Tutorial 7
KAU Rabigh Medical
School
Department of Otolaryngology, Head and
Neck Surgery
Epistaxis
By Razan A. Basonbul, MBBS
Epidemiology
 Epistaxis is the most common bleeding disorder of
the head and neck.
 It is estimated to occur in about 60% of the
population.
 Most cases require no medical intervention.
 The majority of cases occur in children <10 and
adults >50 years old.
 More common in Males than Females.
Anatomy
 Blood Supply of the nose is through branches of both :
 Internal Carotid Artery.
 External carotid Artery .
 Epistaxis based on the location of bleeding is described as
 Anterior.
 Posterior.
 About 90% of cases occur in the region of the Kiesselbach’s
plexus ( Little’s area) along the anterior septum.
 It is Susceptible to bleeding due to fragile mucosa and tight
adherence to underlying mucosa affording little resistance
to mechanical stress.
 The usual location of posterior bleeding is the Woodruff’s
plexus on the lateral wall posterior to inferior/ middle
turbinate.
Little’s area (
Kiesselbach’s plexus)
• Most common site of bleeding (90%)
• Contributing arteries:
1. IC  Ophthalmic  Anterior ethmoid
2. EC  Facial  Superior Labial
3. EC  Maxillary  Desending palatine 
Greater palatine
4. EC  Maxillary  Sphenopalatine ( terminal
branches)
Etiology 80% idiopathic
 Local:
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Trauma/nose picking
Dry nasal mucosa/ Irritants
Tumors
Medications (nasal steroids)
Foreign body
Allergic rhinitis/sinusitis
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 Systemic:
Osler-weber-rendu Disease
Coagulopathies
Hemophilia
Thrombocytopenia
Medications
(anticoagulants/antihistamin
es/antihypertensives/antiinflammatories)
Hypertension / Aspirin!
Systemic infection
Recreational drugs
Alcohol
smoking
Evaluation
 Initial Assessment
 History
 Examination
 Investigation
 Management
Initial Assessment
 ABCs ( Airway, Breathing, IV access)
 Pulse Oxymetry placed prior to the physical exam and
record vitals.
 Unstable patients should have Intravenous (IV)
catheters and fluids started.
 Ask the patient to blow the nose to allow clots to move
out decreasing the bleeding.
 Sit up the patient with body tilted forward to prevent
blood from going down the pharynx.
 Apply continuous pressure to anterior cartilaginous
portion the nose for 5-10 min.
 If stable take a quick history.
History
 Make Sure the patient is
stable !
Disease, on regular oxygen
and ventilators),
 Duration of current episode,  known bleeding disorders,
 Amount of bleeding,
 Medications,
 Location of bleeding,
 recent illnesses,
 Intermittent VS continuous,
 recreational drug use,
 recent trauma,
 prior surgeries,
 prior history and treatment,  herbal medicines,
 chronic medical conditions (
Hypertension, Liver or Kidney
Examination
 Instruments necessary:
 nasal speculum,
 light source,
 suction, and irrigator.
 Inspect the turbinates and septum to identify the
general condition of the mucosa and location of
bleeding.
 Examine Oropharynx for clots ( risk of aspiration)
 Nasal Endoscopy for chronic, recurrent epistaxis
without obvious bleeding source.
 Systemic examination for other causes including
Neck exam and signs of bruises.
Investigations
 For:
 Patients with significant bleeding,
 known liver or renal disease,
 or on anticoagulation therapy.
 Do:
 complete blood count (CBC),
 Type and cross match,
 Prothrombin (PT)/partial thromboplastin time (PTT)/ bleeding
time ,
 Liver function tests and Creatinine.
 Patients with recurrent, unexplained epistaxis should be
evaluated for a hereditary bleeding disorder. The most
common one associated with epistaxis is von Willebrand
factor (vWF).
Management
 Correct hypovolemia ( 3:1 role: for every loss of
100ml blood replace by 300ml crystalloid fluid)
 If hypertensive control with antihypertensive
carefully.
 If known bleeding disorder, replace by
appropriate blood component.
 Apply vasoconstrictive ( Phenylephrine,
oxymetazoline [ Afrin ] ) and if necessary, Local
anesthetic agents ( Lidocaine ) either directly or
on a nasal pledge.
 If minor Bleeding and stopped afterwards,
Chemichal Cauterization ( silver nitrate) can be
used for localized bleeding.
