Epistaxis
Although in the majority of patients this is a
relatively easy clinical problem to deal with, this may not always be the case
and in certain situations the haemorrhage may be life threatening. The most
common site of bleeding is from Kiesselbach’s plexus in Little’s area of the
anterior portion of the septum (Fig. 39.6). The usual cause is microtrauma to
these blood vessels sandwiched between the mucosa and the underlying cartilage.
In young children, heavy bleeding sometimes occurs from an engorged retro-columellar
vein. Less often bleeding arises from the lateral nasal wall. Anterior bleeding
is common in children and young adults as a result of nose blowing or picking.
In the elderly, arteriosclerosis and hypertension are the underlying causes of
arterial bleeding from the posterior part of the nose. The degeneration of the
muscle layer of small arteries with age and the gradual replacement with
collagen and calcification hinder posttraumatic vasoconstriction and prolong
bleeding. Less common causes are trauma, foreign bodies within
the nose, blood diseases, disorders of coagulation and malignant tumours of the
nose or sinuses. Nasopharyngeal angiofibroma is a rare condition that affects
boys and may lead to massive life-threatening attacks of bleeding. Hereditary
haemorrhagic telangiectasia (Osler’s disease) gives rise to recurrent
multifocal bleeding from thin-walled vessels deficient in muscle and elastic
tissue (Fig. 39.8).
Management
of epistaxis
Bleeding from Kiesselbach’s plexus may be
controlled by silver nitrate cautery under local anaesthesia. Bleeding from
further back in the nose, as seen in the elderly, may require anterior nasal
packing with Vaseline-impregnated ribbon gauze. The packing is inserted in
layers starting on the floor of the nasal cavity. Sometimes hypoxia can be
induced by nasal packing and may be exacerbated in patients with chronic
obstructive airways disease. The packing is usually kept in place for 48 hours
and the patient commenced on a broad-spectrum antibiotic. An alternative to
anterior packing
Sometimes
anterior nasal packing alone is not sufficient to control haemorrhage and
posterior nasal packing may be required. This is usually carried out under
general anaesthesia inserting a gauze pack into the naso pharynx, which is then
secured by tapes passed through each side of the nose and tied together across a
protected columella. A third tape is brought out through the mouth and taped to
the patient’s cheek. The nasal fossae are then packed with anterior nasal
packs. All packs are left in for 48 hours and prophylactic antibiotics are
given. The tape attached to the cheek is to facilitate removal of the pack
usually without a general anaesthetic.
In
uncontrolled life-threatening epistaxis where the above methods have proved
ineffective, haemostasis is achieved by vascular ligation. Depending on the
origin of bleeding it
may be necessary
to ligate the internal maxillary artery in the pterygopalatine fossa and the
anterior and posterior ethmoidal arteries within the orbit. An alternative
measure is external carotid artery ligation above the origin of the lingual
artery.
In
Osler’s disease anterior nasal packing is best avoided if at all possible
because it is
most likely to lead to further mucosal trauma and bleeding. High-dose oestrogen
induces squamous metaplasia of the nasal mucosa and has been used effectively in
treating this condition. In some cases however, it may be necessary to resort to excision of the diseased nasal mucosa via a
lateral rhinotomy and replace it with a split skin graft — a
procedure known as septodermoplasty. It is not unknown, however, for the grafted
skin to undergo similar abnormal vascular change over time.
Epistaxis — summary
•
Young people bleed from the anterior septum —
Kiesselbach’s
plexus
•
Older people bleed from the posterior part of the nose
• Silver nitrate cautery is good for controlling anterior septal bleeding
•
Moderate bleeding may require anterior nasal packing
•
Severe bleeding may require anterior and posterior nasal packing
•
Persistent bleeding will probably require arterial ligation