Epistaxis (nasal bleeding) is a common condition. It may be very severe and life-threatening but in most cases is trivial and easily controlled.

ANATOMY

Bleeding usually arises from the nasal septum, which is supplied by the following vessels: Anterior ethmoidal artery
internal carotid artery Posterior ethmoidal artery Greater palatine Sphenopalatine artery
external carotid artery Superior labial artery These vessels form a rich plexus on the anterior part of the septum — Little’s area. Bleeding is less common from the lateral nasal wall, but is more difficult to control.

AETIOLOGY

In many cases of epistaxis, no cause is found. However, there are many caus- es (Table 20.1), two of which are of major importance to the practitioner. Spontaneous epistaxis Spontaneous epistaxis is common in children and young adults; it arises from Little’s area, it may be precipitated by infection or minor trauma, it is easy to stop, and it tends to recur. Hypertensive epistaxis Hypertensive epistaxis affects an older age group. It arises far back or high up in the nose, it is often difficult to stop, and it may recur.

CAUSES OF EPISTAXIS

Local causes and General causes: Spontaneous Cardiovascular conditions Trauma Hypertension Post-operative Raised venous pressure (mitral stenosis) Tumours Coagulation or vessel defects Hereditary telangectasia Haemophilia) Leukaemia Hay fever Anticoagulant therapy Thrombocytopaenia Fevers (rare) Typhoid fever Influenza

TREATMENT

Treating active epistaxis is a very messy business – cover up your own clothes first.

Bleeding from Little’s area 1 Direct digital pressure on the lower nose compresses the vessel on the septum and will arrest the bleeding. Pressure at the root of the nose over the nasal bones is useless.

2 Paint the nasal septum with cocaine paste or apply a plug of cotton wool soaked in lidocaine and phenylephrine and leave for 5–10min.

3 Cauterize the bleeding point.This can be done with silver nitrate crys- tals fused to a wire, or with a proprietary silver nitrate stick.

4 Electric cautery or diathermy can be performed —under local anaes- thetic in cooperative adults and under general anaesthetic in children. It is more effective than chemicals when there is active bleeding.

Bleeding from an unidentified site

1 Apply direct digital pressure to the nose for 10 minutes. The patient should sit leaning forward to allow the blood to trickle, and should breathe through the mouth. Swallowing, which may dislodge a clot, is forbidden.

2 Examine the nose with good lighting and spray with lidocaine and phenylephrine solution if available. If a bleeding site is visible, cauterize it with silver nitrate or bipolar diathermy.

3 Nasal packing. If simple measures fail to control the bleeding, the nose will need to be packed using 1-inch ribbon gauze (Fig. 20.2).The pack can be impregnated with BIPP (bismuth and iodoform paste). The pack is intro- duced along the floor of the nose and built up in loops towards the roof, applying even pressure to the nasal mucosa. Alternatively, an inflatable pack such as a Brighton balloon can be introduced. It is easier to put in but may not be as effective. A further and easier option is to use self-expanding packs such as Merocel which enlarge in the presence of moisture.

4 Post-nasal packing may be necessary if the bleeding is from far back — this is best left to the experts as it is not easy. Elderly patients with epistaxis severe enough to need packing should normally be admitted to hospital.With bed rest and sedation, most cases will settle.The blood pressure should be monitored and the haemoglobin level checked. Coexistent hypertension may need to be controlled

. SURGICAL TREATMENT Surgical treatment is rarely necessary

1. Submucous resection (SMR) if the bleeding is from behind a septal spur or if deviation prevents packing. 2. Ligation of the ethmoidal arteries via the medial orbit.

3 Ligation of the external carotid artery (an easy procedure) or of the sphenopalatine artery by nasal endoscopic surgery (a more difficult procedure).

4 Angiography and vessel embolization may be necessary in rare cases of persistent bleeding. NB. Epistaxis may be severe and may kill the patient. Circulatory resuscitation may be necessary before trying to arrest the bleeding. Do not delay in setting up an intravenous infusion if the patient has circulatory collapse, and at the same time send blood for cross-matching.