Epistaxis (Nosebleed) – Comprehensive ENT Textbook Chapter

Introduction

Epistaxis, commonly known as a nosebleed, is one of the most frequent emergencies encountered in otorhinolaryngology. It affects individuals of all ages and ranges from minor, self-limiting bleeding to severe, life-threatening hemorrhage. Approximately 60% of people experience at least one episode during their lifetime, though only a small percentage require medical intervention.

Epistaxis is not a disease itself; it is a symptom of underlying local, systemic, environmental, or vascular pathology. Proper understanding of nasal anatomy, physiology, and hemostasis is essential for safe and effective management.

Historical Background

Epistaxis has been recognized since ancient medical practice. Classical physicians often considered it a therapeutic method for “removing excess blood.” Modern anatomical understanding evolved after the identification of septal vascular networks by Wilhelm Kiesselbach, who described the anterior septal plexus. Later, George Woodruff contributed to understanding posterior venous bleeding sources.

Surgical Anatomy of the Nose Relevant to Epistaxis

External Nose

The external nose consists of nasal bones, upper and lower lateral cartilages, and septal cartilage. Trauma to this region commonly results in anterior epistaxis.

Nasal Septum

The septum is composed of:

Cartilage (anterior)
Perpendicular plate of ethmoid
Vomer (posterior)

The anterior inferior portion contains Kiesselbach’s plexus (Little’s area), the most common site of bleeding.

Lateral Nasal Wall

It contains inferior, middle, and superior turbinates. Posterior epistaxis frequently arises from branches of the sphenopalatine artery in this region.

Vascular Supply of the Nose

The nasal cavity has a dual arterial supply from both internal and external carotid systems.

External Carotid Contributions

Facial artery (superior labial branch)
Maxillary artery (sphenopalatine artery)
Greater palatine artery

Internal Carotid Contributions

Ophthalmic artery
Anterior and posterior ethmoidal arteries

Kiesselbach’s Plexus (Little’s Area)

This anterior septal plexus is formed by anastomosis of:

Anterior ethmoidal artery
Septal branch of superior labial artery
Greater palatine artery
Sphenopalatine artery

It accounts for approximately 90% of epistaxis cases.

Woodruff’s Plexus

Located in the posterior inferior nasal cavity, this venous plexus is responsible for severe posterior epistaxis, particularly in elderly patients.

Physiology of Nasal Hemostasis

The nasal mucosa is highly vascular because its primary functions are:

Warming inspired air
Humidifying air
Filtering particulate matter

Hemostasis occurs in stages:

Vasoconstriction
Platelet plug formation
Coagulation cascade activation
Fibrin stabilization

Failure in any stage may result in persistent bleeding.

Classification of Epistaxis

Based on Site

Anterior Epistaxis

Originates from Kiesselbach’s plexus
Common in children
Usually mild

Posterior Epistaxis

Originates from posterior nasal cavity
Common in elderly
Often severe

Based on Etiology

Local Causes

Trauma
Infection
Structural abnormalities
Foreign bodies
Tumors

Systemic Causes

Hypertension
Bleeding disorders
Liver disease
Medications

Environmental Causes

Dry climate
High altitude
Air pollution

Local Causes in Detail

Digital Trauma

Most common in children. Repeated nose picking damages anterior septal mucosa, leading to crusting and bleeding.

Blunt Trauma

Seen in road accidents, sports injuries, and assault. Complications include septal hematoma, which requires urgent drainage.

Deviated Nasal Septum

Air turbulence dries the mucosa, predisposing to recurrent bleeding.

Infections

Acute rhinitis
Chronic rhinitis
Sinusitis

Inflammation increases capillary fragility.

Foreign Bodies

Common in children, presenting with unilateral foul discharge and blood-stained secretions.

Systemic Causes

Hypertension

Although not a direct cause, it increases severity and recurrence, especially in posterior epistaxis.

Hematologic Disorders

Thrombocytopenia
Hemophilia
Leukemia
Von Willebrand disease

Epistaxis may be the first presenting symptom.

Liver Disease

Impaired clotting factor synthesis leads to persistent bleeding.

Drug-Induced Epistaxis

Common drugs:

Aspirin
Clopidogrel
Warfarin
Direct oral anticoagulants
NSAIDs

Always review medication history carefully.

Vascular and Tumorous Causes

Hereditary Hemorrhagic Telangiectasia

Also known as Osler-Weber-Rendu syndrome.

Features:

Autosomal dominant
Recurrent spontaneous epistaxis
Telangiectasias on lips and nose

Juvenile Nasopharyngeal Angiofibroma

A highly vascular benign tumor seen in adolescent males. Presents with recurrent severe epistaxis and nasal obstruction.

Malignancy

Red flags include:

Unilateral persistent bleeding
Facial pain
Neck mass
Weight loss

Adult recurrent unilateral epistaxis must always raise suspicion.

Clinical Evaluation

History

Duration and frequency
Laterality
Trauma history
Drug use
Family history
Systemic symptoms

Examination

Vital signs
Anterior rhinoscopy
Nasal endoscopy if required

Investigations

CBC
Platelet count
PT / INR
Liver function tests
Imaging if tumor suspected

First Aid Management

Sit upright
Lean forward
Pinch soft part of nose for 10–15 minutes
Apply cold compress

Avoid tilting head backward.

Medical Management

Topical Vasoconstrictors

Oxymetazoline
Adrenaline-soaked pledgets

Chemical Cauterization

Silver nitrate is used for visible anterior bleeding points. Only one side should be cauterized at a time.

Nasal Packing

Anterior Packing

Used when cautery fails. Left in place for 24–48 hours.

Posterior Packing

Used in severe posterior bleeding. Requires hospital admission and monitoring.

