1. Epistaxis
Dr. Vishal Sharma

2. Definition & Causes Bleeding from within the nasal cavity. Causes:
1. Idiopathic (55 %)
2. Local
3. General

3. Local causes (nose & P.N.S.)
 Congenital: hereditary telengiectasia
 Trauma: nose picking, injury to nose / face / skull base, nasal surgery, foreign body
 Infection: vestibulitis, sinusitis, atrophic rhinitis, rhinosporodiosis, rhinoscleroma
 Neoplasms: angiofibroma, hemangioma, inverted papilloma, malignancy
 Deviated nasal septum (spur)

4. General causes Hypertension Bleeding disorders: haemophilia,
thrombocytopenia, leukemia
Drugs: aspirin, anticoagulants
Physiological: cold + dry climate, high
altitude, vicarious menstruation,
violent exertion, barotrauma
Liver failure
Exanthematous fevers

5. Common causes of epistaxis
Child: nose picking, foreign body,
exanthematous fever
Adolescent: nasopharyngeal angiofibroma,
trauma, sinusitis
Adults: sinusitis, trauma
Elderly: hypertension, malignancy

6. Common sites of epistaxis
Little’s area (80-90 %): Kiesselbach’s arterial plexus at antero-inferior part of septal cartilage. Common in children.
Woodruff’s venous (?) plexus: near posterior end of middle turbinate. Common in elderly, hypertensives.
Retro-columellar vein: common in adults.

7. Common sites of epistaxis

8. Common sites of epistaxis

9. Anterior Epistaxis Posterior Epistaxis
Incidence
More common
Less common
Localization
Easy
Difficult
Common site
Little’s area
Woodruff plexus
Age
< 18 yr
> 40 yr
Common Cause
Trauma
Hypertension
Treatment
Anterior pack
Posterior pack

10. Evaluation of pt. with epistaxis
mode of onset, duration, frequency, amount, side, site, previous bleeding
nasal trauma, purulent nasal discharge
hypertension, hepatic diseases, family history of bleeding, bleeding from other sites, use of anticoagulants, aspirin
measurement of pulse & blood pressure

11. Investigations Hemoglobin, Packed Cell Volume
Blood grouping & cross-matching
Bleeding Time, Clotting Time
Activated Partial Thromboplastin Time
Prothrombin Time
Platelet count
Diagnostic Nasal Endoscopy (D.N.E.)
C.T. scan paranasal sinus

12. General treatment Record pulse & blood pressure
Reassurance + bed rest in sitting posture with back rest
Adequate sedation (Diazepam)
Inj. Ethamsylate 500 mg IV Q8H
Amlodipine / Nifedipine for hypertension
IV fluids / blood transfusion for shock

13. Anterior epistaxis Pinch nostrils + ice pack  Bleeding continues
Insert cotton pledgets soaked in 1: 1000 adrenaline in nasal cavity
Chemical cautery with AgNO3 or electrical cautery (if bleeder is localized) or anterior nasal packing

14. Trotter’s method Elderly pt in sitting position, leaning forward,
mouth open allowing
bleeding to continue till
hypotension develops.
May lead to coronary
thrombosis + death.

15. Adrenaline soaked pledget

16. Chemical cautery

17. Anterior nasal packing
Anterior nasal packing for hrs  antibiotic cover with:
Liquid paraffin + antibiotic cream gauze
Vaseline gauze
Bismuth Iodoform Paraffin Paste gauze
Merocel tampoon
Simpson balloon

18. Anterior nasal gauze packing

19. Anterior nasal gauze packing

20. Anterior nasal gauze packing
Ribbon gauze soaked with liquid paraffin + antibiotic cream used.
Both nasal cavities packed tightly by layering from floor to roof. Pack removed after 48 hrs.
Systemic antibiotics given to prevent sinus infection & toxic shock syndrome.

21. Merocel nasal tampoon

22. Simpson’s nasal balloon

23. Posterior epistaxis
Posterior + anterior nasal packing for hrs  antibiotic cover with:
Post nasal gauze pack
Foley’s catheter
Brighton balloon (double lumen)
Epistat balloon (double lumen)
Bivona balloon (triple lumen)

24. Antero-Posterior Nasal Packing with gauze pack

25. Posterior nasal gauze pack

26. Catheter introduction

27. Tying of pack to catheter tip

28. Guiding pack into nasopharynx

29. Tying of anterior strips

30. Anterior nasal packing

31. Outer nasal packing

32. Posterior nasal packing
Post nasal pack prepared by tying 3 ribbon gauze strips to piece of gauze roll
2 Foley’s catheters passed through each nostril & their ends brought out via mouth
2 ends of gauze strips attached to nasal pack tied to catheter tips & withdrawn from nose

33. Posterior nasal packing
Pack that follows ribbon gauze strips, is guided into nasopharynx with index finger.
Anterior nasal packing done. 2 ribbon gauze strips tied over a gauze piece on columella.
3rd gauze strip brought out from mouth & taped to cheek. Pack removed after hr.

34. Antero-Posterior Nasal Packing with Foley’s catheter

35. Foley’s catheter

36. Catheter introduction

37. Catheter tip in nasopharynx

38. Anterior nasal packing

39. Brighton’s nasal balloon

40. Epistat nasal balloon

41. Bivona triple lumen catheter

42. Epistaxis set

43. Surgical intervention for refractory epistaxis

44. 1. Arterial ligation by external approach
external carotid artery: ligated in neck, distal to superior thyroid artery
internal maxillary artery: ligated in pterygo- palatine fossa (Caldwell-Luc opn)
anterior or posterior ethmoidal artery: ligated in orbit (Lynch-Howarth incision)

46. External Carotid ligation

48. 2. Angiography and embolization
3. Submucosal Resection of septum
4. Septo-dermoplasty:
for hereditary telengiectasia
5. Endoscopic cautery & clipping:
 Sphenopalatine artery
 Anterior or posterior ethmoidal artery

49. Angiography + embolization

50. Endoscopic clipping

51. Thank You