Conditions of the Nose and Paranasal Sinuses » Epistaxis

 

Type

• ANTERIOR
  • Almost always from nasal septum.
  • Confluence of blood vessels (rich supply) to anterior nasal septum called Little’s
    area or Kieselbach’s plexus.
  • Site of 99% of childhood (and most adults) epistaxis

• POSTERIOR
  • Almost always lateral nasal wall.
  • Blood supply is sphenopalatine artery from sphenopalatine foramen. Just below
    posterior end of middle turbinate insertion.
  • Common site of elderly hypertension related epistaxis.

The most common epistaxis is in a healthy child or adult without risk factors who bleeds from the septum. Most likely cause is the cycle of mucosal dryness ? mucosal cracking/crusting ? bleeding.

 

Rick factors

• Hypertension
• Anti-coagulants (eg. ASA, Plavix, Coumadin)
• Trauma (including nose picking)
• Nasal surgery (first 2 weeks post operative)
• Nasal septal perforation
• Hereditary Hemorrhagic Telangiectasias
• Bleeding diatheses
• Rarely, sinonasal tumors

 

Treatment (mild to moderate epistaxis)

• Educate patient/caregiver on proper application of nose pinching (pressure).
• Apply Vaseline or other ointment to anterior nasal septal areas. Preventive effect to break cycle of mucosal dryness leading to bleeding.
• If specific localized bleeding source seen, may cauterize with silver nitrate under topical anesthesia.
• For more diffuse mucosal bleeding, gentle insertion of ointment impregnated packing. Leave in 2-3 days.

Treatment (moderate to severe epistaxis)

• As above for mild to moderate epistaxis.
• If severe , initial treatment options consist of assessment, ABC’s, manage hypertension, measure hemoglobin, type and screen.
• Clean nose, i.e.) clear all blood/clots from nose. Patient nose blowing or suction. Apply topical anesthesia. Try to visualize bleeding.
• Then if localized bleeding, try silver nitrate cautery or electrocautery.
• Then if diffuse bleeding, try anterior and/or posterior nasal packing.
• If still refractory to nasal packing or as an alternative to packing for severe bleeding, consider arterial ligation or embolization.

Additional Resources

• Epistaxis Management Case
  

 

 

 

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