Surgical Management

Indicated if packing fails:

Endoscopic sphenopalatine artery ligation
External carotid artery ligation
Arterial embolization

Complications

Hypovolemic shock
Anemia
Aspiration
Sinusitis
Septal perforation

Prevention

Humidification
Saline nasal sprays
Control hypertension
Avoid digital trauma
Manage underlying disease

Prognosis

Anterior epistaxis: Excellent
Posterior epistaxis: May require aggressive management
Recurrence common if underlying cause untreated

Advanced Pathophysiology of Epistaxis

Epistaxis represents the final clinical manifestation of vascular disruption within the nasal mucosa under conditions where local vessel integrity, systemic coagulation mechanisms, or hemodynamic stability are compromised. Although clinically simple in many cases, its biological basis is complex and involves vascular anatomy, endothelial biology, inflammatory mediators, neurovascular regulation, and systemic hematologic factors.

The nasal mucosa is uniquely vulnerable to bleeding because of:

High vascular density
Superficial location of capillary networks
Continuous environmental exposure
Temperature and humidity fluctuations
Rich autonomic innervation influencing vasomotor tone

The anterior septum is especially predisposed because its mucoperichondrium is thin, and vessels lie immediately beneath the epithelial layer. Minor trauma easily disrupts the submucosal arterial network.

Microanatomy of Nasal Vessels

The nasal mucosa contains:

Arterioles
Venules
Cavernous sinusoids
Capillary networks

The inferior turbinate contains erectile tissue composed of venous sinusoids that engorge and decongest cyclically (nasal cycle). This physiologic congestion increases intravascular pressure locally and may predispose to bleeding in fragile mucosa.

Arterial walls consist of:

Endothelium
Smooth muscle layer
Elastic lamina

Chronic inflammation weakens these layers via:

Cytokine-mediated endothelial damage
Matrix metalloproteinase activation
Reduced collagen support

Endothelial Injury Mechanisms

Endothelial disruption in epistaxis may occur due to:

Mechanical shearing
Dryness-induced epithelial cracking
Infection-induced ulceration
Vasculitis
Neoplastic invasion

When endothelial cells are damaged:

Tissue factor is exposed
Platelets adhere via von Willebrand factor
Coagulation cascade is activated

If platelet function is impaired, bleeding persists.

Hemodynamic Factors

Blood pressure plays a modifying role. Although hypertension is not a primary cause, elevated systolic pressure:

Increases bleeding volume
Prevents stable clot formation
Promotes rebleeding

Posterior epistaxis in elderly hypertensive patients is often more severe due to:

Atherosclerotic vessel rigidity
Loss of vascular elasticity
Fragile arterial walls

Advanced Epidemiology

Epistaxis demonstrates bimodal age distribution:

Pediatric peak (2–10 years)
Geriatric peak (>50 years)

Seasonal variation is observed, with higher incidence during winter due to:

Reduced humidity
Indoor heating
Mucosal dryness

Occupational exposure also increases risk:

Cement workers
Chemical industry workers
Textile workers exposed to dust

In tropical climates, infectious causes contribute more significantly.

Detailed Classification Based on Severity

Epistaxis may be classified clinically as:

Mild

Stops spontaneously
Minimal blood loss
No systemic symptoms

Moderate

Requires medical intervention
May require cauterization or packing
Hemoglobin stable

Severe

Hemodynamic instability
Requires transfusion
Posterior source likely

Emergency Physiology During Severe Epistaxis

Acute blood loss triggers:

Sympathetic activation
Tachycardia
Peripheral vasoconstriction
Activation of renin-angiotensin system

If bleeding exceeds compensatory capacity:

Hypotension
Shock
Altered mental status

Early identification is essential.

Advanced Clinical Evaluation

Proper evaluation follows a structured algorithm.

Airway Assessment

Ensure:

No airway compromise
No aspiration of blood
Patient is sitting upright

In massive posterior bleeding, intubation may be required.

Hemodynamic Stabilization

Monitor:

Pulse
Blood pressure
Oxygen saturation
Level of consciousness

Establish IV access in severe cases.

Detailed Local Examination

After stabilization:

Suction clots
Apply topical vasoconstrictor
Inspect septum
Identify bleeding point

Endoscopic examination allows:

Localization of posterior source
Identification of tumor
Detection of vascular malformation

Laboratory Evaluation in Recurrent or Severe Cases

Indications:

Recurrent bleeding
Severe bleeding
Suspected systemic disease

Tests include:

CBC
Platelet count
PT / INR
aPTT
Liver function
Renal function

In suspected hematologic malignancy:

Peripheral smear
Bone marrow study

Advanced Management Principles

Management depends on:

Severity
Site of bleeding
Underlying cause
Patient comorbidities

Conservative Measures

First-line for anterior bleeding:

Digital compression
Topical vasoconstrictor
Ice pack

Mechanism:

Cold induces vasoconstriction, reducing blood flow.

Chemical Cauterization

Indicated when bleeding point visible.

Silver nitrate works by:

Protein coagulation
Chemical burn
Vessel thrombosis

Precaution:

Do not cauterize both septal sides simultaneously to prevent perforation.

Electrocautery

Used when:

Bleeding persistent
Large vessel visible

Requires:

Adequate anesthesia
Endoscopic visualization

Anterior Nasal Packing – Advanced Considerations

Packing provides:

Direct tamponade
Pressure-induced vessel collapse
Promotion of clot formation

Complications:

Hypoxia (especially in COPD)
Sinus infection
Toxic shock syndrome (rare)

Prophylactic antibiotics are often prescribed.

Posterior Epistaxis Management

Posterior bleeds are:

Less accessible
More severe
Often arterial

Balloon catheters provide:

Posterior tamponade
Simultaneous anterior compression

Requires hospital monitoring due to:

Risk of hypoxia
Vagal stimulation
Cardiac arrhythmia

Surgical Management – Advanced Concepts

Indications:

Failure of packing
Recurrent severe bleeding
Identified arterial source

Endoscopic Sphenopalatine Artery Ligation

Preferred modern technique.

Advantages:

Direct visualization
Minimal morbidity
High success rate

Procedure principle:

Identify sphenopalatine foramen
Clip or cauterize artery

External Carotid Artery Ligation

Used when:

Endoscopic control fails
Massive hemorrhage present

Less commonly performed today due to embolization availability.

Endovascular Embolization

Performed by interventional radiology.

