Epistaxis

  • Main blood supply to nose is the sphenopalatine artery
  • Terminal branch of the external carotid artery
  • Incidence of epistaxis has a bimodal distribution
  • Commonest in childhood and old age
  • Causes are different in the two age groups
  • Epistaxis may be classified as either anterior or posterior
  • 80% of cases are anterior and arise on lower part of nasal septum (Little's area)
  • 80% of cases are idiopathic

Aetiology

Local causes

  • Idiopathic
  • Trauma
    • Minor trauma
    • Nasal fractures
  • Inflammatory
    • Infective rhinitis
    • Atrophic rhinitis
    • Sinusitis
  • Neoplastic
    • Squamous carcinoma
    • Juvenile angiofibroma

General causes

  • Systemic hypertension
  • Haematological abnormalities
  • Anticoagulation

Management of epistaxis

  • Commonest local cause 
    • Spontaneous haemorrhage
    • Usually in children
    • Usually due to anterior nasal haemorrhage
  • Commonest general cause
    • Hypertension
    • Usually in elderly
    • Usually due to posterior nasal haemorrhage
  • After initial clinical assessment will need
    • Blood count, clotting screen and possibly cross match
    • Volume resuscitation may be required
    • Exclude hypertension

Anterior nasal haemorrhage

  • Apply pressure
  • 1: 1000 adrenaline applied to Little's area
  • Consider cautery to retrocolumellar veins
  • Can usually be achieved with a silver nitrate stick
  • Electrocautery may be attempted
  • Anterior nasal packing should be considered if bleeding persists
  • Can be carried out with a nasal tampon or formal nasal pack
  • Prophylactic antibiotics should be used if pack in place for more than 48 hours

Posterior nasal haemorrhage

  • Often can not be controlled with local measures
  • May require insertion of a balloon or posterior nasal pack
  • Performed with layered BIPP ribbon gauze pack
  • If fails to control bleeding need to consider surgery
  • Endoscopic electrocautery can be attempted
  • May require ligation of maxillary and anterior ethmoidal artery

Bibliography

Alvi A,  Joyner-Triplett N. Acute epistaxis:  how to spot the source and stop the flow.  Postgrad Med 1996;  99:  83-96.

Kumar S,  Shetty A,  Rockey J et al.  Contemporary surgical treatment of epistaxis.  What is the evidence for sphenopalatine artery ligation.  Clin Otolaryngol 2003;  28:  360-363.

Tan L K,  Calhoun K H.  Epistaxis.  Med Clin North Am 1999;  83:  43-56.

 

 
 

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