Bleeding from inside the nose is called epistaxis. It is fairly common and is seen in all age groups—children, adults and older people. It often presents as an emergency. Epistaxis is a sign and not a disease per se and an attempt should always be made to find any local or constitutional cause.
BLOOD SUPPLY OF NOSE
Nose is richly supplied by both the external and internal carotid systems, both on the septum and the lateral walls.
NASAL SEPTUM
Internal Carotid System
□ Anterior ethmoidal artery Branches of
□ Posterior ethmoidal artery Ophthalmic artery External Carotid System
□ Sphenopalatine artery (branch of maxillary artery), gives nasopalatine and posterior nasal septalbranches.
□ Septal branch of greater palatine artery (branch of maxillary artery).
□ Septal branch of superior labial artery (branch of facial artery).
LATERAL WALL
Internal Carotid System
□ Anterior ethmoidal Branches of
□ Posterior ethmoidal Ophthalmic artery External Carotid System
□ Posterior lateral nasal branches —> From sphenopalatine artery
□ Greater palatine artery —> From maxillary artery
□ Nasal branch of anterior superior dental -» From infraorbital branch of maxillary artery
□ Branches of facial artery to nasal vestibule
LITTLE’S AREA
It is situated in the anterior inferior part of nasal septum, just above the vestibule. Four arteries-anterior ethmoidal, septal branch of superior labial, septal branch of sphenopalatine and the greater palatine, anastomose here to form a vascular plexus called ‘Kiesselbach’s plexus’. This area is exposed to the drying effect of inspiratory current and to finger nail trauma, and is the usual site for epistaxis in children and young adults.
Retrocolumellar vein: This vein runs vertically downwards just behind the columella, crosses the floor of nose and joins venous plexus on the lateral nasal wall. This is a common site of venous bleeding in young people.
CAUSES OF EPISTAXIS
They may be divided into:
□ Local, in the nose or nasopharynx
□ General
□ Idiopathic
1. LOCAL CAUSES
Nose
□ Trauma. Finger nail trauma, injuries of nose, intranasal surgery, fractures of middle third of face and base of skull, hard-blowing of nose, violent sneeze.
□ Infections.
Acute: Viral rhinitis, nasal diphtheria, acute sinusitis.
Chronic: All ernst-forming diseases, e.g. atrophic rhinitis, rhinitis sicca, tuberculosis, syphilis septal perforation, granulomatous lesion of the nose, e.g. rhinosporodiosis.
□ Foreign bodies.
Non-living: Any neglected foreign body, rhinolith. Living: Maggots leeches.
□ Neoplasms of nose and paranasal sinuses. Benign: Haemangioma, papilloma. Malignant: Carcinoma or sarcoma.
□ Atmospheric changes. High altitudes, sudden decompression (Caisson’s disease).
□ Deviated nasal septum.
NASOPHARYNX
□ Adenoiditis
□ Juvenile angiofibroma
□ Malignant tumours
2. GENERAL CAUSES
□ Cardiovascular system. Hypertension, arteriosclerosis, mitral stenosis, pregnancy (hypertension and hormonal).
□ Disorders of blood and blood vessels. Aplastic anaemia, leukaemia, thrombocytopenic and vascular purpura, haemophilia, Christmas disease, scurvy, vitamin K deficiency, hereditary haemorrhagic telangectasia.
□ Liver disease. Hepatic cirrhosis (deficiency of factor 11, VII, IX &X).
□ Kidney disease. Chronic nephritis.
□ Drugs. Excessive use of salicylates and other analgesics (as for joint pains or headaches), anticoagulant therapy (for heart disease).
□ Mediastinal compression. Tumours of mediastinum (raised venous pressure in the nose).
□ Acute general infection. Influenza, measles, chickenpox, whooping cough, rheumatic fever, infectious mononucleosis, typhoid, pneumonia, malaria, dengue fever.
□ Vicarious menstruation (epistaxis occurring at the time of
3. IDIOPATHIC
Many times the cause of epistaxis is not clear.
SITES OF EPISTAXIS
□ Little’s area. In 90% cases of epistaxis, bleeding occurs from this site.
□ Above the level of middle turbinate. Bleeding from above the middle turbinate and corresponding area on the septum is often from the anterior and posterior ethmoidal vessels (internal carotid system).
□ Below the level of middle turbinate. Here bleeding is from the branches of sphenopalatine artery. It maybe hidden, lying lateral to middle or inferior turbinate and may require infrastructure of these turbinates for localisation of the bleeding site and placement of packing to control it.
□ Posterior part of nasal cavity. Here blood flows directly into the pharynx.
□ Diffuse. Both from septum and lateral nasal wall. This is often seen in general systemic disorders and blood dyscrasias.
□ Nasopharynx.
CLASSIFICATION OF EPISTAXIS
In general epistaxis can be classified as under:
ANTERIOR EPISTAXIS
When blood flows out from the front of nose with the patient in sitting position.
POSTERIOR EPISTAXIS
Mainly the blood flows back into the throat. Patient may swallow it and latter have a ‘coffee coloured’ vomitus. This may erroneously be diagnosed as haematemesis.
The differences between the two types of epistaxis are tabulated herewith.