Indications:

Persistent posterior bleeding
Vascular tumors
Trauma cases

Risks:

Stroke
Tissue necrosis
Facial pain

Special Clinical Situations

Pediatric Epistaxis

Mostly anterior.

Management focus:

Behavioral modification
Saline lubrication
Parental education

Geriatric Epistaxis

Often posterior.

Comorbidities:

Hypertension
Anticoagulant use
Atherosclerosis

Requires careful cardiovascular monitoring.

Epistaxis in Anticoagulated Patients

Approach includes:

Checking INR
Temporarily withholding anticoagulant
Reversal agents if life-threatening

Complications of Epistaxis

Immediate:

Shock
Aspiration
Airway compromise

Delayed:

Septal perforation
Synechiae
Infection

Prevention Strategies

Maintain nasal moisture
Control systemic diseases
Avoid nasal trauma
Proper management of allergies

Advanced Vascular Disorders Associated With Epistaxis

Epistaxis may represent the first clinical sign of underlying vascular pathology. In these patients, bleeding is often spontaneous, recurrent, and disproportionate to local trauma.

Hereditary Hemorrhagic Telangiectasia (HHT)

Also known as Osler-Weber-Rendu syndrome, this is an autosomal dominant vascular dysplasia characterized by abnormal angiogenesis and fragile telangiectatic vessels.

Pathogenesis

Mutation in genes responsible for TGF-β signaling (ENG, ACVRL1) leads to:

Defective endothelial maturation
Absence of capillary bed between arteries and veins
Direct arteriovenous shunting
Thin-walled vessels prone to rupture

Clinical Features

Recurrent spontaneous epistaxis (often beginning in adolescence)
Telangiectasias on lips, tongue, nasal mucosa
Gastrointestinal bleeding
Pulmonary AV malformations
Cerebral AV malformations

Diagnostic Criteria (Curaçao Criteria)

Spontaneous recurrent epistaxis
Multiple telangiectasias
Visceral AV malformations
First-degree relative with HHT

Three or more confirm diagnosis.

Management

Humidification and lubrication
Laser ablation of telangiectasias
Septodermoplasty
Endoscopic cauterization
In refractory cases: Young’s procedure (nasal closure)

Vascular Malformations and Hemangiomas

Capillary or cavernous hemangiomas may arise from:

Nasal septum
Inferior turbinate
Vestibule

Presentation:

Recurrent unilateral bleeding
Nasal obstruction
Visible reddish mass

Treatment:

Endoscopic excision
Preoperative embolization if large

Juvenile Nasopharyngeal Angiofibroma

A benign but highly vascular tumor seen almost exclusively in adolescent males.

Pathophysiology

Arises from posterolateral nasal wall near sphenopalatine foramen
Fed by branches of internal maxillary artery
Lacks muscular layer in vessels → severe bleeding

Clinical Presentation

Profuse recurrent epistaxis
Progressive nasal obstruction
Conductive hearing loss (Eustachian tube obstruction)
Facial deformity in advanced cases

Diagnosis

Contrast-enhanced CT
MRI for intracranial extension
Angiography for vascular mapping

Biopsy is contraindicated due to bleeding risk.

Management

Preoperative embolization
Endoscopic or open surgical excision

Granulomatous and Autoimmune Disorders

Certain systemic inflammatory diseases damage nasal vasculature.

Granulomatosis With Polyangiitis

Formerly known as Granulomatosis with polyangiitis.

Mechanism

Necrotizing vasculitis
Granuloma formation
Septal perforation

Symptoms

Recurrent epistaxis
Crusting
Saddle nose deformity
Pulmonary and renal involvement

Diagnosis supported by:

c-ANCA positivity
Biopsy

Treatment includes immunosuppressive therapy.

Systemic Lupus Erythematosus

Autoimmune-mediated vasculitis and thrombocytopenia may cause mucosal bleeding.

Sarcoidosis

Granulomatous infiltration weakens mucosa leading to chronic crusting and bleeding.

Radiological Evaluation in Epistaxis

Imaging is not required in routine anterior epistaxis but is essential when:

Posterior bleeding persists
Tumor suspected
Trauma present
Recurrent unilateral bleeding

Computed Tomography (CT)

Indications:

Facial fractures
Sinus pathology
Tumor detection

Provides excellent bone detail.

Magnetic Resonance Imaging (MRI)

Better for:

Soft tissue masses
Intracranial extension
Vascular tumors

Digital Subtraction Angiography (DSA)

Gold standard for:

Identifying bleeding vessel
Planning embolization
Mapping vascular tumors

Advanced Surgical Techniques in Detail

Endoscopic Sphenopalatine Artery Ligation

Most commonly performed surgical intervention for refractory posterior epistaxis.

Steps Overview

General anesthesia
Endoscopic visualization
Identification of posterior middle turbinate
Incision over lateral wall
Exposure of sphenopalatine foramen
Clipping or cauterization of arterial branches

Success rate exceeds 90%.

Anterior Ethmoidal Artery Ligation

Indicated when bleeding source is superior septum or roof.

Approach:

External Lynch incision or endoscopic approach
Careful dissection near orbit

Complication risk includes orbital hematoma.

Endovascular Embolization

Performed by interventional radiology.

Materials used:

Polyvinyl alcohol particles
Coils
Gel foam

Indicated in:

Persistent bleeding despite surgery
Traumatic epistaxis
Vascular tumors

Complications:

Stroke
Facial necrosis
Blindness (rare but catastrophic)

Intensive Care Management of Massive Epistaxis

Massive hemorrhage requires multidisciplinary care.

Airway Protection

Indications for intubation:

Altered mental status
Continuous posterior bleeding
Aspiration risk

Volume Resuscitation

IV crystalloids
Blood transfusion
Monitor hemoglobin

Coagulopathy Correction

Vitamin K
Fresh frozen plasma
Platelet transfusion
Reversal of anticoagulants

Recurrent Epistaxis – Long-Term Strategy

Recurrent cases require:

Identification of structural abnormality
Correction of systemic disease
Nasal moisturizing regimen
Avoidance of irritants

In resistant anterior bleeding:

Septodermoplasty may be considered

Pediatric vs Adult vs Geriatric Comparison

Feature	Pediatric	Adult	Geriatric
Site	Anterior	Mixed	Posterior
Cause	Trauma	Hypertension	Atherosclerosis
Severity	Mild	Moderate	Severe
Recurrence	Common	Variable	Higher complication risk

Evidence-Based Management Protocol

Stepwise approach:

Stabilize airway and circulation
Apply compression
Topical vasoconstrictor
Identify bleeding site
Cauterize if visible
Anterior packing if persistent
Posterior packing if needed
Surgical ligation or embolization if refractory

Prognosis

Anterior epistaxis generally has excellent prognosis.

