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  1. Areas of nasal bleed:
    1. Little’s area (antero- inferior part of the nasal septum)     
      1. Arteries contributing:
        1. Sphenopalatine artery
        2. Anterior ethmoidal
        3. Septal branch of greater palatine
        4. Septal branch of superior labial
    2. Retro columellar area (Just behind the columella). Occurs at the anterior edge of the little area
      1. The retro columellar vein of this area then runs along the floor of the nose to
      2. anastomose with the various plexus of the lateral wall of the nose
      3. Features: occurs in young people (<35 yrs)
    3. Woodruffs plexus (Is found in the lateral nasal wall posterior to the inferior meatus)
      1. Contributing vessels: From the posterior pharyngeal wall
      2. Venous bleed
    4. Haemorrhagica nodules (Can occur anywhere)
      1. Features: These are aneurysmal dilatations of an unusually sited muscular artery

Extra Edge. Most common site for epistaxis (90%) is. Little’s area situated on anteroinferior part of nasal septum.

  1. Causes of Epistaxis:
    1. Local
      1. Nose:    
      2. Trauma
        1. Infection
          1. Acute
          2. Chronic (T. B syphilis granulomatous lesion of the nose)
        2. Foreign bodies
        3. Neoplasm of nose and paranasal sinuses (benign/malignant)
        4. Atmospheric changes (high altitudes)
        5. Adenoiditis
        6. Juvenile angiofibroma
    2. General
      1. Cardiovascular causes (mitral stenosis, hypertension)
      2. Blood & blood vessels (anemia, thrombocytopenia)
      3. Liver disease
      4. Kidney disease
      5. Drugs (analgesics, anti coagulant therapy)
      6. Mediastinal tumors.
      7. Acute general infection (influenza, measles. Dengue)
      8. With age: The medium and smaller nasal arteries undergo change. The muscles layer of media is replaced by fibrous tissue.
Differences between anterior and posterior epistaxis
  Antterior epistaxis Post epistarier
 Incidence More common Less common
Site Mostly from Little’s
area or anterior part
Of lateral wall   of nasal cavity; often
difficult to localise
the bleeding point
Age Mostly trauma Spontaneous; often
due to hypertension
or arteriosclerosis
Bleeding Usually mild, can be easily
controlled by local pressure or
 anterior pack
Bleeding is severe,
requires hospitalization
postnasal pack often required
  1. Treatment:
    1. In young person:
      1. Nasal pinching : for 5-10 mins
      2. If bleeder seen cauterize with AgNO3
      3. If diffuse bleeding anterior nasal packing
      4. Post- nasal packing if bleeding does not stop with anterior nasal pack.
    2. Adult patient with recurrent bleeding:
    3. Ask for history of:
      1. Hypertension                       
      2. Alcohol                 
      3. Any current medication
  2. Treatment:
    1. Control blood pressure
    2. Cauterize bleeder with Ag N03
    3. Resistant cases
      1. Submucosal resection                
      2. Septoplasty
      3. Simple elevation of the mucoperichondrium or mucoperiosteal flap
  3. Trotter’s method:                                             
    Old fashioned method of controlling epistaxis
    Make the patient sit up with a cork between his teeth- allow him to bleed till he becomes hypotensive

Extra Edge. Lyre sign. It is splaying apart of internal and external carotid arteries on angiogram in cases of carotid body tumour of the neck.


Vessel Ligation In Uncontrollable Bleeds
  1. External carotid artery ligation  
    1. Operation of choice : elderly and debilitated
    2. Indication : bleeding from the external carotid artery system and all conservative methods have failed.
    3. Site for ligation : above the origin of superior thyroid artery                    
  2. Maxillary artery ligation Performed in the pterygopalatine fossa. Is performed in posterior bleeds
  3. Ethmoidal arteries : In anterosuperior bleed above the middle turbinate not controllable by packing

Extra Edge. Caroticotympanic artery is a branch of internal carotid artery. It anastomoses with branches of external carotid system in the middle ear.

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