MANAGEMENT
In any case of epistaxis, it is important to know:
□ Mode of onset.
□ Duration and frequency of bleeding.
□ Amount of blood loss.
□ Side of nose from where bleeding is occurring.
□ Whether bleeding is of anterior or posterior type.
□ Any known bleeding tendency in the patient or family.
□ History of known medical ailment (hypertension, leukaemias, mitral valve disease, cirrhosis, nephritis).
□ History of drug intake (analgesics, anticoagulant, etc.)
FIRST AID
Most of the time, bleeding occurs from the Little’s area and can be easily controlled by pinching the nose with thumb and index finger for about 5 minutes. This compresses the vessels of the Little’s area. In Trotter’s method patient is made to sit, leaning a little forward over a basin to spit any blood, and breathe quietly from the mouth. Cold compresses should be applied to the nose to cause reflexi vasoconstriction.
CAUTERISATION
This is useful in anterior epistaxis when bleeding point has been located. The area is first anaesthetised and the bleeding point cauterised with a bead of silver nitrate or coagulated with electrocautery.
ANTERIOR NASAL PACKING
In cases of active anterior epistaxis, nose is cleared of blood clots by suction and attempt is made to localise the bleeding site. In minor bleeds, from the accessible sites, cauterisation of the bleeding area can be done. If bleeding is profuse and/or the site of bleeding is difficult to localise, anterior packing should be done. For this, use a ribbon gauze soaked with liquid paraffin. About 1 metre gauze (2.5 cm wide in adults and 12 mm in children) is required for each nasal cavity.
First, few centimetres of gauze are folded upon itself and inserted along the floor, and then the whole nasal cavity is packed tightly by layering the gauze from floor to the roof and from before backwards. Packing can also be done in vertical layers from back to the front. One or both cavities may need to be packed. Pack can be removed after 24 hours if bleeding has stopped. Sometimes, it has to be kept for 2 to 3 days; in that case, systemic antibiotics should be given to prevent sinus infection and toxic shock syndrome.
POSTERIOR NASAL PACKING
It is required for patients bleeding posteriorly into the throat. A postnasal pack is first prepared by tying three silk ties to a piece of gauze rolled into the shape of a cone. A rubber catheter is passed through the nose and its end brought out from the mouth. Ends of the silk threads are tied to it and catheter withdrawn from nose. Pack, which follows the silk thread, is now guided into the nasopharynx with the index finger. Anterior nasal cavity is now packed and silk threads tied over a dental roll.
The third silk thread is cut short and allowed to hang in the oropharynx. It helps in easy removal of the pack later. Patients requiring postnasal pack should always be hospitalised. Instead of postnasal pack, a Folley’s catheter can also be used. The bulb is inflated with saline and pulled forward so that choana is blocked and then an anterior nasal pack is kept in the usual manner. These days nasal balloons are also available. A nasal balloon has two bulbs, one for the postnasal space and the other for nasal cavity.
ENDOSCOPIC CAUTERY
Posterior bleeding point can sometimes be better located with an endoscope. It can be coagulated with suction cautery. Local anaesthesia with sedation may be required.
ELEVATION OF MUCOPERICHONDRIAL FLAP AND SMR OPERATION
In case of persistent or recurrent bleeds from the septum, just elevation of mucoperichondrial flap and then repositioning it back helps to cause fibrosis and constrict blood vessels. SMR operation can be done to achieve the same result or remove any septal spur which is sometimes the cause of epistaxis.
LIGATION OF VESSELS
□ External carotid. When bleeding is from the external carotid system and the conservative measures have failed, ligation of external carotid artery above the origin of superior thyroid artery should be done. It is avoided these days in favour of embolisation or ligation of more peripheral branches.
□ Maxillary artery. Ligation of this artery is done in uncontrollable posterior epistaxis. Approach is via Caldwell-Luc operation. Posterior wall of maxillary sinus is removed and the maxillary artery or its branches are blocked by applying clips.
Endoscopic ligation of the maxillary artery can also be done through nose.
□ Ethmoidal arteries. In anterosuperior bleeding above the middle turbinate, not controlled by packing, anterior and posterior ethmoidal arteries which supply this area, can be ligated. The vessels are exposed in the medial wall of the orbit by an external ethmoid incision.
GENERAL MEASURES IN EPISTAXIS
□ Make the patient sit up with a back rest and record any blood loss taking place through spitting or vomiting.
□ Reassure the patient. Mild sedation should be given.
□ Keep check on pulse, BP and respiration.
□ Maintain haemodynamics. Blood transfusion may be required.
□ Antibiotics may be given to prevent sinusitis, if pack is to be kept beyond 24 hours.
□ Intermittent oxygen may be required in patients with bilateral packs because of increased pulmonary resistance from nasopulmonary reflex..
□ Investigate and treat the patient for any underlying local or general cause.
Hereditary haemorrhagic telangectasia: It occurs on the anterior part of nasal septum and is the cause of recurrent bleeding. It can be treated by using Argon, KTP or Nd: YAG laser. The procedure may require to be repeated several times in a year as telangectasia recurs in the surrounding mucosa. Some cases require septodermoplasty where anterior part of septal mucosa is excised and replaced by a split skin graft.