Epistaxis


By

Dr. T. Balasubramanian M.S. D.L.O.

Definition: Epistaxis is defined as bleeding from the nasal cavity. This is a Greek word meaning nose bleed. Since it is a very common problem its true incidence is very difficult to predict.

History: Hippocrates said that pinching the nose for sometime and asking the patient to breath through the mouth stopped bleeding from the nose. Carl Michel and James Little were the first to identify the vascular plexus in the anterior part of the nasal septum as the common area from which nasal bleeding occurs. Pilz was the first person to treat epistaxis by surgically ligating the external carotid artery, seiffert ligated the internal maxillary artery through the maxillary antrum via caldwelluc approach.

The nose has a rich supply of blood vessels with good contribution from both external and internal carotid systems. The general rule of the thumb is that the area of nasal cavity below the level of middle turbinate has rich blood supply from the external carotid system, where as the area above the middle turbinate receives extensive supply from the internal carotid artery. Anastomosis occur between the external and internal carotid system throughout the nasal cavity.

External carotid system: Blood from the external carotid system reaches the nasal cavity via the facial and the internal maxillary arteries which are branches of the external carotid artery. The artery of epistaxis is the sphenopalatine branch of internal maxillary artery. This is called so because this vessels supplies the major portion of the nasal cavity. It enters the nasal cavity at the posterior end of the middle turbinate to supply the lateral nasal wall, it also gives off a septal branch which supplies the nasal septum.

Facial artery: the superior labial branch of the facial artery is one of its terminal branches. It supplies the anterior nasal floor and anterior portion of the nasal septum through its septal branch.

Internal maxillary artery: after entering into the pterygopalatine fossa this vessel gives rise to 6 branches. These branches are posterior superior aleveolar artery, descending palatine artery, infra orbital artery, sphenopalatine artery, pterygoid artery, and pharyngeal artery. The descending palatine artery enters the nasal cavity through the greater palatine canal to supply the lateral wall of the nose, it also contributes blood supply to the nasal septum through its septal branch.

Internal carotid system: the internal carotid artery supplies the nasal cavity via its ophthalmic artery. It enters the orbit via the superior orbital fissure and divides into many branches. The posterior ethmoiod artery one of the branches of ophthalmic artery exits the orbit via the posterior ethmoidal foramen located 2-9 mm anterior to the optic canal. The anterior ethmoidal artery which is larger leaves the orbit through the anterior ethmoidal foramen. Both these vessels cross the roof of the ethmoid and descends into the nasal cavity through the cribriform plate. It is here that these vessels divide into lateral and septal branches to supply the nose.

Blood supply of lateral nasal wall


Little's area: This area is located in the anterior part of the cartilagenous portion of the nasal septum. Here there is extensive submucous anastomosis of blood vessels both from the external and the internal carotid systems. Bleeding commonly occurs from this area since it is highly vascular and is also exposed to the exterior. Anastomosis occur between the septal branches of sphenopalatine artery, greater palatine artery, superior labial artery and the anterior ethmoidal artery. This plexus is also known as Keisselbach's plexus. Bleeding from this area is common because mucosal drying occurs commonly here and this area is easily accessible to nose picking. Among the vessels taking part in the anastomosis the anterior ethmoidal artery is from the internal carotid system while the other vessels are from the external carotid system. Bleeding from this area is clearly seen and easily accessible and flows through the anterior nasal cavity hence it is known as anterior bleed.












Little's area of nose

Woodruff's plexus: is responsible for posterior bleeds. This area is located over the posterior end of the middle turbinate. The anastomosis here is made up of branches from the internal maxillary artery namely its sphenopalatine and ascending pharyngeal branches. The maxillary sinus ostium forms the dividing line between the anterior and posterior nasal bleeds. Posterior nasal bleeds are difficult to treat because bleeding area is not easily accessible. Bleeding from Woodruff's plexus commonly occur in patients with extremely high blood pressure. Infact this plexus acts as a safety valve in reducing the blood pressure in these patients, lest they will bleed intracranially causing more problems. In patients with posterior bleeds it is difficult to access the amount of blood loss because most of the blood is swallowed by the patient.

Etiology: The etiology of epistaxis is not just simple or straight forward. It is commonly multifactorial, needing careful history taking and physical examination skill to identify the cause. For purposes of clear understanding the etiology of epistaxis can be classified under two broad heads, i.e. local and systemic causes.

Local factors causing epistaxis: include vascular anamolies, infections and inflammatory states of the nasal cavity, trauma, iatrogenic injuries, neoplasms and foreign bodies. Among these causes the commonest local factors involved in epistaxis is infection and inflammation. Infections and inflammation of the nasal mucous membrane may damage the mucosa leading on to bleeding from the underlying exposed plexus of blood vessels. Chronic granulomatous lesions like rhinosporidiosis can cause extensive epistaxis.

