Epistaxis: Çağatay Oysu, M.D. Professor of Otolaryngology

E P I S TA X I S
ÇAĞATAY OYSU, M.D.

PROFESSOR OF OTOLARYNGOLOGY
VIDEO-1
Epistaxis: Bleeding from inside the nose
Etymology is Greek “epi” means up and “staxis” means flow

Epidemiology
Epistaxis is the most common otolaryngologic emergency and affects up to 60%
of the population in their lifetime, and 6% require medical attention.
It has been estimated that nosebleeds affect 108 per 100,000 population per
year.
Peaks in incidence are seen in those under 10 years of age and in people aged
over 40 years
Women of menstrual age have fewer hospital admissions with epistaxis, which
may be due to estrogens that provide protection of the nasal vasculature.
Which one is the most common cause of
childhood epistaxis?
a) Tumors
b) Trauma
c) Coagulopathy
d) Iatrogenic
e) Idiopathic
Etiology
The etiology of epistaxis in the
majority of patients is idiopathic.
Traumatic
Iatrogenic
Primary neoplasms
Why Nose?
Situated in a vulnerable position as it protrudes on the face.
Has a very rich blood supply.
Supplied by both internal and external carotid system.
Various anastomoses between arteries and veins.
Vasculature runs just under the mucosa.
Exposed to the drying effect of inspiratory current.

Blood Supply
Inferior part of the nasal cavity (ECA)
◦ Facial artery
◦ Superior Labial art  vestibule of the nose
◦ Maxillary artery
◦ Grater palatine art.
◦ Sphenopalatine art
Superior part of the nasal cavity (ICA)