Posterior epistaxis carries:

Higher morbidity
Increased hospitalization rate
Greater recurrence

Mortality is rare but possible in massive hemorrhage with delayed management.

Emerging Therapies and Future Directions

Research areas include:

Topical tranexamic acid
Novel hemostatic agents
Endoscopic laser therapy
Biologic agents for HHT
Advanced embolization materials

Minimally invasive endoscopic approaches have significantly reduced need for open surgical ligation.

Operative Anatomy in Refractory Epistaxis Surgery

Successful surgical control of epistaxis depends on precise understanding of lateral nasal wall anatomy, arterial branching patterns, and anatomical variations.

Detailed Anatomy of the Sphenopalatine Foramen

The sphenopalatine foramen is located:

Posterior to the middle turbinate
At junction of superior meatus and lateral nasal wall
Near crista ethmoidalis

The sphenopalatine artery (terminal branch of internal maxillary artery) may divide into:

Posterior septal branch
Posterior lateral nasal branches

Anatomical variation exists:

Single trunk (most common)
Multiple branches (important to identify all to prevent recurrence)

Failure to ligate accessory branches is a common cause of persistent bleeding.

Endoscopic Sphenopalatine Artery Ligation – Technical Depth

Patient Positioning

Supine
Head slightly elevated
Reverse Trendelenburg to reduce venous pressure

Key Landmarks

Middle turbinate
Posterior fontanelle
Ethmoid crest

Operative Steps

Decongest mucosa with topical vasoconstrictor
Infiltrate local anesthetic with adrenaline
Raise mucoperiosteal flap posterior to middle turbinate
Identify crista ethmoidalis
Locate sphenopalatine foramen
Clip or cauterize all visible branches
Replace flap

Hemostasis confirmed before closure.

Success rates exceed 90–95%.

Anterior Ethmoidal Artery Ligation – Detailed Anatomy

The anterior ethmoidal artery:

Branch of ophthalmic artery
Passes through anterior ethmoidal foramen
Lies near fovea ethmoidalis

Surgical caution:

Close proximity to orbit
Risk of orbital hematoma
Risk of CSF leak

Indicated when bleeding originates from superior septum or roof.

Histopathology of Nasal Vascular Lesions

Microscopic examination provides insight into bleeding propensity.

Capillary Hemangioma

Features:

Proliferation of small capillaries
Thin endothelial lining
Minimal supporting stroma

Explains tendency to bleed easily.

Cavernous Hemangioma

Large dilated vascular spaces
Thin walls
Slow flow but prone to rupture

Angiofibroma Histology

Fibrous stroma
Irregular vascular channels
Absence of muscular coat in vessels

Absence of smooth muscle makes vessel contraction impossible, leading to profuse bleeding.

Molecular Mechanisms of Mucosal Fragility

Chronic inflammation increases:

TNF-α
Interleukins
Matrix metalloproteinases

These degrade collagen and elastin, weakening vascular support.

Vitamin C deficiency (rare but possible) impairs collagen synthesis and increases bleeding tendency.

Tumor-Related Epistaxis – Comprehensive Differential

Persistent unilateral epistaxis must raise suspicion of neoplasm.

Benign Tumors

Inverted papilloma
Hemangioma
Angiofibroma

Malignant Tumors

Squamous cell carcinoma
Adenocarcinoma
Lymphoma
Melanoma

Warning signs:

Progressive obstruction
Facial numbness
Epiphora
Proptosis

Imaging and biopsy are mandatory in suspicious cases.

Complication Management Algorithms

Septal Perforation After Cautery

Management:

Saline irrigation
Petroleum jelly
Septal button if symptomatic

Large perforations may require surgical repair.

Toxic Shock Syndrome (Rare Packing Complication)

Symptoms:

High fever
Rash
Hypotension

Management:

Immediate pack removal
IV antibiotics
ICU monitoring

Hypoxia From Posterior Packing

Posterior packs reduce airflow significantly.

Monitor:

Oxygen saturation
Cardiac rhythm
Respiratory effort

Elderly patients with COPD require special caution.

Case-Based Clinical Scenarios

Case 1: Child With Recurrent Anterior Epistaxis

Findings:

Crusting at anterior septum
Habit of nose picking

Management:

Saline spray
Topical antibiotic ointment
Behavioral modification

Case 2: Elderly Hypertensive With Posterior Bleed

Findings:

Bleeding from throat
No visible anterior source

Management:

Posterior packing
Blood pressure control
Consider sphenopalatine ligation if persistent

Case 3: Adolescent Male With Profuse Recurrent Bleeding

Findings:

Nasal obstruction
Mass in nasopharynx

Suspect angiofibroma → Imaging → Preoperative embolization → Surgery.

Forensic Aspects of Epistaxis

Epistaxis may occur:

After assault
In strangulation
During blunt trauma

Forensic evaluation must distinguish:

Accidental injury
Self-inflicted trauma
Associated skull base fracture

Documentation is crucial.

Medicolegal Considerations

Failure to:

Control severe bleeding
Diagnose underlying tumor
Monitor posterior packing

May result in litigation.

Proper documentation should include:

Vital signs
Estimated blood loss
Interventions performed
Informed consent

Public Health and Preventive Medicine Perspective

Community education reduces incidence:

Avoid nose picking
Maintain indoor humidity
Early treatment of allergies
Blood pressure screening programs

In resource-limited settings, simple compression techniques save lives.

Comparative Global Practice Patterns

In developed settings:

Early endoscopic ligation preferred

In resource-limited settings:

Packing remains primary modality

Advances in minimally invasive surgery are gradually replacing prolonged packing.

