Conditions of the Nose and Paranasal Sinuses » Epistaxis
- Almost always from nasal septum.
- Confluence of blood vessels (rich supply) to anterior nasal septum called Little’s
area or Kieselbach’s plexus.
- Site of 99% of childhood (and most adults) epistaxis
- Almost always lateral nasal wall.
- Blood supply is sphenopalatine artery from sphenopalatine foramen. Just below
posterior end of middle turbinate insertion.
- Common site of elderly hypertension related epistaxis.
The most common epistaxis is in a healthy child or adult without risk factors who bleeds from the septum. Most likely cause is the cycle of mucosal dryness ? mucosal cracking/crusting ? bleeding.
- Anti-coagulants (eg. ASA, Plavix, Coumadin)
- Trauma (including nose picking)
- Nasal surgery (first 2 weeks post operative)
- Nasal septal perforation
- Hereditary Hemorrhagic Telangiectasias
- Bleeding diatheses
- Rarely, sinonasal tumors
Treatment (mild to moderate epistaxis)
- Educate patient/caregiver on proper application of nose pinching (pressure).
- Apply Vaseline or other ointment to anterior nasal septal areas. Preventive effect to break cycle of mucosal dryness leading to bleeding.
- If specific localized bleeding source seen, may cauterize with silver nitrate under topical anesthesia.
- For more diffuse mucosal bleeding, gentle insertion of ointment impregnated packing. Leave in 2-3 days.
Treatment (moderate to severe epistaxis)
- As above for mild to moderate epistaxis.
- If severe , initial treatment options consist of assessment, ABC’s, manage hypertension, measure hemoglobin, type and screen.
- Clean nose, i.e.) clear all blood/clots from nose. Patient nose blowing or suction. Apply topical anesthesia. Try to visualize bleeding.
- Then if localized bleeding, try silver nitrate cautery or electrocautery.
- Then if diffuse bleeding, try anterior and/or posterior nasal packing.
- If still refractory to nasal packing or as an alternative to packing for severe bleeding, consider arterial ligation or embolization.