Epistaxis: Causes And Management

They may be divided into:
A. Local, in the nose or nasopharynx.
B. General.
C. Idiopathic.
A. Local Causes
Nose
1. 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.
2. Infections.
Acute: Viral rhinitis, nasal diphtheria, acute sinusitis.
Chronic: All crust-forming diseases, e.g. atrophic
rhinitis, rhinitis sicca, tuberculosis, syphilis septal
perforation, granulomatous lesion of the nose, e.g.
rhinosporidiosis.
3. Foreign bodies.
Non-living: Any neglected foreign body, rhinolith.
Living: Maggots leeches.
4. Neoplasms of nose and paranasal sinuses.
Benign: Haemangioma, papilloma.
Malignant: Carcinoma or sarcoma.
5. Atmospheric changes. High altitudes, sudden decompression
(Caisson's disease).
6. Deviated nasal septum.
Nasopharynx
1. Adenoiditis
2. Juvenile angiofibroma
3. Malignant tumours
B. General Causes
1. Cardiovascular system. Hypertension, arteriosclerosis,
mitral stenosis, pregnancy (hypertension and
hormonal).
2. Disorders of blood and blood vessels. Aplastic anaemia,
leukaemia, thrombocytopenic and vascular purpura,
haemophilia, Christmas disease, scurvy, vitamin K
deficiency, hereditary haemorrhagic telangectasia.
3. Liver disease. Hepatic cirrhosis (deficiency of factor
II, VII, IX & X).
4. Kidney disease. Chronic nephritis.5. Drugs. Excessive use of salicylates and other analgesics
(as for joint pains or headaches), anticoagulant
therapy (for heart disease).
6. Mediastinal compression. Tumours of mediastinum
(raised venous pressure in the nose).
7. Acute general infection. Influenza, measles, chickenpox,
whooping cough, rheumatic fever, infectious
mononucleosis, typhoid, pneumonia, malaria, dengue
fever .
8.Vicarious Menstruation
C. Idiopathic
Many times the cause of epistaxis is not clear.
SITES OF EPISTAXIS
1. Little's area. In 90% cases of epistaxis, bleeding
occurs from this site.
2. 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).
3. Below the level of middle turbinate. Here bleeding is from
the branches of sphenopalatine artery. It may be
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.
4. Posterior part of nasal cavity. Here blood flows
directly into the pharynx.
5. Diffuse. Both from septum and lateral nasal wall.
This is often seen in general systemic disorders and
blood dyscrasias.
6. Nasopharynx.
CLASSIFICATION OF EPISTAXIS
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 later have a "coffee coloured" vomitus.
This may erroneously be diagnosed as haematemesis.
Management
In any case of epistaxis, it is important to know:
1. Mode of onset. Spontaneous or finger nail trauma.
2. Duration and frequency of bleeding.
3. Amount of blood loss.
4. Side of nose from where bleeding is occurring.
5. Whether bleeding is of anterior or posterior type.
6. Any known bleeding tendency in the patient or
family.
7. History of known medical ailment (hypertension,
leukaemias, mitral valve disease, cirrhosis, nephritis).
8. History of drug intake (analgesics, anticoagulants,
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 sp it any blood, and breathe quietly from the mouth.
Cold compresses should be applied to the nose to cause
reflex vasoconstriction.
Cauterisation
ThiS IS useful ll1 anterior epistaxIs when bleedll1g 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, nos~ 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 (Fig. 33.4). 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 Foley'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
(a) External carOM. 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.
(b) Maxilla?")' arte?")'. 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
a lso be done through nose.
(c) 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
1. Make the patient sit up with a back rest and record any
blood loss taking place through sp itting or vomiting.
2. Reassure the patient. Mild sedation should be given.
3. Keep check on pulse, BP and respiration.
4. Maintain haemodynamics. Blood transfusion may
be required.
S. Antibiotics may be given to prevent sinusitis, if
pack is to be kept beyond 24 hours.
6. Intermittent oxygen may be required in patients
with bilateral packs because of increased pulmonary
resistance from nasopulmonary reflex.
7. Investigate and treat the patient for any underlying
local or general cause.