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

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.

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)

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

Woodruff’s Plexus:

Lying just inferior to posterior end of inferior turbinate Pharyngeal & Post. Nasal AA of Sphenopalatine A (IMAX)? venous plexu

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 epistaxisIncidence 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 ageCause Mostly trauma Spontaneous(HTN,arteriosclerosis)

Bleeding Mild,ctrl by local pressure or anterior pack

Severe,hospitalization,post nasal pack often required

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

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

Physiological causesHigh 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

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

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

Previous bleeding episodesNasal traumaFamily history of bleedingHypertension - current medications and how tightly controlledHepatic diseasesUse of anticoagulantsOther medical conditions - DM, CAD, etc.

Hematological investigations

CBC with platelet count

Clotting and bleeding profiles

Blood grp and cross matching

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+PNPointment FOLEYS WITH TAMPONADE

WITH ANP

Ctl unctrl

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UNCTRL CTRL

Consider bld transfusion

VESSEL LIGATION

LOW BLEEDING UIDENTIFIED HIGH BLEEDINGSITE SITE

IMA LIGATION/ ANT & POST ETHMOIDAL

TESPAL LIGATION

CTRL UNCTRL CTRL

ARTERIOGRAPHY & EMBOLISATION

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

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

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

Surgical management

Continued epistaxis consists of:

Posterior packing

Ligation techniques

Septal surgery techniques

Embolisation techniques

Posterior nasal packs

Posterior pack- rolling 4 *4 inch gauze sponge into

A 1 inch dameter pack secured with 3 heavy silk suture

10 french Foleys used

Epistaxis

The step of posterior

nasal packing

• 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

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

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

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

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

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.

Recurrent epistaxis in HHT

No bld transfusions bld transfusion

Mild moderate severe

Septodermoplastyhormonesantifibrinolytics agentsarterial ligationselective embolisation

Coagulating laser Nasal closure

eg.argon

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 #.