Epistaxis. ENT Lab. Asist. Univ. Dr.

Florentina Severin 2020

EPISTAXIS

This disease represents the number one nasal emergency. Bleeding can begin in many places in the
nose and can result from many conditions.

The blood supply of the nose is through two arterial systems. The ethmoid arteries arise from the
internal carotid system and the sphenopalatine artery is supplied by the external carotid system
through the internal maxillary artery.

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The most common site of bleeding is Kiesselbach's plexus= Little area, which lies near the surface
of the mucous membrane covering the anterior one third of the nasal septum.

This plexus is formed by the anastomosis of the septal branches of the sphenopalatine artery with
the septal branches from the ethmoid arteries.

Other areas of hemorrhage are found around the anterior end of the inferior turbinate and posterior
by at the posterior end of the inferior meatus.
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 Epistaxis. ENT Lab. Asist. Univ. Dr. Florentina Severin 2020

The common causes of epistaxis are: trauma, environmental conditions, and perforation of the
septum, blood dyscrasias, growths, genetic factors, hypertension and debilitating illness.

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 Epistaxis. ENT Lab. Asist. Univ. Dr. Florentina Severin 2020

Anterior bleeding
This is the common site, bleeding comes from septal blood vessels on Kiesselbach area. It has been
suggested that bleeding occurs from this site because it is the center of the septal arterial
vascularisation but this lacks anatomical proof.
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 Epistaxis. ENT Lab. Asist. Univ. Dr. Florentina Severin 2020

Posterior bleeding is most commonly occurs in patients with non-contractable arteriosclerotic

nasal blood vessels. These patients are difficult to manage since the bleeding paint is inaccessible to
vision and to pressure. In the majority of patients the posterior bleeding point is never identified, but
a proper examination should be performed to exclude any underlying pathology like neoplasm.

Treatment
The upper part of the body at least should be upright. Cold compresses are applied to the nape of the
neck and on the dorsum of the nose.

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Mild pressure is applied to both nasal alae for several minutes.

In cases of simple bleeding from the anterior septum or turbinate, place a cotton pledged
soaked with ephedrine solution in the nose to cover the bleeding area and apply external
compression for 5-6 min.

If the bleeding is controlled, apply a local anesthetic to the blood area and touch the bleeding
area with a silver nitrate tipped applicator.

Instead of silver nitrate, chronic or trichloracetic acid hemostasis may be due with cold
cautery, electrocautery, radiofrequency and laser.

If the bleeding is profuse and cannot be controlled by the methods above, it may be
necessary to pack the nose.

The anterior packing is inserted in a zig-zag pattern starting at the floor of the nostril and
then cranially.

Both ends should be left at the anterior nostril for at the least 24-48hours.

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 Epistaxis. ENT Lab. Asist. Univ. Dr. Florentina Severin 2020

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If despite this there is still bleeding usually visible on the back of the throat, the nose should
be repacked or alternatively a postnasal pack inserted.

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 Epistaxis. ENT Lab. Asist. Univ. Dr. Florentina Severin 2020

Now we use for stopping the nasal bleeding a Foley catheter or other types of balloons that
can apply direct pressure on the nasal cavity walls and close the choanae. The packing stays for 78h
hours

It has been recommended the prophylactic antibiotics should be given to prevent these clots
becoming infected.

Vascular ligation is the procedure which must be carried out for uncontrolled life threatening
epistaxis, if the methods is described above have not been effective.

It may be necessary to ligate the internal maxillary artery in the pterygopalatine fossa, the
anterior and posterior ethmoidal arteries or external carotid artery above the origin of the superior
thyroid artery.

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Today is possible to use selective embolisation of the branch of the external carotid artery.

Sometimes blood transfusion is needed in order to treat the blood loss and vitamin C,
systemic hemostatic agents.
Nasal fracture
There will be swelling and localized tenderness over the fracture line and some loss of
function of the nose as an airway. There may or may not be bony displacement.

The main aim of diagnosis is to assess nasal displacement.

Nasal deformity can be classified as deviation of the nasal pyramid, saddling of the nose
from the crushing of the dorsum and widening as the result of lateral displacement of the nasal
bones. It's possible to find fracture or dislocation of the nasal septum.

Essentially, displaced nasal fractures can be categorized as to whether de main direction of

the face has come from the side or has come from the front, though, obviously, combinations can

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 Epistaxis. ENT Lab. Asist. Univ. Dr. Florentina Severin 2020

occur depending on how many times and how the nose has been hit. It's possible to observe nasal
obstruction or bleeding. External examination can observe a lateral injury or a frontal one. It's
necessary to observe the stage of the nasal pyramid, the presence of ecchymosis, orbital swelling,
proptosis, limitation of eye movement, nasal obstruction and the bleeding or rhinorrhea if are
unilateral or bilateral.

The nose should be bimanually palpated to see if the pyramid is mobile and to note crepitus
resulting from the movement of bone fragments.

Where there is frontal force, the fracture can extend to involve ethmoid bones, the cribriform
plate and the floor of the orbit. It's possible to find rhinorrhea or the presence of cerebrospinal fluid
(CSF). CSF will give a halo of moisture around the blood.

Loss of the sense of smell in cribriform plate fractures, can also occur as the nose is blocked
by oedema or blood clots.

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 Epistaxis. ENT Lab. Asist. Univ. Dr. Florentina Severin 2020

Treatment
Simple nasal fractures involving only the nasal bones with free mobility of the fragments
can be corrected by elevating the bridge of the nose with a thin instrument placed in the nostril and
manually realigning the fragments of the nasal bones.

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A small pack and external stent may be needed to hold the fragments in alignment.

Fractures of the nose involving the septum, the orbit, or saddling of the nose from a crushing
blow or when there has been serious hemorrhage or rhinorrhea following an accident must be

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 Epistaxis. ENT Lab. Asist. Univ. Dr. Florentina Severin 2020

solved. CSF requires prophylactic antibiotics to prevent ascending meningitis. For the patient with
an old lateral displacement, the most satisfactory treatment is septorhinoplasty.

Nasal foreign body

This is commonly occurs in children and a large variety of objects are known to have been
inserted.

Most foreign bodies in the nasal cavity elicit a profuse inflammatory response and foul nasal
discharge.

Organic materials particularly behave this way. Many objects remain asymptomatic until a
discharge develops. So a unilateral discharge must be assumed to be due to a foreign body and
examination of the nose is indicated.

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 Epistaxis. ENT Lab. Asist. Univ. Dr. Florentina Severin 2020

A secondary inflammation of the nasal vestibular skin may develop in response to a constant
discharge.

Small non organic foreign objects may lie unnoticed in the nose for many years. Nasal
secretions may solidify around the object and a nasal concretion, rhinolith may develop.

Foreign body removal: suction tip, bayonet and tobey forceps, curret and hock.

ATTENTION == risk of pulmonary aspiration in children!!!!

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Epistaxis. ENT Lab. Asist. Univ. Dr. Florentina Severin 2020

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