Research Frontiers

Emerging areas include:

Topical tranexamic acid superiority trials
Biologic therapy in hereditary hemorrhagic telangiectasia
Advanced vascular imaging
Hemostatic biomaterials
3D endoscopic navigation systems

Summary of Advanced Clinical Pearls

Always stabilize airway first
Posterior bleed suspected if blood flows into throat
Never cauterize both sides of septum simultaneously
Consider tumor in unilateral recurrent epistaxis
Elderly posterior bleeds require admission
Surgical ligation has higher long-term success than repeated packing

Pediatric Epistaxis – Comprehensive Clinical Framework

Epistaxis in children differs significantly from adult presentations in etiology, anatomy, severity, and management strategy.

Epidemiology in Children

Peak age: 2–10 years
Mostly anterior septal origin
Rarely life-threatening
Frequently recurrent

Most cases are benign and related to mucosal irritation.

Pediatric Nasal Anatomy Considerations

In children:

Septal mucosa is thinner
Vessels are superficial
Behavioral trauma common

Even minimal digital trauma disrupts capillaries in Little’s area.

Common Causes in Children

Nose picking
Allergic rhinitis
Upper respiratory infection
Dry air
Foreign body
Rare bleeding disorders

Recurrent bleeding should prompt evaluation for platelet disorders or Von Willebrand disease.

Management Principles in Children

Conservative First

Saline nasal spray
Topical antibiotic ointment
Humidification
Nail trimming

Cautery

Only if:

Visible bleeding point
Recurrent despite conservative care

Use minimal chemical cautery under local anesthesia.

When to Investigate

Investigate if:

Bilateral frequent episodes
Bleeding from other sites
Family history of coagulopathy
Unexplained anemia

Geriatric Epistaxis – Cardiovascular and Systemic Interactions

Epistaxis in elderly patients carries higher morbidity due to systemic comorbidities.

Age-Related Vascular Changes

Atherosclerosis
Reduced vascular elasticity
Fragile arterial walls
Increased systolic pressure

These factors predispose to posterior epistaxis.

Polypharmacy and Anticoagulation

Common medications:

Warfarin
Direct oral anticoagulants
Dual antiplatelet therapy
NSAIDs

Always assess INR in anticoagulated patients.

Cardiovascular Monitoring

Posterior packing may cause:

Hypoxia
Vagal stimulation
Arrhythmia

Continuous monitoring recommended.

ICU Protocol for Massive Epistaxis

Massive epistaxis is defined as bleeding causing hemodynamic instability or requiring transfusion.

Stepwise Critical Care Protocol

1. Airway

Position upright
Suction clots
Intubate if needed

2. Breathing

Oxygen supplementation
Monitor saturation

3. Circulation

Two large-bore IV lines
Crystalloids
Blood transfusion

Transfusion Thresholds

Hemoglobin <7 g/dL in stable patients
Higher threshold in cardiac disease

Platelets indicated if:

<50,000/mm³ with active bleeding

Coagulation Correction

Vitamin K for warfarin
Prothrombin complex concentrate
Fresh frozen plasma
Platelet transfusion

Pharmacology of Hemostatic Agents in Epistaxis

Topical Vasoconstrictors

Mechanism:

Alpha-adrenergic receptor stimulation
Arteriolar constriction

Examples:

Oxymetazoline
Adrenaline

Tranexamic Acid

Antifibrinolytic agent.

Mechanism:

Inhibits plasminogen activation
Stabilizes clot

Studies show reduced need for packing in anterior epistaxis.

Topical Thrombin and Hemostatic Matrices

Promote rapid clot formation.

Used in refractory anterior bleeding.

Nasal Packing Materials – Comparative Analysis

Ribbon Gauze

Advantages:

Cheap
Widely available

Disadvantages:

Uncomfortable
Risk of infection

Merocel (Polyvinyl Acetate Sponge)

Advantages:

Expands when moistened
Uniform pressure

Disadvantages:

Painful removal

Balloon Catheters

Used in posterior bleeding.

Advantages:

Controlled pressure
Faster placement

Disadvantages:

Requires monitoring

Endoscopic Anatomy Variations

Important variations affecting surgical control:

Multiple sphenopalatine branches
Accessory foramen
High septal deviation
Prominent crista ethmoidalis

Failure to recognize variations increases recurrence.

Algorithm for Recurrent Epistaxis

Detailed history
Endoscopic evaluation
Rule out tumor
Evaluate coagulation
Consider surgical ligation if recurrent posterior source

Academic Viva Discussion Points

Common examination questions include:

Explain vascular supply of nasal septum
Differentiate anterior vs posterior epistaxis
Describe management protocol
Indications for surgical ligation
Complications of nasal packing
Approach to epistaxis in anticoagulated patient

Structured Revision Table

Aspect	Key Point
Most common site	Kiesselbach’s plexus
Most severe type	Posterior epistaxis
First-line management	Digital compression
Surgical gold standard	Endoscopic sphenopalatine ligation
Common pediatric cause	Nose picking
Red flag sign	Unilateral persistent bleeding

Preventive Strategies in High-Risk Groups

For Hypertensive Patients

Strict BP control
Regular monitoring

For Dry Climate

Humidifiers
Saline irrigation

For Anticoagulated Patients

Regular INR monitoring
Dose adjustment

Long-Term Outcomes

Anterior epistaxis:

Excellent prognosis
Rare complications

Posterior epistaxis:

Higher admission rate
Possible recurrence

Surgical ligation provides durable control in most refractory cases.

Advanced Endovascular Management of Epistaxis

When conservative measures, cautery, packing, and surgical ligation fail, endovascular embolization becomes a critical option. It is particularly useful in:

Refractory posterior epistaxis
Traumatic vascular injury
Vascular tumors
Postoperative hemorrhage

Vascular Anatomy Relevant to Embolization

The primary arterial supply involved in severe epistaxis originates from:

Internal maxillary artery
Sphenopalatine artery
Descending palatine artery
Facial artery

Interventional radiology identifies the bleeding vessel using digital subtraction angiography.