 Topical hemostatic agents as Gelfoam, surgicel,
floseal can be placed that provides
procoagulant effect after cauterization attempts.
( nasal spray is needed for several days to allow
resorption).
 If bleeding is still active, Nasal Packing is
preformed.
 Anterior Nasal Packing:
 Nasal Tampons and extendable sponges; provide
pressure against nasal mucosa
 Vaseline Strep-Gauze; placed to posterior choanae,
controls most posterior bleeds, Placed for 3-5 days,
provided with anti- staphylococcal antibiotics.
 Posterior Nasal Packing:
 Foley catheter, pneumatic nasal catheter or
posterior packing is placed.
 Nasal Balloons; ( 2 balloons one in nasopharynx and
other in nasal cavity) is advisable
 Packing of both sides or posterior packing is an
indication for Hospital admission!!
 If bleeding persists;
1. Posterior packing.
2. Endoscopic cautery.
3. Endoscopic clipping of the sphenopalatine artery.
4. Transantral ligation of internal maxillary artery.
5. Angiograpgy with embolization.
 In Summery:
Squeeze - Look & Cauterize - Anterior Pack - Balloon - Posterior
pack - Surgery or Embolization.
Typical contents of an epistaxis tray. Top row: nasal decongestant
sprays and local anesthetic, silver nitrate cautery sticks, bayonet
forceps, nasal speculum, Frazier suction tip, posterior double balloon
system and syringe for balloon inflation. Bottom row: Packing
materials, including nonadherent gauze impregnated with petroleum
jelly and 3 percent bismuth tribromophenate (Xeroform), Merocel,
Gelfoam, and suction cautery.
Anterior Nasal
packing
Posterior Nasal Packing
Nasal Balloon Packing
Complications
Complications may occur as a result of any
treatment intervention and include:
 Infection (localized or spread into surrounding
tissues),
 Abscess formation,
 Septal Necrosis,
 Septal hematoma,
 Septal perforation.
Questions ?
Take Home Messages
 Most common (90%) site of bleeding is Anterior
bleeds from Little’s area ( Kiesselbach’s plexus)
 Most common cause of epistaxis in children is
nasal picking (trauma) and dry mucosa and viral
URTIs with frequent nose blowing.
 Systemic illness and medications are important
causes of nose bleeding in Adults.
 Check ABCs and Stabilize the patient first!
 “Blow your nose”, “Sit up and tilt forward” and
apply CONTINOUS pressure for 5-10 min.
 Tips to prevent a nosebleed:
 Keep the lining of the nose moist by gently applying a
light coating of petroleum jelly or an antibiotic
ointment with a cotton swab three times daily,
including at bedtime.
 Keep children’s fingernails short to discourage nosepicking.
 Counteract the effects of dry air by using a humidifier.
 Use a saline nasal spray to moisten dry nasal
membranes.
 Quit smoking. Smoking dries out the nose and irritates
it.
 Tips to prevent rebleeding after initial bleeding has
stopped:
 Do not pick or blow nose.
 Do not strain or bend down to lift anything heavy.
 Keep head higher than the heart.
 Admit the person to hospital if:
 Epistaxis continues despite efforts to stop the
bleeding.
 Bleeding from the posterior area of the nose is
suspected.
 A nasal pack has been inserted in primary care.
 Consider admission to hospital if the person is
elderly or has a comorbid condition (such as
coronary artery disease, severe hypertension,
clotting disorder, or significant anemia).
 Consider referral to ORL specialist if the person
has recurrent episodes and is at high risk of
having a serious underlying cause,
 Use clinical judgment and consider referral in the
following groups:
 Males 12–20 years of age — angiofibroma is
possible (but rare).
 People with any symptoms suggestive of cancer
— such as nasal obstruction, facial pain, hearing
loss, eye symptoms (proptosis or double vision), or
palpable neck glands.
 People with a family history of hereditary
haemorrhagic telangiectasia and suggestive
features upon examination — telangiectasia on
the lips, mucous membranes, and fingers.
 People with occupational exposure to wood dust
or chemicals as they are prone to nasopharyngeal
cancer.
Thank you 
 References:
 Books:
 Primary care otolaryngology.
 Taylor’s Manual of family Medicine.
 Otolaryngology head and neck surgery by Raza Pasha,MD
 Websites:
 http://www.entnet.org/EducationAndResearch/cool.cfm
 http://www.cks.nhs.uk/epistaxis/management/scenario_recur
rent_epistaxis/referral