1. Epistaxis
JC Fleming
ENT Specialty Registrar

2. Anatomy
 Kiesselbach’s plexus – responsible for >90%
 Located at anterior nasal septum
 Confluence of vessels:
 INTERNAL CAROTID
 Opthalmic -> Ant. Ethmoid
 EXTERNAL CAROTID
 Facial -> Superior labial
 Maxillary -> Descending palatine -> Greater palatine
 Maxillary -> Sphenopalatine
From the anatomical literature and drawings collection at
Heidelberg University—HeidICON
http://www.flickr.com/photos/double-
m2/sets/72157626344216704/

4. Anatomy
 Woodruff’s Plexus
 Common cause of posterior bleeds
 Lies inferior to posterior end of inferior turbinate
 Confluence of vessels:
 EXTERNAL CAROTID only
 Maxillary -> Sphenopalatine
 Ascending pharyngeal
 Also be aware of retrocolumellar vein – 2mm posterior
to columella. Easily reachable by a child’s finger!

5. Classification
 Multiple methods!
 Main ones to remember are common sense:
 ADULT v CHILDHOOD (bimodal distribution)
 PRIMARY v SECONDARY (causal factor attributable
– more on this later!)
 ANTERIOR v POSTERIOR – the one you’re likely to
hear on the wards. Piriform aperture used as
anatomical landmark

6. PRIMARY v SECONDARY
 Primary or Idiopathic:
 Accounts for 80%
 Risk factors: Autumn/Winter, NSAIDS, Alcohol,
Hypertension
 Secondary:
 Trauma, Surgery, Anticoagulation, Hereditary
haemorrhagic telangiectasia

7. Management
 The nose is part of the upper airway
 Therefore MUST adequately assess Airway,
Breathing and Circulation
 Often high incidence of co-morbidities, placing these
patients in high-risk bracket
 Full history after resuscitation/stabilisation to elucidate
any underlying causes
 Try and get estimate of loss but often difficult for
patients to accurately determine

8. Management
 First Aid measures have often already been attempted
(badly!)
 Pinch ala nasi – remember directly compresses anterior
source of majority of bleeds
 IV Access and FBC/G&S (coagulation studies not
routinely required unless suspected abnormality from
history)
 Detailed and accurate assessment of nose
 Adequate light! (headlight ideally)
 Semi-recumbent position if stable
 Suction and topical vasoconstrictive solution +/- LA
 Protective clothing/gloves/glasses

9. Therapeutic Ladder
 As treatment ascends up ladder, specialist input from
ENT required
 DIRECT vs INDIRECT therapy

10. Indirect
 Used if no bleeding point identified
 Nasal pack
 As with bleed, can be anterior or posterior (or both!)
 Traditionally BIPP ribbon gauze
 Newer anterior packs – Merocel (sponge), Rapid Rhino (inflatable)
 Posterior packs usually Foley catheter fed into post nasal space and
inflated, pulling forward until it lodges in posterior choanae.
 Needs to be secured anteriorly with protection to columella skin (usually
with umbilical clip)
 Very painful therefore warn patient and adequate analgesia! GA
sometimes necessary
 Antibiotics required if pack remains longer than 48 hours (risk of toxic
shock syndrome)

11. Direct
 Directly treat bleeding vessel – optimal for patient
 Endoscope allows superior visualisation
 Silver Nitrate cautery +/- direct haemostatic agents
 If unsuccessful, ongoing uncontrolled bleed or
inadequate haemostasis from indirect techniques ------
------- THEATRE

12. Surgical management
 Direct identification and cautery of bleeding point +/- further ant/post
packing
 Sphenopalatine artery ligation
 Transantral Maxillary artery ligation (classic approach)
 External Carotid artery ligation (rarely required)
 Anterior/posterior ethmoidal artery ligation – usually only required in
confirmed ethomidal bleeds e.g. traumatic injury
 Also – septoplasty

13. And . . . .Embolisation
http://commons.wikimedia.org/wiki/File:MCA_an
gio_lateral.jpg
Courtesy of Dr Frank Gaillard
Very useful for intractable
haemorrhage surgically
inaccessible sites/non-operativ
candidates BUT highly
dependent on local radiologica
expertise

14. TAKE HOME MESSAGE
 Epistaxis:
 Can be a severe, life-threatening condition
 High-risk patients with multiple co-morbidities
 Range of treatment options: direct if possible
 Early involvement of ENT team