Embolization Materials

Common agents include:

Polyvinyl alcohol particles
Gel foam
Microcoils
Liquid embolic agents

Selection depends on:

Vessel size
Location
Risk of collateral circulation

Complications of Embolization

Although effective, complications can include:

Facial skin necrosis
Cranial nerve palsy
Stroke
Blindness (if ophthalmic circulation affected)

Therefore, embolization requires experienced operators.

Skull Base Trauma and Epistaxis

Severe facial trauma may cause life-threatening bleeding.

Mechanism

Fracture of ethmoid bone
Laceration of internal maxillary artery branches
Disruption of skull base vessels

Differentiating Epistaxis from CSF Rhinorrhea

CSF leak characteristics:

Clear watery discharge
Increases on bending forward
Positive beta-2 transferrin

Trauma-associated epistaxis may coexist with CSF leak, requiring neurosurgical consultation.

Epistaxis in Pregnancy – Advanced Physiology

Hormonal changes during pregnancy increase nasal vascularity.

Mechanism

Elevated estrogen
Increased blood volume
Mucosal edema

Results in:

Pregnancy rhinitis
Mild recurrent epistaxis

Usually resolves postpartum.

Severe bleeding warrants investigation for:

Gestational hypertension
Coagulopathy

Infectious Causes of Severe Epistaxis

Though rare, certain infections cause destructive bleeding.

Fungal Infections

Seen in:

Diabetic patients
Immunocompromised individuals

Invasive fungal sinusitis may erode vessels and cause severe bleeding.

Tuberculosis

Granulomatous destruction of nasal mucosa can result in chronic bleeding.

Epistaxis in Immunocompromised Patients

High-risk groups:

Leukemia patients
Chemotherapy recipients
HIV infection

Mechanisms:

Thrombocytopenia
Mucosal ulceration
Secondary infections

Management requires multidisciplinary coordination.

Global Clinical Guidelines Comparison

Different countries recommend stepwise approaches:

Conservative First

Universal recommendation.

Early Surgical Ligation

Increasingly preferred over repeated posterior packing in modern centers.

Embolization

Reserved for refractory cases.

Trend worldwide favors:

Minimally invasive endoscopic techniques
Reduced hospital stay
Faster recovery

Advanced Differential Diagnosis of Unilateral Epistaxis

Unilateral recurrent bleeding in adults must raise suspicion for:

Tumor
Vascular malformation
Chronic sinusitis
Foreign body (rare in adults)
Septal ulcer

Imaging is mandatory in persistent unilateral cases.

Clinical Case Bank for Postgraduate Learning

Case Scenario: Refractory Posterior Bleed in 65-Year-Old

Presentation:

Persistent bleeding despite anterior packing
Hypertensive history

Management:

Posterior balloon pack
BP control
Endoscopic sphenopalatine ligation if rebleeding

Case Scenario: Young Male with Nasal Mass

Symptoms:

Recurrent severe bleeding
Nasal obstruction

Diagnosis:

Imaging
Suspect angiofibroma

Management:

Preoperative embolization
Surgical excision

Case Scenario: Anticoagulated Patient

Presentation:

INR elevated
Persistent bleeding

Management:

Reverse anticoagulation
Packing
Monitor cardiac status

Structured MCQs for Academic Revision

Most common site of epistaxis?
→ Kiesselbach’s plexus
Most common cause in children?
→ Digital trauma
Gold standard surgery for refractory posterior epistaxis?
→ Endoscopic sphenopalatine artery ligation
Most common systemic cause in elderly?
→ Hypertension
Dangerous complication of embolization?
→ Stroke

Long-Term Recurrence Prevention

Patients with recurrent episodes should receive:

Nasal moisturization protocol
Treatment of allergic rhinitis
Blood pressure management
Hematology evaluation if indicated

For structural causes:

Septoplasty
Tumor excision

Comprehensive Clinical Pearls for Practice

Always suction before examining
Do not panic in anterior bleeds
Posterior bleeding suspected if blood flows into throat
Never cauterize bilaterally
Admit elderly posterior bleeds
Always rule out malignancy in unilateral adult cases

Detailed Operative Techniques in Refractory Epistaxis

When conservative, medical, and packing strategies fail, operative intervention becomes necessary. Modern ENT practice favors minimally invasive endoscopic approaches over traditional open vascular ligations.

Endoscopic Posterior Septal Artery Control

The posterior septal artery, a branch of the sphenopalatine artery, supplies the posterior septum and contributes significantly to severe posterior epistaxis.

Operative Principles

Adequate nasal decongestion
Identification of middle turbinate
Elevation of mucoperiosteal flap
Visualization of vascular pedicle
Bipolar cauterization or clipping

Failure to identify accessory branches may result in recurrence.

Transantral Internal Maxillary Artery Ligation (Historical Technique)

Before endoscopic techniques became standard, transantral ligation was commonly performed.

Approach

Caldwell-Luc incision
Entry into maxillary sinus
Identification of internal maxillary artery
Ligation within pterygopalatine fossa

This approach is now rarely performed due to higher morbidity and availability of endoscopic methods.

Advanced Anatomical Variations Affecting Bleeding Control

Important variations include:

Multiple sphenopalatine foramina
High posterior septal spur
Enlarged inferior turbinate obscuring view
Accessory ethmoidal arteries

Preoperative imaging can help anticipate these variations.

Rare Vascular Syndromes Associated With Epistaxis

Ehlers-Danlos Syndrome

A connective tissue disorder characterized by:

Defective collagen synthesis
Fragile blood vessels
Easy bruising

Epistaxis may be recurrent and difficult to control.

Idiopathic Thrombocytopenic Purpura (ITP)

Autoimmune platelet destruction leads to:

Low platelet count
Mucosal bleeding
Recurrent nosebleeds

Management includes corticosteroids and platelet support.

Epistaxis in Hematologic Malignancy

Leukemia patients often present with:

Persistent epistaxis
Gingival bleeding
Petechiae

Mechanism:

Bone marrow suppression
Thrombocytopenia
Coagulation abnormalities

Urgent hematology consultation is required.

