Epistxis bleeding from inside nose History. a/ Hippocrates 5thcenturyBC b/Ail bIn Rabat AD 850(the Paradise of wisdom) c/Merging 1769AD(syringe the nose with cold water and wine d/ Mahomed 1880.

Vascular Supply of Nose:

Nasal Septum : Internal carotid(Anterior and posterior Ethmoidal) External carotid:Sphenopaltine and greater palatine. superior labial branch of fascial artery.

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 pharyngeal branches ascending Phyrangeal Branches.pharyngeal branchesWoodruff'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

Epistaxis from septum in vast majority.Littles area described by James Little. the bleeding from this area is Arterial. The Dynamics of Nasal circulation.(arterioarterial anastomosis and contribution from internal and external carotid.)

Causes of Epistaxis : Local a/ Trauma, Acute facial trauma, nose picking,intranasal surgery. b/ Infections Acute/Chronic c/ Foreign Bodies, Rhinolith d/ Neoplasm, hemangioma,Oslers disease, malignant e/Septal deviations, f/Atmospheric

General Causes, Hypertension, arteriosclerosis, Blood dyscrasia,hereditary telangiectasia(osler disease) Drugs NSAID,ASPIRIN, ANTICOAGULANTS..INR 2/ Nasopharynx. Juvenile Angiofibroma

Vast majority of epistaxis is from Septum..Littles area, its arterial.(o h shaheen) In children epistaxis from retro columllerVein.

Anterior bleeding, Its common,recurrent,mild to moderate,littles area. posterior bleeding, Its severe, spontaneous.occasional,difficult to manage.old age and are hypertensive,

Management: History, onset, how much blood lost, recurrent.side of the nose bleeding tendency,hypertension,diabetes, if on anticoagulant ask about INR Which side is bleeding? Which side was bleeding initially? What is the estimated amount of blood loss? Is it recurrent? Is it in the pharynx? Has any trauma recently occurred? Are symptoms of hypovolemia present? What are the patient’s past medical history and current medications (eg, aspirin, warfarin)?[3]

General care: patient in sitting position, IV cannula,Blood for Hb and Group and croos match and save. Explain to patient,how you are going to stop bleeding.

In sever b leeding, clear clots, Local anaesthetic spray, Try to Visualize bleeder or Endoscopic examination And Cauterize with Silver nitrate if still bleeding,Merocele packing and Hospitalize and IV antibiotics

90% Nasal bleeding stops with Merocele Packing, its easy to insert, painless Anterior nasal Bipp Packing

In very few cases may need Posterior packing or catheter or brighton baloon.

Posterior nasal packing.

SMR if bleeding persist when nasal packing removed. Ligation of blood vessels. 1/internal Maxillary artery, 2/ external carotid artery. 3/ Anterior ethmoidal artery

Unusual causes of epitaxis; Oslers disease (hereditary haemorrhagic telangiectasia)red spots on lips,tongue,face and nose, may be in the gut and lungs. recurrent epistxis, difficult to treat. Harrison (1957) estrogen

Saunders (1963) excise nasal mucous membrane from anterior septum and replace with skin..septodermoplasty. Application of laser.

Nasopharyngeal Angiofibroma:It is benign yet aggressive tomour. origin Posterior nose and nasophyrnx. Histology endothelial lined spaces and fibrous tissue,,, Incidence and age, not common,adolescent,male

Clinical featurs. nasal obstruction and epistaxis.less common eustachian tube dysfunction and conductive deafness, fascial swelling,proptosis. Reddish purple nodular mass in posterior nares and nasopharynx. Spread by expansile growth throug natural fissures.

diagnosis:age,sex history,and physical findings are often diagnostic. radiology CT/MRI Treatment: Surgery

wagners granuloma; autoimmune, non healing ulceration of septum with granulations and cause septal perforation. crusts form and can cause epistaxis. diagnosis by biopsy giant cell granuloma and polyartritis nodosa in grnulations. Treatment: high doses of steroid and prognosis monitored by ESR.

Question enumerate causes of epistaxis and its management in detail.