EPISTAXIS: Causes and Management - NEET PG ENT

Epistaxis or nosebleed is one of the most common emergencies of the ear, nose, throat (ENT) where patients get taken to the emergency room or primary care. 

Epistaxis is one of the most crucial topics for your ENT preparation. Read everything you need to know about the condition and elevate your NEET PG preparation. 

What is Epistaxis ?

The epistaxis means bleeding from the nose. Epistaxis can be classified into two parts: 

• Anterior Epistaxis: Any bleeding that occurs anterior to the pyriform aperture is called anterior epistaxis. 

• Posterior Epistaxis- Any bleeding that occurs posterior to the pyriform aperture is called posterior epistaxis. 

Epistaxis is also divided into primary and secondary.  

• Primary: When there is no attributable cause or when it is idiopathic it is called primary epistaxis. 
• Secondary: Any bleeding causing secondary to a specific cause like infection, trauma, or Neoplasm drug-related issue, liver pathology, etc. 
• Epistaxis is also divided into childhood epistaxis and adult epistaxis. Bleeding occurs for anyone less than the age of 16 years is  called childhood epistaxis. 

	Anterior Epistaxis	Posterior epistaxis
Incidence	More common	Less common
Site	Littles area	Woodruffs plexus
Age	Children	After 40 years of age
Cause	Trauma	HTN
Bleeding	Mild can be controlled by local pressure or anterior pack	Bleeding is severe, require hospitalization and poston pack

The septum is divided into two imaginary halves. 

• The upper half of the septum receives its blood from the internal carotid artery.
  • It is giving rise to the ophthalmic artery which is further divided into an anterior ethmoidal artery and a posterior ethmoidal artery. 
• The lower half of the septum receives its blood from the external carotid artery. This is further divided into two parts:
  • Facial artery: This gives rise to a superior labial artery. The superior labial artery supplies the septum inferiorly via the septal branch.
  • Internal maxillary artery: It is further divided into the sphenopalatine artery and the greater palatine artery. 

Kiesselbachs	Woodruffs plexus
Arterial  Anteriorly  Children  Mild	Venous  Posteriorly  Adults  Severe

• All these arteries supply to the septum and they will form a plexus in the anteroinferior portion of the septum except the Posterior Ethmoidal artery. This is called the little area also called Kiesselbachs plexus. It is an arterial plexus.
• Corresponding to the arteries some veins drain the Posterior inferior part of the Septum. That venous plexus is called a Woodruff's plexus.  

Causes of Epistaxis

Causes of epistaxis can be divided into:

Local causes	General cause
Trauma  Infection  Foreign body  Neoplasm of nose and paranasal sinus Deviated nasal septum	Hypertension  Disorders of  Blood vessels  Coagulopathy  Liver disease Renal disease  Drugs  Vicarious Menstruation

• Local causes
• General causes or systemic factors.
• Idiopathic causes: When there is no attributable cause for the nosebleed it is called an idiopathic cause.

Management of Epistaxis

Trotters method digital pressure

• Application of digital pressure over Kisselbach’s plexus for at least 15-20 minutes

• In this method, the patient is asked to pinch their nose and bend their head forward,  and stay in this position for 15 to 10 minutes. By pinching the nose, the patient is applying pressure in the little area which is the most common site of bleeding.  Only the pinching of the nose is called the Hippocrates method. 

Initial medical review and resuscitation 

• In this process, the patient is asked about the history of the bleeding. An order to access any trauma, infection, or any other problem that has caused this bleeding. 
• The query will also determine whether the cause is local, general, or idiopathic. The blood samples are sent or CBC, coagulation profile to rule out any coagulopathies. 
• With this, the patient is also given IV fluid, Crystalloids or colloids to replace the intravascular volume or whatever amount of blood loss has occurred. This entire process is called initial medical review and resuscitation.

ENT Preparation Articles:

NASAL POLYPS : Causes, Symptoms and Treatment : NEET PG ENT	Anatomy of Middle Ear - NEET PG ENT
Eustachian Tube (Anatomy, Physiology and Diagnostic Tests)	How to Prepare ENT for PG Entrance Exams
Disorders of Nose and Paranasal Sinus - NEET PG ENT

Prepare for Nasal Endoscopy

• This will give a clear picture of whether any internal bleeding is still taking place or not in the patient. Since the patient will already be in panic due to bleeding,  it is recommended to give a pledge of cotton soaked in 4% Xylocaine + Adrenaline.
  • Initial medical severe 
  • Direct therapy 
  • Indirect therapy 
  • Surgeries 
  • Embolization 
• In endoscopy if there is a single bleeding point then it needs to be cauterised:
  • Chemical cautery: silver nitrate solution can be used.
  • Electrical cautery: Thermal cautery.

Anterior nasal packing

↓Fails

Posterior nasal packing

↓Fails

• Surgeries (Ligation of artery)
  • Sphenopalatine Artery
  • Internal Maxillary Artery
  • Ethmoidal Artery 
  • ECA
• Case of no endoscopy or multiple bleeding points is spotted during the endoscopy.
  • In this case, the surgeon can do the packing; it is an indirect therapy. First anterior nasal packing is done if that fails after that posterior nasal packing is done. And when posterior nasal packing also fails then. The surgery is the ligation of arteries firstly sphenopalatine artery as it is called artery of epistaxis Embolization should be done if surgery fails.

