Epistaxis

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Rhinology: High-Yield Epistaxis

Revision Notes for Board Review & PG Entrance Examinations

Epistaxis (nasal bleeding) is one of the most frequent clinical emergencies in otorhinolaryngology. For competitive examinations, understanding the distinct vascular anatomy, key anatomical plexuses, clinical differences between anterior and posterior bleeds, and the stepwise management algorithm is essential.

1. Vascular Anatomy & Critical Plexuses

The nasal cavity is highly vascularized by a rich anastomosis supplied by both the Internal Carotid Artery (ICA) and External Carotid Artery (ECA) systems.

  • Little’s Area / Kiesselbach’s Plexus (Anterior Epistaxis): Located on the anteroinferior part of the nasal septum. This is the site for 90% of all epistaxis cases, primarily due to mucosal drying, finger picking (digital trauma), or foreign bodies. It is formed by the confluence of 4 key arteries:
    1. Anterior Ethmoidal Artery (branch of Ophthalmic Artery ← ICA system)
    2. Sphenopalatine Artery (terminal branch of Maxillary Artery ← ECA system)
    3. Greater Palatine Artery (branch of Maxillary Artery ← ECA system)
    4. Septal branch of the Superior Labial Artery (branch of the Facial Artery ← ECA system)
  • Woodruff’s Plexus (Posterior Epistaxis): Located on the lateral wall of the nasal cavity, posterior to the inferior turbinate. It is the primary site for posterior epistaxis (accounting for ~10% of cases), typically presenting in older adults with systemic comorbidities. It is formed mainly by:
    • Sphenopalatine Artery (dominant supply)
    • Pharyngeal branches of the Maxillary Artery
    • Ascending Pharyngeal Artery (branch of ECA)

2. Anterior vs. Posterior Epistaxis

Feature Anterior Epistaxis Posterior Epistaxis
Primary Site Little’s Area on the nasal septum Woodruff’s Plexus on the postero-lateral wall
Incidence & Age Most common (90%); Children & young adults Less common (10%); Elderly (>50 years)
Common Etiologies Local trauma (picking), dry air, foreign body Systemic: Hypertension, atherosclerosis, anticoagulants
Bleeding Direction Mainly exits through the nares anteriorly Drains down the posterior pharynx (swallowed)
Initial Control Trotter’s method / Local cautery Requires posterior packing or surgical ligation

3. Stepwise Emergency Management Algorithm

When a patient presents with active epistaxis, management should follow a systematic, escalating protocol:

  • Step 1: ABCs and Primary Assessment: Secure the airway, monitor hemodynamics, and establish intravenous access if the bleeding is severe.
  • Step 2: Trotter’s Method: The immediate first-aid maneuver. The patient sits upright, leans slightly forward (to prevent swallowing blood and subsequent aspiration or hematemesis), and firmly pinches the cartilaginous part of the nose for 10–15 minutes while breathing through the mouth.
  • Step 3: Topical Vasoconstrictors & Chemical Cautery: If an active bleeding vessel is localized on Little’s area after clearing clots, apply topical vasoconstrictors (e.g., Oxymetazoline or Adrenaline). If visible, perform chemical cauterization with a Silver Nitrate (AgNO3) stick or electrocautery.

    Examiner Trap: Never cauterize both sides of the nasal septum simultaneously during the same session, as this compromises vascularity and risks an iatrogenic septal perforation.

  • Step 4: Anterior Nasal Packing: If cautery fails or the bleeding source is not visualized, place an anterior nasal pack using ribbon gauze impregnated with liquid paraffin/antibiotic ointment, or compressed nasal tampons (Merocel). Left in place for 24–48 hours.
  • Step 5: Posterior Nasal Packing: Indicated if bleeding continues despite adequate anterior packing (blood seen streaming down the oropharynx). Can be performed using a traditional gauze pack tied with silk threads or utilizing a Foley’s catheter (No. 12–14 French) passed into the nasopharynx, inflated with 5–10 mL of saline, and pulled forward snugly against the posterior choana.
  • Step 6: Surgical Ligation / Endovascular Embolization: Refractory epistaxis demands targeted surgical intervention:
    • Sphenopalatine Artery (SPA) Ligation: Endoscopic approach; the single most effective surgical intervention for severe posterior epistaxis.
    • Anterior Ethmoidal Artery Ligation: Required if bleeding stems from the high septum/roof, accessed via a Lynch incision.
    • Maxillary Artery / External Carotid Ligation: Historical procedures, now largely superseded by transarterial embolization or SPA ligation.

4. Systemic Conditions & High-Yield Syndromes

  • Osler-Weber-Rendu Syndrome (Hereditary Hemorrhagic Telangiectasia – HHT): An autosomal dominant vascular disorder characterized by localized angiodysplasias and multiple telangiectasias across the nasal mucosa, lips, and gastrointestinal tract. Presents with severe, recurrent, refractory epistaxis.
  • Juvenile Nasopharyngeal Angiofibroma (JNA): A benign but locally aggressive vascular tumor seen exclusively in adolescent males. Classic presentation is a triad of progressive unilateral nasal obstruction, unprovoked profuse epistaxis, and a mass in the cheek/nasopharynx. Biopsy is absolutely contraindicated due to the extreme risk of catastrophic hemorrhage; diagnosis is made via contrast-enhanced CT or angiography.