2. EPISTAXIS
Epistaxis or nose bleeding is a very
common condition. The bleeding can be
unilateral or bilateral.
Little’s Area
The anteroinferior part of the septum is
the most common site of bleeding in
majority of the cases. This is a highly
vascular area marking the anastomosis
between the branches of various blood
vessels supplying the nose.
Branches from the anterior ethmoid,
sphenopalatine, greater palatine and
superior labial arteries take part in this
anastomosis (Kiesselbach’s plexus).
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3. There is a venous plexus near the posterior
end of the inferior turbinate called, which is
another common site of bleeding in the
nose.
The patient may be a habitual nose picker
and repeated ulceration maybe the cause of
the nose bleed.
Hypertension is a very common disease and
causes epistaxis frequently in elderly
patients. The site of bleeding is usually high
up posteriorly in the nose. Some Well-
defined cause may be evident on
examination.
Factors like coughing, sneezing, straining,
and blowing play a contributing role by
causing rise in the vascular pressure.
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4. Aetiology
The main causes of epistaxis are grouped as
under:
Local
• Trauma: External trauma to the nose
(accidental), repeated nose picking
(intentional), surgical trauma (iatrogenic),
foreign body in the nose (animate or
inanimate).
– i. Infection
• Vestibulitis
• Acute rhinitis
• Adenoiditis
• Diphtheritic rhinitis
• Atrophic rhinitis
• Rhinitis caseosa
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5. • ii. Granulomatous diseases
• Lupus
• Leprosy
• Syphilis
• Tuberculosis
• Stewart’s and Wegener’s granuloma
• Malignancy of the nose and paranasal
sinuses
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6. • iii. Fungal infection
• Rhinosporidiosis
• Blastomycosis
• Coccidiomycosis
– Physiological epistaxis
• Violent exertion or excitement
• Extremes of heat and cold
• Extreme alteration of pressure
– Congenital
• Telangiectasia (Osler-Weber-Rendu
syndrome)
•
– Tumours
• Juvenile angiofibroma of the
nasopharynx
• Haemangioma
• Inverted papilloma
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8. Management
• General assessment of the patient’s condition
is essential. The pulse and blood pressure are
monitored and resuscitative measures like
intravenous infusions or blood transfusion
started if thought necessary. In majority of the
cases of epistaxis, the bleeding is minor and
stops spontaneously. When a patient is seen
during a bleed, he is asked to clean the nose
which is then pinched for about 10 minutes.
This stops the bleeding by pressure. Once the
bleeding is controlled, the nose is examined
and the site located.
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9. • Cauterisation The bleeding point can be
cauterised by electric, chemical or thermal
cautery. The area is anaesthetised by local
xylocaine pack and cauterisation done.
Chemicals used for cauterisation include silver
nitrate (freshly prepared solution, a bead or a
crystal) or dilutes solutions of carbolic acid and
trichloroacetic acid.
• Lubricating ointments and liquid paraffin help
to prevent crusting.
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10. • Nasal packing Every attempt should be made
to control the bleeding without packing the
nose, as this causes further trauma to the
nasal mucosa, is troublesome for the patient,
and delays recovery.
• Anterior nasal packing: Anterior nasal packing
is needed when bleeding is profuse and does
not stop on pinching the nose. A lubricated or
medicated gauze is used for this purpose.
Packing should never be done with a dry
gauze. Nasal packing should be tight, starting
from the floor upwards. The pack is usually
removed after 24 to 48 hours. Subsequently
after pack removal, the nose is again
examined and bleeding points cauterised.
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11. • Posterior nasal packing: If bleeding is
continuous inspite of proper anterior nasal
packing, then posterior nasal pack may be
necessary. This can be done under general or
local anaesthesia supplemented by sedation.
Rubber catheters are passed from the nose to
the oropharynx. The threads of the pack are
attached to the ends of the catheters which
are then Withdrawn into the nasopharynx,
pulling a gauze pack along with it. The pack is
guided by fingers behind the soft palate. The
threads on the rubber catheter are tied on a
rubber piece at the columella. Tight anterior
packing is done. A separate thread attached to
the gauze pack is brought out through the
mouth.
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12. • Adjuvant therapy Bed rest and sedation are
important. Antibiotics are prescribed if the
nose is packed, as packing disturbs the nasal
physiology and leads to stagnation of the
secretions with resultant infection. Various
haemostatic preparations like adenochrome,
vitamin C and K, and calcium preparations
play only an adjuvant role in stopping the
bleeding.
• Alternatively, nasal packing may be replaced
by a specially devised (Brighton) balloon
which has a fixed nasopharyngeal and sliding
anterior nasal balloon. Pressure on the
bleeding vessels is exerted by inflating the
balloons.
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13. • Ligation of blood vessels Rarely a situation
may arise when bleeding does not stop by an
efficient nasal packing. In such cases ligation
of the blood vessels supplying the nose may
be the only alternative.
• The nose' is mostly supplied by the external
carotid artery through its sphenopalatine
branches. Thus ligation of theexternal carotid
artery in the neck or the internal maxillary
artery in the sphenopalatine fossa arrests
bleeding.
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14. • Sometimes, bleeding is high up in the nose
from the area supplied by the anterior ethmoid
artery. The ligation of ethmoid vessels is done
through a periorbital incision in the medial
canthus of the eye.
• Besides these measures of controlling
bleeding from the nose, attention should be
paid to the underlying cause like hypertension,
blood dyscrasias, local pathology in the nose
and the treatment accordingly instituted.
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