When Blood Flows Out from the front of nose with the patient in sitting position
Mainly the blood flows back into the throat. Patient may swallow it and later have a “coffee-coloured” vomitus. This may erroneously be diagnosed as haematemesis. The differences between the two types of epistaxis are tabulated herewith (Table 33.1)
Site More Common Mostly from Less common Mostly From
Little’s area or anterior part posterrosu-perior part of nasal cavity;
of lateral wall often difficult to locallize the bleeding point
Age Mostly occurs in children After 40 years of age
or young adults
Cause Mostly trauma Spontaneous; often due to hypertension or
Bleeding Usually mid, can be easily Bleeding is severe,requires hospitaliza-
controlled by local pressure tion; postnasal pack often required
or anterior pack
In any case of epistaxis , it is important to know:
1. Mode of onset. Spontaneous or finger nail trauma.
2. Duration and frequency of bleeding.
3. Amount of blood loss.
4. Side of nose from where bleeding is occurring.
5. Whether bleeding is of anterior or posterior type.
6. Any known bleeding tendency in the patient or family.
7. History of known medical ailment (hypertension, leukae-mia, mitral valve disease, cirrhosis and nephritis).
8. History of drug intake (analgesics, anticoagulants, etc. ).
Most Of the time, bleeding occurs from the little’s area and can be easily controlled by pinching the nose with thumb and index finger for about 5 min. This compresses the vessels of the Little’s area. In Trotter’s method patiend is made to sit, leaning a little forward over a basin to spit any blood and breathe quietly from the mouth. Cold compresses should be applied to the nose to cause reflex vasoconstriction.
This is useful in anterior epistaxis when bleeding point has been located. The area is first topically anaesthetized and the bleeding point cauterized with a bead of silver nitrate or coagulated with electrocautery.
In cases of active anterior epistaxis, nose is cleared of blood clots by suction and attempt is made to localize the bleeding site. In minor bleeds, from the accessible sites, cauterization of the bleeding area can be done. If bleeding is profuse and/ or the site of bleeding is difficult to localize, anterior packing should be done. For This, use a ribbon Gauze soaked with liquid paraffin. About i m gauze (2.5 cm wide in adults and 12 mm in children) is required for each nasal cavity. First, few centimetres of gauze are folded upon itself and inserted along the floor and then the whole nasal cavity is packed tightly by layering the gauze from floor to the roof vertical layers from back to the front. In that case, systemic antibiotics should be given to prevent sinus infection and toxic shock syndrome.
It is required for patients bleeding posteriorly into the thoroat. A postnasal pack is first prepared by tying three silk ties to a piece of gauze rolled into the shape of a cone. A rub-ber catherter is passed through the nose and its end brought out from the mouth. Ends of the silk threads are tied to it and catheter withdrawn from nose. Pack, which follows the silk thread,is now guided into the nasopharynx with the index finger. Anterior nasal cavity is now packed and silk threads tied over a dental roll. The third silk thread is cut short and allowed to hang in the oropharynx. Its helps in easy removal of the pack later. The bulb is infladed with saline and pulled forward so that choana is blocked and then an anterior nasal pack kept in the usual manner. These days nasal balloons are also avail able.A nasal balloon has two bulls, one for the postnasal space the other for nasal cavity.
using topical or general anaestheaia, bleeding point is localized with a rigid endoscope. it is then cauterized with a malleable unipolar suction cautery or a bipolar cautery. The procedure is effective with less morbididity and decreased hospital stay. The procedure has a limitation when profuse bleeding does not permit localization of the bleeding point.
in Case Of persistent or recurrent bleeds from The septum, Just elevation of mucoperichondrial flap and then repositioning it back helps to cause fibrosis and constrict blood vessels. SMR operation can be done to achieve the same result or remove any septal spur which is sometimes the cause of epistaxis.
1. External Carotid. when bleeding is from the external carotid system and the conservaitve measures have failed, ligation of external carotid artery should be done. It is avoided these days in favour of embolization on ligation of more peripheral of sphenopatine artery.
Ligation Of this artery is done in uncontrollable posterior epistaxis. Approch is via caldwell-Luc-opration. posterior wall of maxillary sinus is removed and the maxillary artery or its branches are blocked by applying clips. This procedrue is now superceded by trans-nasal endossocopic artrery light ( TESPAl).
In anterrosuperier bleeding above the middle turbinate, not controlled by packing, anterior and posterior ethmoidal arteries, WHICH SUPPLY this area, can be lighted. The Vessels are expossed in the medail wall of the orbit by an external ethmiod (Lynch) incision.