Epistaxis

Define epistaxis.

Bleeding from inside the nose, either anterior nasal or posterior nasal.

Epi : from aboveStaxis : drop by drop drip of

fluid.

Epistaxis is a sign, NOT a diseaseIt should never be treated as a

harmless event.

Anatomical considerationsNasal cavity: mucosa and

turbinates are very vascularReceives blood supply from

branches of both internal and external carotid arteries.

Network of arteries : Kiesselbach’s plexus, woodruff’s plexus

Blood supplyNasal septumLateral wall of nose

Question 1

Describe the blood supply of the nose.

Blood supply of nasal septum

Blood supply of the lateral wall of nose

Little’s areaSituated over the anteroinferior part of

nasal septum, just above the vestibuleCaudal part of the nasal septum which

has a rich submucosal arterial network(Kiesselbach’s plexus) by septal branches of

- anterior ethmoidal- sphenopalatine- superior labial- greater palatine

Prone for drying (effect of inspired air ) and microtrauma by nose picking

Commonest site for epistaxis in children

Question 2The following is true regarding little’s area of

the nose, except:A) Situated over the anteroinferior part of the

lateral wall of the noseB) Has a rich submucosal vascular plexus named

Kiesselbach’s plexusC) Bleeding from Retrocolumellar vein is one of

the differential diagnoses of little’s area epistaxis

D) The kiesselbach’s plexus is formed by the septal branches of anterior ethmoidal, sphenopalatine, greater palatine, and superior labial arteries

Answer :A.Little’s area is situated over the

anteroinferior part of the nasal septum

Retrocolumella veinThis vein runs vertically downwards

behind the columella.It crosses the floor of nose & joins venous

plexus on the lateral wall of nose.Common site of venous bleeding in young

people

Question 3Which statement is true about

Retrocolumellar vein?A. This vein runs vertically downwards below

the columella.B. It crosses the floor of nose & joins venous

plexus on the nasal septum.C. It crosses the floor of nose & joins venous

plexus on the lateral wall of nose.D. It crosses the roof of nose & joins venous

plexus on the lateral wall of nose.E. Common site of venous bleeding in old

people.

Answer C

Woodruff’s AreaVascular area situated over the

posterior end of inferior turbinateSphenopalatine artery

anastomoses with posterior pharyngeal artery

Posterior epistaxis occur

Question 4Which statement is true about

Woodruff’s area?A. Site for anterior epistaxisB. Greaterpalatine artery anastomoses with

posterior pharyngeal artery hereC. Vascular area situated under posterior

end of inferior turbinateD. Vascular area situated above posterior

end of inferior turbinateE. Vascular area situated under posterior

end of middle turbinateAnswer : C

Sites of epistaxisLittle’s Area (90%)Above the level of middle

turbinateBelow the level of middle

turbinatePosterior part of nasal cavityDiffuse. ie : septum & lateral wallNasopharynx

Question 5Which is the commonest site of

epixtaxis?A. Above the level of middle

turbinateB. Below the level of middle

turbinateC. Posterior part of nasal cavityD. Little's area

AnswerD, 90% of the epistaxis site is

from little’s area.

Epistaxis

Anterior epistaxis

Posterior epistaxis

Blood flows out from the front of nose with the patient is in sitting position.

Blood flows back into the throat. Patient may swallow it and have “coffee-coloured” vomitus.

** may misdiagnosed as haematemesis

Differences between anterior and posterior epistaxis

Anterior epistaxis Posterior epistaxis

Incidence more Less

site Little’s area or anterior part of lateral wall

Posterosuperior part of nasal cavity; difficult to localise the bleeding point

age Children and young adult

>40 years

cause Trauma Spontaneous; often due to hypertension or arteriosclerosis

Bleeding Mild bleeding, can be controlled by local pressure or anterior nasal pack

Severe bleeding; requires hospitalisation and postnasal pack

Question 6Which of these statements are true?A. Anterior epistaxis is usually caused

by hypertensionB. Posterior epistaxis is more commonC. Anterior epistaxis does not usually

occurs in children and young adultsD. Anterior epistaxis bleeding is usually

mild

AnswerD, posterior epistaxis is more

severe, usually requires hospitalisation and postnasal pack;while anterior epistaxis is usually mild bleeding.

Etiology of epistaxisLocal causesSystemic causesIdiopathic ( primary )

Local causesI) congenital: Telengectasia ( Osler-Weber-

Rendau syndrome), hemangiomaII) Infections :

*Viral : Influenza, measles*Bacterial : (non-specific)- acute/ chronic rhinitis / sinusitis, artophic rhinitis(specific)- diphtheria, TB, syphilis, other granulomas*Fungal : rhinosporidiosis, fungal sinusitis*Parasites : maggots

III) Trauma:◦Microtrauma – nose picking◦Foreign body◦Accidental◦Iatrogenic◦Barotrauma : Caisson’s disease

IV) Neoplastic :◦Benign : JNA, Inverted papilloma,

hemangioma◦Malignant : Nose, PNS, Nasopharynx

V) Miscellaneous :◦Deviated nasal septum,spur,

rhinolith

Systemic causesCVS oHypertensionoAtherosclerosisoMitral stenosisoPregnancy (HTN & hormonal)

Liver Cirrhosis oVitamin K deficiencyoDeficiency of factor ii, vii,ix and x

HemotologicaloAplastic anaemiaoThrombocytopeniaoLeukemiaoLymphomaoAgranulocytosisoScurvyoVitamin K deficiency

Renal diseaseoChronic nephritis

DrugsoSalicylatesoAnalgesicsoAnticoagulant

Mediastinal compressionoTumours of mediastinum raised

venous pressure in the nose

Acute general infectionoInfluenzaoMeaslesoChicken poxoWhooping cough

Vicarious menstruation

What is the commonest cause of epistaxis?

A. IdiopathicB. Deviated nasal septumC. Fracture to the base of skullD. HypertensionE. Finger nail trauma

AnswerA, idiopathic

ReferrenceDisease Of Ear, Nose, Throat. 5th

Edition. PL Dhingra & Shruti Dhingra

ENT secrets. 2nd Edition. Bruce W. Jafek

Thank you