1. Epistaxis
Dr. Abdussalam M jahan ENT depart, Misurata university, faculty of medicine

2. Arterial supply of the septum
Woodruff’s plexus = naso-nasopharyngeal plexus
Kisselbach’s plexus in Little’s area

3. Kiesselbach’s Plexus/Little’s Area:
-Anterior Ethmoid (ICA)
-Superior Labial A (Facial)
-Sphenopalatine A (IMAX)
-Greater Palatine (IMAX)
Woodruff’s Plexus:
- Sphenopalatine A (Pharyngeal & Post. Nasal branches) (IMAX)
-Posterior ethmoid (ICA)

4. Classification: Anterior epistaxis (90%) Posterior epistaxis (10%)
Bleeding from Little’s area.
Controlled by an anterior pack
Younger patients
Posterior epistaxis (10%)
Occurs in the area of Woodruff’s plexus
Older patients
Epistaxis not controlled by anterior nasal packing.

5. Local Factors - Inflammation
Etiology:
Local Factors - Inflammation
URI
allergic rhinitis
Sinusitis
Increased vascularity and greater friability of vessels in inflamed mucosa

6. -Trauma Nose picking Nose blowing/sneezing Nasal fracture
Nasogastric/nasotracheal intubation
Trauma to sinuses, orbits, middle ear, base of skull
Barotrauma

7. -Iatrogenic nasal injury
Functional endoscopic sinus surgery
Septoplasty or Rhinoplasty
Nasal reconstruction

8. -Neoplasm Juvenile angiofibroma Inverted papilloma SCCA Adenocarcinoma
Melanoma
Lymphoma

9. -Others: Cold, dry air—more common in wintertime Dry heat.
Anatomic abnormalities (ie:
nasal septal deformity -
turbulent flow (dry mucosa
leading to crusting)
Atrophic rhinitis

10. foreign bodies
Intranasal parasites
Septal perforation
Chemical (cocaine, nasal sprays, ammonia)

11. Systemic factors
Vascular.
Infection/Inflammation.
Coagulopathy.

12. :- Vascular Hypertension
Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease)
subepidermal vessels lacking elastic tissue in capillary wall and deficiency of smooth muscle

13. – Infection/Inflammation
Tuberculosis
Syphillis
Wegener’s Granulomatosis
Periarteritis nodosa
SLE

14. – Coagulopathies
Primary coagulopathies (hemophilia, von Willebrand’s disease, thrombocytopenia and polycythemia vera).
Secondary coagulopathies (uremia, alcoholism, chronic liver disease, leukemia, myeloma, aplastic anemia, idiopathic thrombocytopenis purpura or hypovitaminosis).
Iatrogenic coagulopathies (heparin)

15. Etiology and Age Children - foreign body, nose picking
Adults - trauma, idiopathic
Middle age - tumors
Old age - hypertension

16. Management: Initial Management: ABC’s. Vital signs—need IV.
Medical history/Medications.
Labs.
Physical exam –
Rhinoscopy

17. Exam and treatment options

18. Non-surgical treatments
Topical decongestants/vc.
Cautery (AgNo3)
Nasal packing.
Control of hypertension
Correction of: coagulopathies/thrombocytopenia

19. Nasal packing: Anterior nasal packs Posterior nasal packs Traditional
Recent modifications
Posterior nasal packs

20. Packing

21. Posterior Packs – Admission
Elderly and those with other chronic diseases may need to be admitted to the ICU
Continuous cardiopulmonary monitoring
Antibiotics
Oxygen supplementation may be needed
Mild sedation/analgesia
IVF

23. Discharge instructions
Humidity/emolients
Nasal saline sprays
Avoidance of nose picking/blowing
Sneeze with mouth open
Avoid straining
Avoid hot/spicy food

24. Indications for surgery:
Continued bleeding despite nasal packing
Nasal anomaly interfering with packing
Patient refuse/intolerance of packing
Posterior bleeding with failed non surgical treatment after >72hrs

25. :Surgical treatment Transmaxillary IMA ligation
Transnasal Sphenopalatine ligation
External carotid artery ligation
Anterior/Posterior Ethmoidal A. ligation
Last one

26. The end