◦ Ophtalmic artery
◦ Anterior ethmoid artery
◦ Posterior ethmoid artery
Kiesselbach’s plexus (Little’s area)
In anterior inferior part of nasal
septum.
Most common site for epistaxis.
Mainly anterior epistaxis.
Four arteries:
1) Septal branch of sphenopalatine artery
(IMAX)
2) Anterior ethmoidal artery (Optic art)
3) Septal branch of labial artery (Facial art)
4) Greater palatine artery (IMAX)
Woodruff’s Plexus
Posterior end of middle turbinate.
Most common site for posterior
epistaxis.
It is anastomoses of two arteries:
1. Sphenopalatine artery
2. Posterior pharyngeal artery
Site of Epistaxis
ANTERIOR POSTERIOR EPISTAXIS
Incidence: More common. Blood flow back into the throat.
Site: Mostly from Little’s area or anterior part Incidence: Less common.
of lateral wall. Site: Mostly from posterosuperior part of nasal
cavity; often difficult to localize the bleeding
Age: Mostly occurs in children or young adults. point.
Cause: Idiopatic. Age: After 40 years of age.
Bleeding: Usually mild, can be easily Cause: Spontaneous; often due to hypertension
controlled by local pressure or anterior pack. or arteriosclerosis.
Bleeding: severe, requires hospitalization;
postnasal pack often required.
History
Quantity of blood loss
Which side is bleeding
Family history (eg:Osler Weber Rendu)
Comorbidities
◦ Coagulopathy
◦ Anticoagulants/ASPIRIN
◦ Hypertension
◦ Trauma
Etiology
Local factors
◦ Vascular
◦ Infectious/Inflammatory
◦ Trauma (most common)
◦ Iatrogenic
◦ Neoplasm
◦ Dessication
◦ Foreign Bodies/other
Etiology
Systemic factors
◦ Vascular
◦ Infection/Inflammation
◦ Coagulopathy
◦ Hypertension
◦ Drugs
◦ Malnutrition
Vascular
ICA Aneurysms
◦ extradural
◦ cavernous sinus
Trauma
Nose picking
Nose blowing/sneezing
Nasal fracture
Nasogastric/nasotracheal intubation
Trauma to sinuses, orbits, middle ear,
base of skull
Barotrauma (SCUBA)
Inflammation
Rhinitis/Sinusitis
◦ Allergic
◦ Bacterial
◦ Fungal
◦ Viral
Iatrogenic
Septoplasty
Functional endoscopic sinus surgery
Rhinoplasty
Which one is most probable diagnosis in
adolescent male with recurrent epistaxis?
A) Nasopharyngeal cancer
B) Nasopharyngeal angiofibroma
C) Intranasal aneurism
D) Metastatic cancer
E) Septal Schwannoma
Neoplasm
Juvenile nasopharyngeal angiofibroma
Inverted papilloma
SCC
Adenocarcinoma
Melanoma
Esthesioneuroblastoma
Lymphoma
Vascular
Hypertension/Arteriosclerosis
Hereditary Hemorrhagic Telangectasias (OWR)
Infection-Inflammation
Tuberculosis
Syphillis
Wegener’s Granulomatosis
Periarteritis nodosa
SLE
Coagulopathies
Thrombocytopenia
Platelet dysfunction
◦ Systemic disease (Uremia)
◦ Drug-induced (Coumadin/NSAIDs/Herbal supplements)
Clotting Factor Deficiencies
◦ Hemophilia
◦ VonWillebrand’s disease
◦ Hepatic failure
Hematologic malignancies
Management
First-aid measures include asking the patient to apply constant, firm pressure
over the lower, nonbony part of the nose for 20 minutes and to lean forward
with the mouth open over a bowl so that further blood loss can be estimated.
Otherwise, blood dripping postnasally will be swallowed, and the next warning
sign could be several hundred milliliters of blood being vomited.
Laboratory
Complete blood count
Coagulation studies
Type and cross
Non-surgical treatments
Control of hypertension
Correction of coagulopathies/thrombocytopenia
 FFP or whole blood/reversal of anticoagulant/platelets
Pressure/Expulsion of clots
Topical decongestants/vasocontrictors
Cautery (AgNo3)
Nasal packing (effective 80-90% of time)
Greater palatine foramen block
bayonet forcepts vaseline gauze
suction
T.C.A.
bacitracin
gelfoam
good light
anesthetic epistat Afrin
endoscopes
silver nitrate
suction bovie/bipolar merocels surgicel
Anterior packing
Posterior packing
VIDEO-2
Balloon packing
Complications of epistaxis management
Infection
Septal perforation
Apnea,hypoxia
Hypovolemic shock
Alar rim-columella necrosis
Aspiration of packing
Neurovascular insult
Surgical methods
Ligation of the external carotid artery
Ligation of the sphenopalatine artery
Embolisat
Sphenopalatine artery is the branch of
which following vessel?
A) Anterior ethmoid art.
B) Internal Carotid art.
C) Labial art.
D) Internal maxillary art.
E) Greater palatine art.
Epistaxis is the most common otolaryngologic emergency.
The most common etiology: idiopathic traumaticiatrogeniccoagulopathicneoplastic.
Management ranges from emergency replacement of blood loss, direct visualization and
cautery, nasal packing, and surgical-endoscopic or external embolization.
Localizing the site of bleeding is of the utmost importance.
The basic approach to treatment is to locate the site of bleeding, stop the bleeding, and treat
the cause.
The majority of posterior idiopathic bleeds are from the septum, usually from the septal branch
of the sphenopalatine artery.
If a bleeding point cannot be found, ideally the nose is packed with an absorbable hemostatic
agent that produces minimal mucosal trauma.

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E P I S TA X I S

ÇAĞATAY OYSU, M.D.

Etymology is Greek “epi” means up and “staxis” means flow

Has a very rich blood supply.

Supplied by both internal and external carotid system.

Various anastomoses between arteries and veins.

Vasculature runs just under the mucosa.

Exposed to the drying effect of inspiratory current.

Superior part of the nasal cavity (ICA)

Incidence: More common. Blood flow back into the throat.

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