7.2 Epistaxis (Nosebleeds)

Question 1

What is Epistaxis?

Answer 1

Bleeding from the nose (very common)

Question 2

What are the 2 broad causes of Epistaxis?

Answer 2

Local or Systemic

Question 3

Are Anterior or Posterior nose bleeds more common?

Answer 3

Anterior (90%)

Question 4

Where do posterior nose bleeds arise from? What does this mean in terms of treatment?

Answer 4

Sphenopalatine artery

Much more difficult to treat

Question 5

What are the 2 main branches of the ECA that supply the nose?

What specific branches do each give off?

Answer 5

1) Facial A gives of:
* Branch of superior labial A
2) Maxillary A gives of:

• Sphenopalatine A
• Greater palatine A

Question 6

What is the main branch of the ICA which supplies the nose?

What 2 branches does this give off?

Answer 6

Ophthalmic A which gives off the:

• Anterior ethmoidal A
• Posterior ethmoidal A

Question 7

Which wall of the nasal cavity do most nose bleeds arise from and why?

Answer 7

From the medial/septal wall

Most are anterior and derive from Little’s area (Kiesselbach`s plexus) which is a localised region of the antero-inferior septum (medial wall)

Commonly occur here because there is a huge anastomoses of BVs

Question 8

What is the internal and external venous drainage of the nose?

Answer 8

Internally to:

• Cavernous sinus
• Pterygoid plexus

Externally to Facial vein

Question 9

Where do most blood vessels in Little’s area come from?

(Anterior circulation)

Answer 9

External Carotid branches:

• Greater Palantine
• Superior Labial

Anastomosing with Internal Carotid:

• Anterior Ethmoidal

Question 10

What blood vessels are involved in the posterior vascular supply of the nose?

What is the name for the ‘anastomosis here’?

Answer 10

Primarily from the Internal maxillary artery, with predominant flow down the Sphenopalantine branch

Some superior supply by the posterior ethmoidal

The anastomosis here is called Woodruffs plexus.

Question 11

Who is most affected by Epistaxis?

Answer 11

Bimodal distribution (young and old)

Question 12

Give 4 risks for Epistaxis and state which are the most common

Answer 12

1) Trauma (common)
2) Anticoagulants (common in elderly)
3) Mucosal drying (common)
4) Vascular abnormalities
5) Coagulation defects
6) Infections
7) NSAIDs

Question 13

What are the first two things that should be done for a nose bleed?

Answer 13

1) Compression: squeeze the nostrils together (little area is 1-2cm back from here)
2) Ice: add a cold compress (ie. ice pack) in order to try and constrict the vessels

This should be done for 10mins, if time reaches20+ mins, take to A & E

Question 14

What can a doctor do to try and stop a bleed if first measures fails?

Answer 14

Cautery (silver nitrate or electro)

Question 15

If Cautery fails what else can be tried?

Explain how these are inserted and where they sit?

Answer 15

Nasal tampons

Place in straight backwards (remember nose goes back not up). Should sit directly back

Question 16

If the bleed is identified as posterior bleed what can be done?

Answer 16

Posterior packing

Pack the inside of nose with gauze, layering it up and down and aiming to push it as far back the nose as possible. May work…. if it doesn’t a catheter tends to be used in additon to packing infront

Question 17

If all interventions fail (worst case scenario) what are the last resorts?

Answer 17

1) Surgical intervention with ligation of branches (in order)

• SPA ligation
• Maxillary artery ligation
• External carotid ligation

2) Radiological embolisation (more common then ligation)

Question 18

Summarise the 6 basic steps (in order) for management of Epitaxis

Answer 18

1) compress and ice
2) cautery silver nitrate
3) nasal tampon
4) anterior packing
5) bigger anterior pack + posterior pack
6) ligating arteries or embolisation