Epistaxis

Epistaxis or nosebleed, is a condition where bleeding occurs from inside the nose.

Age of Occurrence: It can occur in all age groups but shows a bimodal age distribution and occurs more often in hot and dry weather.

• • Common in children.
  • Peaks again in people around their 60s.

Triggers for Bleeding:

• • Blowing the nose.
  • Sneezing or coughing.
  • Straining or pregnancy.
  • These factors can lead to “spontaneous or idiopathic epistaxis” where bleeding occurs without an obvious cause.

Epistaxis serves as a symptom, not a disease, necessitating an investigation to identify underlying local or systemic causes and often requires emergency intervention. Effective management relies on a thorough understanding of nasal anatomy, particularly its vascular supply from the internal and external carotid arteries. The nose has a rich blood supply from two major arteries—the internal and external carotid arteries. These arteries connect extensively in the nasal cavity, making it prone to bleeding if damaged or irritated.

Arterial supply of the Lateral Wall of the Nasal Cavity

Internal carotid system

• Anterior ethmoidal artery – Originates from the ophthalmic artery in the orbit. Both anterior and posterior ethmoidal arteries supply the anterosuperior quadrant. During sinus surgeries, transection of this artery can result in retraction of the bleeding end into the orbit causing serious complications, such as pressure haematoma and potential loss of vision.
• Posterior ethmoidal artery – Originates from the ophthalmic artery in the orbit.  It is smaller than the anterior ethmoidal artery and is present in only 80% of individuals.

External carotid system

1. Branches of sphenopalatine artery – It is a terminal branch of the maxillary artery. It enters the nasal cavity via the sphenopalatine foramen and immediately divides into:

• • The posterior lateral nasal branch supplies a large part of the lateral wall (inferior and middle turbinate and meatii) and septum.
  • The posterior septal branch supplies the posterior part of the septum.

2. Greater palatine artery –Originates from the maxillary artery in the pterygopalatine fossa. Supplies the anterior nasal cavity floor and medial wall- anastomoses with sphenopalatine and superior labial arteries.
3. Nasal branch of anterior superior dental –Originates from the infraorbital branch of the maxillary artery.
4. Branches of the facial artery to the nasal vestibule.

• Anterosuperior part: supplied by anterior/posterior ethmoidal arteries.
• Anteroinferior part: supplied by the branches from the facial artery.
• Posterosuperior part: dominantly supplied by the sphenopalatine artery.
• Posteroinferior part: supplied by the greater palatine artery.

Venous drainage of the Lateral Wall of the Nasal Cavity

The veins follow the arteries within the mucosa. The veins form a plexus that drains anteriorly into the facial vein; the middle part to the pterygoid plexus of veins and posteriorly, into the pharyngeal plexus of veins.

Key features and areas of the Lateral Wall of the Nasal Cavity

1. Retrocolumellar Vein. The retrocolumellar vein runs vertically 2mm behind the columella (the tissue separating the nostrils) at the anterior edge of Little’s area. This vein is a common site of venous bleeding, particularly in young individuals.
2. Woodruff’s Plexus. Woodruff’s plexus is a network of veins located below the posterior end of the inferior turbinate. It is a significant site for posterior epistaxis (nosebleeds) in adults.

 Arterial supply of the Medial Wall of the Nasal Cavity (Nasal septum)

• Internal carotid system
  • Anterior and posterior ethmoidal arteries (branches of the ophthalmic artery).
• External carotid system
  • Sphenopalatine artery (nasopalatine and posterior medial nasal branches).
  • Septal branch of the greater palatine artery.
  • Septal branch of the superior labial artery.

• Anterosuperior part: supplied by anterior/posterior ethmoidal arteries.
• Anteroinferior part: supplied by the septal branch of the superior labial artery.
• Posterosuperior part: dominantly supplied by the sphenopalatine artery.
• Posteroinferior part: supplied by the greater palatine artery which pierces the perpendicular plate of palatine bone and passes up through the incisive fossa.

Venous drainage of nasal septum. Plexus forms in Little’s area, draining:

• Anteriorly into the facial vein.
• Posteriorly via the sphenopalatine vein to the pterygoid plexus.

Key features and areas of nasal septum

1. Little’s area (Kiesselbach’s plexus)
   • James Little in 1879 and the same plexus was described one year later by Kiesselbach.
   • It is vascular network in the anteroinferior part of the nasal septum.
   • It is formed by anastomoses of the anterior ethmoidal, sphenopalatine, greater palatine, and superior labial arteries.
   • The common site for epistaxis (nosebleeds) and site for the origin of the bleeding polypus (haemangioma) of the nasal septum
2. Trauma and deviation
   • The septal cartilage is vulnerable to displacement from the vomerine groove or anterior nasal spine, leading to nasal obstruction.

Common bleeding sites of epistaxis from nasal cavity

1. Little’s Area: This is the most frequent site of bleeding (around 90% of cases).
2. Above the Middle Turbinate: Bleeding here is often due to the anterior and posterior ethmoidal arteries.
3. Below the Middle Turbinate: Caused by branches of the sphenopalatine artery.
4. Posterior Nasal Cavity: Blood flows directly into the throat.
5. Diffuse Bleeding: Involves multiple areas and is linked to systemic conditions and blood dyscrasias.
6. Nasopharynx: Rare cases occur here.

 Classification of epistaxis

1. Adult or childhood epistaxis

• Childhood: <16 years
• Adult: >16 years

2. Primary or secondary

• Primary: no proven causal factor
• Secondary: proven causal factor

3. Anterior and posterior epistaxis

• Anterior: There is bleeding anterior to piriform aperture typically from the Little’s area. Blood flows out of the nostrils in sitting position.
• Posterior: There is bleeding posterior to piriform aperture. Blood flows back into the throat. the patient might swallow it, leading to a “coffee-coloured” vomitus which can sometimes be mistaken for haematemesis. This may erroneously be diagnosed as haematemesis.

 

Causes of Epistaxis (Nosebleeds)

Nasal bleeds can occur due to local, general, or unknown (idiopathic) causes:

 

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Reference Textbooks.

• Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
• Cummings, Otolaryngology-Head and Neck Surgery.
• Stell and Maran’s, Textbook of Head and Neck Surgery and Oncology.
• Ballenger’s, Otorhinolaryngology Head And Neck Surgery
• Susan Standring, Gray’s Anatomy.
• Frank H. Netter, Atlas of Human Anatomy.
• B.D. Chaurasiya, Human Anatomy.
• P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
• Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
• Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery.
• Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
• Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
• Arnold, U. Ganzer, Textbook of  Otorhinolaryngology, Head and Neck Surgery.
• Ganong’s Review of Medical Physiology.
• Guyton & Hall Textbook of Medical Physiology.

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