Anterior Nasal Packing

• Anterior nasal packing means packing the nasal cavity from the vestibule anteriorly to the choana posteriorly. A Ribbon gauze is inserted which is dipped into bismuth iodoform paraffin paste. 

Posterior Nasal Packing

• Posterior nasal packing is performed to achieve haemostasis in cases of epistaxis from a suspected source located posteriorly in the nasal cavity, nasopharynx is also occluded in posterior nasal packing. 
• Modern-day packing is generally performed in the emergency department, commonly using balloon catheters. 

Ligation of Arteries

1. Sphenopalatine artery → Artery of Epistaxis 
2. Internal maxillary artery → Pterygopalatine fossa 
3. Ethmoidal artery 
4. External carotid artery 
   • Ligation of the artery begins with ligation of the Sphenopalatine artery is present in the sphenopalatine foramen, which is present near the posterior wall of the maxillary sinus.  
   • Internal maxillary artery: it is ligated in the Pterygopalatine fossa. 
   • Anterior and posterior ethmoidal arteries are found on the medial wall of the orbit. On the medial wall of the orbit, about 24 mm behind the Anterior ethmoidal foramen is presently transmitting the anterior ethmoidal artery. About 12 mm posterior to it Posterior ethmoidal foramen is present transmitting the posterior ethmoidal artery. 6 mm behind that is the optic canal transmitting the optic nerve. 
   • External carotid artery: It must be ligated at the level of the neck. At the level of the hyoid bone, the common carotid artery is divided into internal carotid and external carotid arteries (it has branches). 

Hereditary Haemorrhagic Telangiectasia (HHT)

• Autosomal dominant condition 
• Affects the blood vessels 

• Hereditary haemorrhagic telangiectasia (HHT) is an autosomal dominant condition that affects the blood vessels. The most common locations affected are the nose, lungs, brain, and liver. Management is different as compared to the normal epistaxis patient. 

Management of HHT

Recurrent bleeds
Blood not transfusion required Mild ↓ Moderate ↓ Laser photocoagulation Packing and antifibrinolytic agents ↓ Septodermoplasty	Blood transfusion required ↓ Severe ↓ Nasal closure youngs operation

• The first thing in the management of HHT is to check whether the bleeding is mild or severe. If a blood transfusion is not required, it is mild bleeding. If a blood transfusion is needed, then it is severe bleeding. In Septodermoplasty the mucosa is elevated over the septum and the entire mucosa is removed. 
• Along with the mucosa, the telangiectasia spots will also get removed. The cartilage and the bone of the septum are covered with facias or skin drafts. Complete closure of the nasal cavity is called a young's operation. 

One Liners 

• Most common cause of epistaxis is trauma
• Most common cause of epistaxis in children is trauma 
• Most common cause of epistaxis with foul smelling nasal discharge which is unilateral in children is FB
• Most common cause of recurrent unprovoked profuse epistaxis in adolescent male is JNA
• Most common cause of epistaxis in elderly is HTN
• Most common site of epistaxis is from Hitter area 
• Anterior epistaxis if venous occurs from Retrocolcemella-V
• Artery of epistaxis is SPA
• Posterior epistaxis occurs from WOODRUFF’S
• TESPAL stands for

Q. If you have a patient that is leaning forward and spitting up blood; what type of nosebleed would you assume ?

Ans. It is due to posterior epistaxis. 

Q. If someone comes into clinic with a nosebleed, upon PE you notice they also have a distended abdomen, what should you first thought be?

Ans. Portal hypertension or cirrhosis which is causing a distended abdomen. Also, whenever there is a liver disease nasal bleeding can occur. 

Q. Why is silver nitrate contraindicated for a bilateral nose bleed?

Ans. Silver nitrate is contraindicated for a bilateral nosebleed Because if it is applied to the corresponding area It can result in septal perforation. 

Q. If you are working in an urgent care and have a patient who complains of biweekly nosebleeds from unknown origins, what would be your initial work up?

Ans. Most often there could be systemic causes there can be local causes but since the cause mentioned here is unknown it can be a system cause.

• Epistaxis with a clinical picture like shown in the image, the probable diagnosis would be?

HHT management procedure should be followed. 

Q. Why patients with COPD and advanced cardiac conditions are preferable avoided with nasal packing ?

Ans. The patient will not be able to breathe properly and especially when the sleeping, the tongue is more likely to fall backwards, resulting in sleep apnoea. 

Q. After endoscopic sinus surgery a patient developed periorbital ecchymosis and blurring of vision. The cause of this is 

A. Sphenopalatine bleeding 

B. Anterior ethmoidal artery bleed

C. IMA bleed

D. Facial artery bleed

• Blurring of vision is mostly caused by the traumatized ethmoidal artery. As they are travelling from the medial wall of the orbit to the ethmoidal sinuses.

And that is everything you need to know about Epistaxis for your ENT preparation. For more informative and interesting blog posts to upgrade your NEET PG preparation, download the PrepLadder App and keep following our blog.