Aneurysms involving the internal carotid artery may occur following head injury, injury sustained during surgical procedures. These extradural aneuryms and aneurysms involving the cavernous sinus may extend into the sphenoid sinus wait for the opportune moment to rupture. It can cause sudden fatal epistaxis, or blindness. Urgent embolisation is the preferred mode of management of this condition.

Trauma is one of the common local causes of epistaxis. It is commonly caused by the act of nose picking in the Little's area of the nose. This is commonly seen in young children. Acute facial trauma may also lead to epistaxis. Patients undergoing nasal surgeries may have temporary episodes of epistaxis.

Irritation of the nasal mucous membrane: any disruption of normal nasal physiology can cause intense drying and irritation to the nasal mucosa causing epistaxis. These episodes are common during extremes of temperature when the nasal mucosa is stressed to perform its airconditioning role of the inspired air. In these conditions there is extensive drying of nasal mucosa causes oedema of the nasal mucous membrane. This oedema is caused due to venous stasis. Ultimately the mucosa breaches exposing the underlying plexus of blood vessels casuing epistaxis.

Anatomical abnormalities: Common anatomical abnormality causing epistaxis is gross septal deviation. Gross deviations of nasal septum causes disruption to the normal nasal airflow. This disruption leads to dessication / drying of the local mucosa. The dry mucosa cracks and bleeds.

Septal perforations: Chronic non healing septal perforations can cause bleeding from the granulation tissue around the perforation.

Neoplasms: involving the nose and paranasal sinuses can cause epistaxis. Neoplasms include benign vascular tumors like hemangioma, juvenile nasopharyngeal angiofibroma, and malignant neoplasms like squamous cell carcinoma. If epistaxis occurs along with secretory otitis media then nasopharyngeal carcinoma should be the prime suspect.

Systemic causes for epistaxis:

Hypertension is one of the common systemic causes of epistaxis. Accumulation of atheroscerotic plaques in the blood vessels of these patients replaces the muscular wall. This replacement of muscular wall reduces the ability of the blood vessels to constrict facilitating epistaxis. This is one of the common causes of posterior nasal bleeds. It commonly arises from the Woodruff's plexus found close the posterior end of the middle turbinate.

Hereditary hemarrhagic telengectasia is another systemic disorder known to affect the blood vessels of the nose. This disease causes loss of contractile elements within the blood vessels causing dilated venules, capillaries and small arteriovenous malformations known as telengectasia. These changes can occur in the skin, mucosal lining the whole of the respiratory passage and urogenital passage. Bleeding from these telengectasia is difficult to control. Bleeding invariably starts when the patient reaches puberty. Common cause of mortality in these patients is gastrointestinal bleed.

Systemic diseases like syphilis, tuberculosis & wegner's granulomatosis cause epistaxis because of their propensity to cause ulceration of the nasal mucous membrane.

Blood dyscrasias can also cause epistaxis. A low platelet count is one common cause of nasal bleed in this category. In thrombocytopenia the platelet count is less than 1 lakh. Epistaxis can start when the platelet count reduces to 50,000. Platelet deficiency can be caused by ingestion of drugs like aspirin, indomethacin etc. Hyperspenism can cause thrombocytopenia in idiopathic thrombocytopenic purpura. These patients need to be transfused fresh blood in adequate quantities. Only when thee platelet count increases will the nasal bleed stop.

Incidence: The incidence of epistaxis is known to be slightly higher in males. It also has a bimodal distribution affecting young children and old people.

Evaluation: While evaluating a patient with epistaxis it is absolutely necessary to assess the quantum of blood loss. The blood pressure and pulse rate of these patients must be constantly monitored. These patients will have tachycardia. Infusion of fluid must be started immediatly. Initially ringer lactate solution will suffice. If the patient has suffered blood loss of more than 30% of their blood volume (about 1.5 liters) then blood transfusion becomes a must. Further examination should be started only after the patient's general condition stabilises.

History: Careful history taking is a must. History taking should cover the following points:

1. History regarding the freqency, severity and side of the nasal bleed.

2. Aggravating and relieving factors must be carefully sought.

3. History of drug intaken must be sought.

4. History of systemic disorders like hypertension and diabetes mellitus must be sought.

Physical examination:

The nasal pack if any must be removed. Anterior nasal examination should be done, first attempted without the use of nasal decongestants. If visualisation is difficult due to oedema of the nasal mucosa then nasal decongestants can be used to shrink the nasal mucosa. The solution used for anesthetising the decongesting the nose is a mixture of 4% xylocaine and xylometazoline.

Nasal endoscopy can be performed under local anesthesia to localise posterior bleeds.

Investigations:

If bleeding is minimal no investigation is necessary.