Evidence-Based Outcomes in Surgical Management

Recent data shows:

Endoscopic sphenopalatine ligation success rate >90%
Reduced hospital stay compared to repeated posterior packing
Lower recurrence rates

Posterior packing alone has higher discomfort and recurrence.

Pharmacologic Dosing Protocols in Epistaxis

Oxymetazoline

Concentration: 0.05%
2–3 sprays into affected nostril
Avoid prolonged use to prevent rebound congestion

Adrenaline (Epinephrine)

Dilution: 1:1000 or 1:10,000
Applied topically via pledget

Monitor for tachycardia in elderly.

Tranexamic Acid

Topical soaked pledget
Oral dosing in recurrent cases (under supervision)

Complications of Surgical Intervention

Orbital Complications

Possible during ethmoidal artery ligation:

Orbital hematoma
Visual disturbance

Immediate ophthalmology referral required.

Cerebrospinal Fluid Leak

Rare but possible when working near skull base.

Signs:

Clear nasal discharge
Headache
Positive beta-2 transferrin

Requires neurosurgical input.

Postoperative Care After Surgical Ligation

Nasal saline irrigation
Avoid nose blowing
Monitor for rebleeding
Follow-up endoscopy

Most patients recover without major complications.

Rehabilitation and Long-Term Follow-Up

Recurrent epistaxis patients benefit from:

Allergy control
Hypertension management
Smoking cessation
Environmental humidity optimization

Regular ENT follow-up ensures early detection of recurrence.

Advanced Viva Simulation (Postgraduate Level)

Examiner may ask:

Describe vascular supply of nasal cavity in detail.
Explain management of posterior epistaxis.
Discuss complications of nasal packing.
Compare embolization vs ligation.
Approach to epistaxis in a patient on anticoagulants.
Differential diagnosis of unilateral epistaxis in adult.

Structured answers improve examination performance.

Statistical Outcomes and Prognostic Data

Majority (≈90%) anterior and self-limiting
5–10% require packing
<5% require surgical intervention
Mortality rare but reported in massive untreated hemorrhage

Early intervention reduces morbidity.

Clinical Flow Strategy (Conceptual Framework)

Stabilize airway
Assess severity
Identify anterior vs posterior
Apply compression
Topical vasoconstrictor
Cautery if visible
Packing if persistent
Surgical ligation or embolization if refractory
Address underlying cause

Summary of High-Yield Advanced Points

Anterior epistaxis most common and benign
Posterior epistaxis more severe in elderly
Always rule out tumor in unilateral persistent bleeding
Endoscopic ligation superior to prolonged packing
Embolization reserved for refractory cases
Multidisciplinary approach needed in severe cases

Tumor Pathology Associated With Epistaxis

Persistent, recurrent, or unilateral epistaxis must always raise suspicion of underlying neoplasm, particularly in adults over 40 years.

Benign Tumors Causing Epistaxis

Inverted Papilloma

Characteristics:

Arises from lateral nasal wall
Locally aggressive
Risk of malignant transformation

Symptoms:

Unilateral obstruction
Recurrent epistaxis
Nasal discharge

Management:

Complete endoscopic excision
Long-term surveillance

Hemangioma

Usually capillary type.

Features:

Red vascular mass
Bleeds on touch
Common in septum or vestibule

Treatment:

Endoscopic excision
Cautery

Malignant Tumors and Epistaxis

Squamous Cell Carcinoma

Most common sinonasal malignancy.

Red flags:

Persistent unilateral bleeding
Facial pain
Epiphora
Neck nodes

Diagnosis:

Endoscopic biopsy
CT and MRI staging

Management:

Surgery
Radiotherapy
Chemotherapy

Nasopharyngeal Carcinoma

Often presents with:

Epistaxis
Neck mass
Conductive hearing loss

Requires imaging and biopsy confirmation.

Skull Base and Major Vascular Injuries

Severe trauma may involve:

Internal carotid artery
Cavernous sinus
Ethmoidal arteries

Carotid Artery Injury

Presentation:

Massive pulsatile bleeding
Rapid hemodynamic collapse

Management:

Immediate angiography
Endovascular stenting or embolization
Neurosurgical collaboration

Rare Infectious Destructive Lesions

Invasive Fungal Sinusitis

Seen in:

Uncontrolled diabetes
Immunocompromised patients

Features:

Black necrotic tissue
Severe facial pain
Epistaxis

Requires:

Urgent debridement
IV antifungal therapy

Syphilitic or Tuberculous Nasal Lesions

Chronic ulceration may lead to:

Septal perforation
Recurrent bleeding

Diagnosis by biopsy and microbiologic testing.

Comparative Global Surgical Techniques

In advanced centers:

Early endoscopic ligation preferred

In resource-limited areas:

Packing remains primary method

Trend shows increasing use of minimally invasive endoscopic vascular control worldwide.

Algorithmic Clinical Tables

Rapid Severity Assessment

Parameter	Mild	Moderate	Severe
Hemodynamics	Stable	Mild tachycardia	Hypotension
Site	Anterior	Mixed	Posterior
Intervention	Compression	Cautery	Packing/Surgery

Posterior Epistaxis Risk Indicators

Age > 50
Hypertension
Anticoagulation
Blood flowing into throat

Research Trials and Evidence Insights

Recent studies show:

Topical tranexamic acid reduces need for packing
Early surgical ligation decreases hospital stay
Endoscopic approaches reduce recurrence

Meta-analyses favor minimally invasive surgical management over repeated posterior packing.

Full Postgraduate Revision Bank – Conceptual Questions

Describe blood supply of nasal cavity in detail.
Compare anterior vs posterior epistaxis management.
Indications for embolization.
Discuss management in anticoagulated patient.
Explain complications of posterior packing.
Approach to unilateral epistaxis in adult patient.

Advanced Clinical Integration

Epistaxis management requires integration of:

Anatomy
Hematology
Radiology
Critical care
Surgical expertise

Effective treatment depends on early identification of:

Site
Severity
Systemic contribution

Holistic Long-Term Care Strategy

For recurrent cases:

Regular nasal moisturization
Allergy management
Blood pressure optimization
Hematologic screening
Tumor surveillance if indicated

Lifestyle modifications significantly reduce recurrence.

