping and Cross-matching are important
• Plasma fibrinogen content and Fibrin degradation products (FDPs)
• Estimation of Factor VIII both c and vwf fractions
• BUSE/ BLOOD SUGER / LFT/ CHOLESTEROL
• X-RAY : PNS/ NASOPHARYNX/ CHEST
• CT SCAN
• FIBRE OPTIC RHINOSCOPY/ NASOPHARYNGOSCOPY TO SEE THE
BLEEDER DIRECTLY OR ANY OTHER PATHOLOGY.
Dengue haemorrhagic fever
• Recent or ongoing fever
• Bodyache, Malaise
• Nose bleeds
• Go for platelet count which might be reduced in DHF and cause coagulation
disorder.

TREATMENT
• To control /stop bleeding immediately
(investigate what is the cause of bleeding also)
• To treat the underlying cause
• Supportive measures : blood transfusion/ infusion etc.
• Set up IV line and Normal saline
• Maintain vitals
• Control HTN (if any)
But don’t put ice to eyes
To insert cotton
pledget soaked
in adrenalin
soln. or
vasoconstrictor
drop
\
• Anterior pack- then posterior pack- then chemical cauterization
 NASAL PACKING
•Done Under local or General anaes
•Very painful.
•Material used : A) 0.5 inch ribbon gauze impregnated with BIPP /
vaseline / antibiotic oint.
B) Lots of ready made nasal tampons of various sorts which
all essentially work by same mechanism that is by exerting pressure
on the nasal walls.
We can inflate them with water or air.

ANTERIOR NASAL PACK

NASAL PACKING
• There are some other products available

• Some absorbable materials like Surgicel, gelfoam etc. can be

used for packing.
• These can be left for longer period but not much effective for
massive bleeds.
NASAL PACKING
• Bleeds not controlled by ant pack demands posterior packing which
can be achieved by a
• Gauze Pad inserted into the nasopharynx against the post nasal
openings with the help of catheter and secured against the
columella.
• Sometimes Foley's catheter with inflatable balloon is used as PNS
pack.
• After post pack an ant pack is also given.
 POSTERIOR NASAL PACKING
(verypainful/uncomfortable)

66
Nasal packing
• Complications of nose packing includes
• Vaso vagal attack
• Being uncomfortable, with added anxiety and blocked nose can
give rise to elevated BP.
• Embarrasses respiration: ↓PO2, ↑PCO2
• Respiratory failure in those with chest problems
• Alar necrosis, nasal infection, sinusitis
• All these packings should be removed by 3 days
• All pts must be admitted in hospital sometimes require cardio-
respiratory monitoring.
How packing stops bleeding?
• By compression
• By facilitating clot formation by stabilization
• Allowing rest to the ulcer

• A pack can be left for 48 hours

• By this time you have to look for the underlying
cause.
• And then refer to the respective discipline
Surgical Procedures
• Ligation of the feeding artery namely Internal maxillary
• Ethmoid arteries Spheno palatine External carotid
• Embolization of vessel
 - A 45 y/o Chinese man is complaining of
- Epitaxies on and off for 1 moth
Dd: NPC
- Relate epistaxis with systemic problem-
Holistic approach

• 5 years old boy presenting with

• Rt ear discharge for 5days
• Nasal discharge
• Earache
• Examination findings: Ear drum shows a tiny
perforation containing pus
Diagnosis: Acute Suppurative Otitis Media