If bleeding is more then a complete blood work up to rule out blood dyscrasias is a must. It includes bleeding time, clotting time, platelet count and partial thromboplastin time.

Imaging studies like CT scan of the para nasal sinuses must be done to rule out local nasal conditions of epistaxis. Imaging must be done only after 24 hours of removing the nasal packing. Scans done with the nasal pack or immediatly after removing the nasal pack may not be informative.

In diffiucult and intractable cases angiography can be done and the internal maxillary artery can be embolised in the same sitting. This procedure should be reserved only for cases of intractable nasal bleeding.

Management:

Conservative:

Nasal packing: Anterior nasal packing using roller gauze impregnated with liquid paraffin is sufficient to manage a majority of anterior nasal bleeds. The liquid paraffin acts as a lubricant, and as a moistoning agent. The tamponoding effect of a nasal pack is sufficient to stop nasal bleeding. This type of roller gauzes can be kept inside the nasal cavity only up to 48 hours after which it has to be removed and changed. The newer packs like the BIPP (Bismuth Iodine paraffin paste) packs can be left safely in place for more than a week.

Anterior nasal packing













 



Merocel packs

To manage post nasal bleed a post nasal pack is a must. Post nasal packing can be done in 2 ways:

Post nasal packing (conventional): A gauze roll about the size of the patient's naso pharynx is used here. Three silk threads must be tied to the gauze roll. One at each end and the other one at the middle. The patient should be in a recumbent position. After anesthetising the nasal cavity with 4% xylocaine the mouth is held open. Two nasal catheters are passed through the nasal cavities till they reach just below the soft palate. These lower ends of the catheters are grasped with forceps and pulled out through the mouth. The silk tied to the ends of the gauze is tied to the nasal catheters. The post nasal pack is introduced through the mouth and gradually pushed into the nasopharynx, at the same time the nasal catheters on both sides of the nose must be pulled out. When the pack snugly sits inside the nasopharynx, the two silk threads tied to its end would have reached the anaterior nares along with the free end of the nasal suction catheter.

Post nasal packing

The two silk threads tied to the suction catheters are untied. The catheters are removed from the nose. The silk thread is used to secure the pack in place by tying both the ends to the columella of the nose. The silk tied to the middle portion of the gauze pack is delivered out through the oral cavity and taped to the angle of the cheek. This middle portion silk will help in removal of the nasal pack. In addition to the postnasal pack anterior nasal packing must also be done in these patients.

Postnasal pack using baloon catheters: Specially designed baloon catheters are available. This can be used to perform the post nasal pack. Foleys catheter can be used to pack the post nasal space. Foley's catheter is introduced through the nose and slid up to the nasopharynx. The bulb of the catheter is inflated using air through the side portal of the catheter. Air is used to inflate the bulb because even if the bulb ruptures accidentally there is absolutely no danger of aspiration into the lungs. After the foleys catheter is inflated the free end is knotted and anchored at the level of the anterior nares.

Foley's catheter

Problems of nasal packing:

1. Epiphora (watering of eyes) occur due to blocking of the nasal end of the nasolacrimal duct.

2. Heaviness /headache due to blocking of the normal sinus ostium.

3. Prolonged post nasal pack can cause eustachean tube block and secretory otitis media.

4. Prolonged nasal packing can cause secondary sinusitis due to blockage of sinus ostium.

Newer packing materials: Newer packing materials made of silicone are available. The advantages of these material are that they are not irritating, patient can breath through the nose with the pack on through the vent provided, these packs can be retained inside the nasal cavity for more than 2 weeks. They can be removed and repositioned if necessory. The only disadvantage is that they are expensive.

Fig showing baloon packs

Surgical management:

Endoscopic cauterisation can be tried if the bleeders are localised and accessible. If not accessible, ligation of the internal maxillary artery can be done through caldwelluc approach. Spenopalatine artery clipping can be done endoscopically. It is accessible close to the posterior end of the middle turbinate. In rare cases external carotid artery ligation at the neck can be resorted to. External carotid artery is differentiated from the internal carotid in the neck by the fact that internal carotid artery does not give rise to branches in the neck, while the external carotid artery does so.

Ethmoidal artery ligation: If epistaxis occur high in the nasal vault, anterior and posterior ethmoidal arteries may be ligated using ligaclips. These arteries can be accessed using an external ethmoidectomy incision. The anterior ethmoidal artery is usually found 22mm from the anterior lacrimal crest. If ligation of the anterior ethmoidal artery does not stop bleeding then posterior ethmoidal artery should also be ligated. The posterior ethmoidal artery can be found 12mm posterior to the anterior ethmoidal vessel.

Epistaxis caused by the presence of tumors both benign and malignant calls for definitive treatment of the tumor perse.