Epistaxis

Introduction & Anatomy - Nosebleed Nuances

• Epistaxis: Bleeding from the nose.
• Nasal Septum Vascular Supply:
  • Little's Area (Kiesselbach's Plexus): Anterosuperior septum. Arteries: 📌 Superior labial, Anterior ethmoidal, Greater palatine, Sphenopalatine (SAGS).
  • Woodruff's Plexus: Posteroinferior, primarily sphenopalatine artery.
• Lateral Wall Supply: Sphenopalatine, ant/post ethmoidals, facial & greater palatine artery branches.

⭐ Kiesselbach's plexus in Little's area is the most common site (~90%) for anterior epistaxis.

Etiology - The Bleed Breakdown

Clinical Evaluation - Source Sleuthing

• History: Onset (spontaneous/traumatic), duration, frequency, severity, laterality, site clues (anterior/posterior), provoking factors. Medical Hx (HTN, coagulopathy), Drug Hx (anticoagulants, nasal sprays).
• Examination:
  • Assess hemodynamic stability (pulse, BP).
  • Anterior rhinoscopy: remove clots, identify bleeding point.
  • Nasal endoscopy: if site unclear or posterior bleed suspected.
• Differentiating Anterior vs. Posterior Epistaxis:

• Investigations:
  • CBC (assess blood loss).
  • Coagulation profile (PT, aPTT, INR): if recurrent/severe/systemic cause suspected/on anticoagulants.
  • CT/MRI: for suspected tumors/sinus pathology or refractory epistaxis.

⭐ Posterior epistaxis typically involves bleeding from branches of the sphenopalatine artery (Woodruff's plexus) and often presents with blood trickling down the pharynx.

Management - Flow Stoppers

• Initial: ABCs. Trotter's method (pinch soft nose, lean forward, mouth breathe 10-20 mins). Ice pack (nasal bridge).

• Medical/Cautery (if bleeding point visible):

  • Topical vasoconstrictors: Oxymetazoline, Adrenaline 1:1000.
  • Cauterization: Chemical ($AgNO_3$ - avoid bilateral septal), Electrocautery.

• Nasal Packing (24-72 hrs):

  • Anterior: Absorbable (Surgicel, Gelfoam); Non-absorbable (Merocel, BIPP - add prophylactic antibiotics).
  • Posterior: Foley's catheter (10-14 Fr), Epistat/Brighton balloon.

• Surgical/Interventional (refractory/severe posterior):

  • ESPAL (Endoscopic Sphenopalatine Artery Ligation) - Treatment of Choice.
  • A/P Ethmoidal Artery Ligation. Maxillary Artery Ligation.
  • Arterial Embolization (Interventional Radiology).

⭐ ESPAL has >90% success for intractable posterior epistaxis, preferred over older methods.

Complications & Special Cases - Red Alert Risks

• Epistaxis Complications: Anemia, hypovolemic shock, aspiration, sinusitis.
• Management Complications:
  • Nasal Packing: Pain, infection, sinusitis, Toxic Shock Syndrome (TSS) (📌 Staph. aureus), septal perforation, alar necrosis.
  • Cautery: Crusting, septal perforation, synechiae.
  • Surgery/Embolization: Anesthesia risks, blindness, stroke.
• Special Cases:
  • Children: Usually anterior; consider foreign body, JNA (adolescent males).
  • Anticoagulated: ↑risk; manage anticoagulation.
  • HHT: Recurrent; laser, septodermoplasty, Avastin.

⭐ Toxic Shock Syndrome (TSS), with fever, rash, hypotension, is a rare but life-threatening risk of prolonged nasal packing.

High‑Yield Points - ⚡ Biggest Takeaways

• Little's area (Kiesselbach's plexus) is the most common site for anterior epistaxis.
• Posterior epistaxis often arises from Woodruff's plexus (sphenopalatine artery branches), common in elderly/hypertensives.
• Initial management: ABCs, Trotter's method (direct pressure), anterior/posterior nasal packing, then cautery.
• Sphenopalatine Artery Ligation (SPAL) is a key surgical option for refractory posterior epistaxis.
• Suspect Juvenile Nasopharyngeal Angiofibroma (JNA) with recurrent, profuse epistaxis in adolescent males.
• Hereditary Hemorrhagic Telangiectasia (HHT) presents with recurrent epistaxis and multiple telangiectasias.
• Uncontrolled hypertension is a major risk factor, especially for severe or posterior bleeds.