Ultra-Detailed Microanatomy of Nasal Vascular Supply

Understanding the three-dimensional microanatomy of the nasal vasculature is essential for precision surgery and prevention of recurrence.

External Carotid System – Deep Branching Pattern

The internal maxillary artery divides into:

Mandibular part
Pterygoid part
Pterygopalatine part

The pterygopalatine segment gives rise to:

Sphenopalatine artery
Descending palatine artery
Infraorbital artery
Posterior superior alveolar artery

The sphenopalatine artery enters via the sphenopalatine foramen and typically divides into:

Posterior septal branch
Posterior lateral nasal branches

Anatomical variation:

One trunk (≈65%)
Two trunks (≈25%)
Multiple branches (≈10%)

Failure to control accessory trunks explains persistent postoperative bleeding.

Internal Carotid Contributions

The ophthalmic artery gives rise to:

Anterior ethmoidal artery
Posterior ethmoidal artery

These pass through the ethmoid bone and supply:

Superior septum
Nasal roof

Injury during surgery near the skull base can lead to significant hemorrhage.

Venous Drainage and Its Role in Posterior Epistaxis

Venous blood drains via:

Submucosal venous plexus
Facial vein
Pterygoid venous plexus

Woodruff’s plexus is a posterior inferior venous plexus prone to rupture in elderly hypertensive patients.

Venous bleeding:

Darker
Continuous
Less pulsatile

But can still be profuse.

Neurovascular Regulation of Nasal Blood Flow

The nasal mucosa is under autonomic control.

Sympathetic Control

Vasoconstriction
Reduces blood flow
Decreases bleeding

Parasympathetic Control

Vasodilation
Increases congestion
May predispose to bleeding

Inflammatory mediators shift balance toward vasodilation.

Advanced Hemostatic Physiology

Hemostasis occurs in stages:

Primary Hemostasis

Platelet adhesion
Platelet aggregation

Secondary Hemostasis

Coagulation cascade
Fibrin formation

Fibrinolysis

Clot breakdown

Excessive fibrinolysis leads to recurrent bleeding; this is the rationale for tranexamic acid use.

Coagulation Disorders and Epistaxis – In-Depth

Platelet Disorders

Qualitative or quantitative defects result in mucosal bleeding.

Examples:

Thrombocytopenia
Bernard-Soulier syndrome
Glanzmann thrombasthenia

Clinical features include:

Petechiae
Gum bleeding
Easy bruising

Coagulation Factor Deficiencies

Defects in:

Factor VIII
Factor IX
Factor XI

Cause prolonged bleeding episodes.

Epistaxis in Liver Failure – Mechanistic Insight

Liver dysfunction leads to:

Reduced clotting factor production
Thrombocytopenia (due to splenomegaly)
Impaired fibrinogen synthesis

Management may require:

Fresh frozen plasma
Vitamin K
Platelets

Advanced Surgical Microdissection Principles

Hemostasis Before Visualization

Adequate suction and vasoconstriction are essential.

Poor visualization increases risk of:

Missed arterial branch
Orbital injury
Skull base injury

Bipolar vs Monopolar Cautery

Bipolar cautery preferred because:

Precise energy delivery
Reduced collateral damage
Lower perforation risk

Septodermoplasty – Advanced Technique

Indicated in severe recurrent bleeding, especially in hereditary hemorrhagic telangiectasia.

Procedure:

Remove diseased septal mucosa
Replace with split-thickness skin graft

Reduces frequency of recurrent bleeding.

Young’s Procedure (Nasal Closure)

Reserved for extreme refractory cases.

Principle:

Surgical closure of nostrils
Eliminates airflow-induced trauma

Used primarily in severe vascular dysplasia.

Postoperative Complications in Detail

Septal Hematoma

Presentation:

Nasal obstruction
Pain
Swelling

Requires urgent drainage to prevent cartilage necrosis.

Synechiae Formation

Adhesion between septum and turbinate.

Prevention:

Spacers
Careful mucosal preservation

Atrophic Rhinitis After Aggressive Surgery

Excessive mucosal removal may lead to:

Dryness
Crusting
Foul odor

Conservative surgical philosophy reduces this risk.

Epistaxis and Systemic Hypertension – Deep Analysis

While hypertension does not directly initiate bleeding, chronic elevated pressure:

Weakens arterial walls
Promotes atherosclerosis
Reduces clot stability

Acute BP spikes may precipitate rupture in fragile vessels.

BP control is essential during acute management.

Advanced Risk Stratification Model

High-Risk Features:

Age > 60
Posterior bleeding
Anticoagulation
Hemodynamic instability
Comorbid cardiovascular disease

Low-Risk Features:

Child
Visible anterior source
Self-limited bleeding

Risk stratification guides admission decisions.

Emerging Technologies in Epistaxis Management

Endoscopic 4K Visualization

Improves identification of:

Accessory arterial branches
Small vascular malformations

Navigation-Guided Surgery

Useful in:

Complex skull base anatomy
Tumor-related bleeding

Advanced Hemostatic Biomaterials

New-generation absorbable materials:

Promote clotting
Reduce infection
Dissolve without removal

Advanced Comparative Outcomes

Modern trend shows:

Endoscopic ligation superior to repeated posterior packing
Shorter hospital stay
Lower recurrence
Greater patient comfort

Posterior packing associated with:

Hypoxia
Discomfort
Longer admission

Integrated Multidisciplinary Approach

Severe epistaxis may require:

ENT surgeon
Interventional radiologist
Hematologist
Intensivist
Neurosurgeon (in skull base trauma)

Collaboration improves survival in complex cases.

Advanced Clinical Summary

Epistaxis represents a spectrum:

Minor anterior capillary bleed
Severe posterior arterial hemorrhage
Manifestation of systemic coagulopathy
Indicator of malignancy
Complication of trauma
Vascular malformation presentation

Management requires:

Anatomical precision
Hemodynamic awareness
Systemic evaluation
Surgical skill