Epistaxis ent
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Epistaxis
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Define epistaxis.
Bleeding from inside the nose, either anterior nasal or posterior nasal.
Epi : from aboveStaxis : drop by drop drip of
fluid.
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Epistaxis is a sign, NOT a diseaseIt should never be treated as a
harmless event.
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Anatomical considerationsNasal cavity: mucosa and
turbinates are very vascularReceives blood supply from
branches of both internal and external carotid arteries.
Network of arteries : Kiesselbach’s plexus, woodruff’s plexus
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Blood supplyNasal septumLateral wall of nose
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Question 1
Describe the blood supply of the nose.
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Blood supply of nasal septum
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Blood supply of the lateral wall of nose
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Little’s areaSituated over the anteroinferior part of
nasal septum, just above the vestibuleCaudal part of the nasal septum which
has a rich submucosal arterial network(Kiesselbach’s plexus) by septal branches of
- anterior ethmoidal- sphenopalatine- superior labial- greater palatine
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Prone for drying (effect of inspired air ) and microtrauma by nose picking
Commonest site for epistaxis in children
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Question 2The following is true regarding little’s area of
the nose, except:A) Situated over the anteroinferior part of the
lateral wall of the noseB) Has a rich submucosal vascular plexus named
Kiesselbach’s plexusC) Bleeding from Retrocolumellar vein is one of
the differential diagnoses of little’s area epistaxis
D) The kiesselbach’s plexus is formed by the septal branches of anterior ethmoidal, sphenopalatine, greater palatine, and superior labial arteries
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Answer :A.Little’s area is situated over the
anteroinferior part of the nasal septum
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Retrocolumella veinThis vein runs vertically downwards
behind the columella.It crosses the floor of nose & joins venous
plexus on the lateral wall of nose.Common site of venous bleeding in young
people
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Question 3Which statement is true about
Retrocolumellar vein?A. This vein runs vertically downwards below
the columella.B. It crosses the floor of nose & joins venous
plexus on the nasal septum.C. It crosses the floor of nose & joins venous
plexus on the lateral wall of nose.D. It crosses the roof of nose & joins venous
plexus on the lateral wall of nose.E. Common site of venous bleeding in old
people.
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Answer C
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Woodruff’s AreaVascular area situated over the
posterior end of inferior turbinateSphenopalatine artery
anastomoses with posterior pharyngeal artery
Posterior epistaxis occur
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Question 4Which statement is true about
Woodruff’s area?A. Site for anterior epistaxisB. Greaterpalatine artery anastomoses with
posterior pharyngeal artery hereC. Vascular area situated under posterior
end of inferior turbinateD. Vascular area situated above posterior
end of inferior turbinateE. Vascular area situated under posterior
end of middle turbinateAnswer : C
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Sites of epistaxisLittle’s Area (90%)Above the level of middle
turbinateBelow the level of middle
turbinatePosterior part of nasal cavityDiffuse. ie : septum & lateral wallNasopharynx
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Question 5Which is the commonest site of
epixtaxis?A. Above the level of middle
turbinateB. Below the level of middle
turbinateC. Posterior part of nasal cavityD. Little's area
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AnswerD, 90% of the epistaxis site is
from little’s area.
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Epistaxis
Anterior epistaxis
Posterior epistaxis
Blood flows out from the front of nose with the patient is in sitting position.
Blood flows back into the throat. Patient may swallow it and have “coffee-coloured” vomitus.
** may misdiagnosed as haematemesis
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Differences between anterior and posterior epistaxis
Anterior epistaxis Posterior epistaxis
Incidence more Less
site Little’s area or anterior part of lateral wall
Posterosuperior part of nasal cavity; difficult to localise the bleeding point
age Children and young adult
>40 years
cause Trauma Spontaneous; often due to hypertension or arteriosclerosis
Bleeding Mild bleeding, can be controlled by local pressure or anterior nasal pack
Severe bleeding; requires hospitalisation and postnasal pack
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Question 6Which of these statements are true?A. Anterior epistaxis is usually caused
by hypertensionB. Posterior epistaxis is more commonC. Anterior epistaxis does not usually
occurs in children and young adultsD. Anterior epistaxis bleeding is usually
mild
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AnswerD, posterior epistaxis is more
severe, usually requires hospitalisation and postnasal pack;while anterior epistaxis is usually mild bleeding.
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Etiology of epistaxisLocal causesSystemic causesIdiopathic ( primary )
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Local causesI) congenital: Telengectasia ( Osler-Weber-
Rendau syndrome), hemangiomaII) Infections :
*Viral : Influenza, measles*Bacterial : (non-specific)- acute/ chronic rhinitis / sinusitis, artophic rhinitis(specific)- diphtheria, TB, syphilis, other granulomas*Fungal : rhinosporidiosis, fungal sinusitis*Parasites : maggots
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III) Trauma:◦Microtrauma – nose picking◦Foreign body◦Accidental◦Iatrogenic◦Barotrauma : Caisson’s disease
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IV) Neoplastic :◦Benign : JNA, Inverted papilloma,
hemangioma◦Malignant : Nose, PNS, Nasopharynx
V) Miscellaneous :◦Deviated nasal septum,spur,
rhinolith
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Systemic causesCVS oHypertensionoAtherosclerosisoMitral stenosisoPregnancy (HTN & hormonal)
Liver Cirrhosis oVitamin K deficiencyoDeficiency of factor ii, vii,ix and x
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HemotologicaloAplastic anaemiaoThrombocytopeniaoLeukemiaoLymphomaoAgranulocytosisoScurvyoVitamin K deficiency
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Renal diseaseoChronic nephritis
DrugsoSalicylatesoAnalgesicsoAnticoagulant
Mediastinal compressionoTumours of mediastinum raised
venous pressure in the nose
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Acute general infectionoInfluenzaoMeaslesoChicken poxoWhooping cough
Vicarious menstruation
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What is the commonest cause of epistaxis?
A. IdiopathicB. Deviated nasal septumC. Fracture to the base of skullD. HypertensionE. Finger nail trauma
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AnswerA, idiopathic
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ReferrenceDisease Of Ear, Nose, Throat. 5th
Edition. PL Dhingra & Shruti Dhingra
ENT secrets. 2nd Edition. Bruce W. Jafek
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Thank you