Epistaxis And The Anatomy Of The Nose Biology Essay

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Epistaxis is the term used for nose bleeds. It occurs in approximately 60% of people during their lifetimes with 6% requiring or seeking medical attention (1, 2).Reports of epistaxis occur more frequently in the colder dryer months of the year generally occurring more frequently in males than females. There is also an increasing incidence with age with 70% of adult males over 60 years having experienced an episode (3).

The causes of epistaxis can be local or systemic and are classified by the location either anterior or posterior. The most common being anterior bleeds and occurring in an area known as Kiesselbach's area, or Little's area. This is a localised region of mucosa in the anteroinferior region of the nasal septum where four arteries anastamose forming Kiesselbach's plexus, named after Wilhelm Kiesselbach, (1 December 1839 - 4 August 1902), a German otolaryngologist. (4)

Anatomy of the nose

Blood supply

The arterial blood supply to the nasal region comes from both the internal and external carotid arteries (5, 6). The external carotid supplies most of the nasal fossa via branches that form the internal maxillary arteries which are the greater palatine artery and the sphenopalatine artery. The sphenopalatine artery supplies the nasal fossa via its lateral and medial branches with the lateral branch supplying the middle, inferior and superior turbinates with the middle branch supplying the nasal septum. The greater palatine artery

The external carotid supplies the superior labial branch of the supplies the inferior nasal septum where it joins to form an anastamosis with medial branches of the sphenopalatine artery. The medial wall of the nasal vestibule which is the most anterior part of the nasal cavity is supplied by the superior labial artery which is a branch of the facial artery.

The internal carotid artery gives off branches which form the posterior and anterior ethmoidal arteries, usually branching off the ophthalmic artery. This passes through the cribiform plate and forms an anastamosis with branches of the sphenopalatine artery and hence forming the pre mentioned Kiesselbach's area, or Little's area. (4).

Figures 1.1 and 1.2 , these show the blood supply to the nasal septum and lateral nasal wall.

Epistaxis occurrence

Epistaxis or nosebleeds can be mild or severe and in rare cases even fatal with the majority requiring no intervention or just simple nasal packing (8).

Anterior nosebleeds, occurring in Kiesselbach's area, are the most common accounting for 90% of cases, due to the rich anastomotic blood supply (9). These are usually easy to manage and usually do not require hospitalization. The further 10% occurring posterior usually occur in the older population with one report showing the mean age to be 64years (10). The pathogenesis of posterior epistaxis is unknown but due to the common occurrence in older populations the cause could be seen to be linked to age related vascular degeneration and due to the location of such bleeds management is much more difficult (11).

Epistaxis Aetiology

The major aetiological factors for epistaxis can be of local cause as in trauma, for example self induced digital trauma, (nose picking) which is a common occurrence in children, polyps and foreign bodies or systemic such as coagulation disorders such as haemophilia or drug induced coagulopathies due to the administration of warfarin or aspirin (2). The other major causes and rarer causes of epistaxis can be found in Table 1

Aim 2

Current Guidelines and management plans for treating epistaxis

Currently there are no NICE guidelines for the management of epistaxis and all NHS trust are guided by their own policies and procedures, yet the majority of institutions, (85%) as noted in a UK survey carried out, failed to have a written policy or protocol and therefore decisions on management being made at the time of admission with no guidance on the optimum therapeutic intervention for the patient (12, 13)

The institution in which the author is linked to has its own local policies for the treatment and management of patients attending the hospital for with epistaxis and these policies and guidelines closely follow those in the previously mentioned literature details and are detailed below.

Staff members who are involved in such care are required to complete a competency statement to ensure they are aware of how to treat such patients. This competency statement can be found in appendix 1 (14).

Management of epistaxis patients

On admission of a patient with epistaxis it is essential that the examining practitioner is prepared and ready this means donning gloves and personal protective equipment. As for any emergency the patients "ABC"s are the most important and the patient must be resuscitated before any other interventions. The first intervention is pinching of the nose as shown in figure 2, this may be required for 10-15 minutes. Ice packs placed over the nose may also be helpful. If this procedure fails to work the mext step is cauterisation.

Cauterisation requires local anaesthetic spray and if available a vasoconstrictor spray, a headlight, speculum and silver nitrate cautery sticks or bipolar diathermy. The procedure is explained to the patient and the spray in administered to each nostril. Once the area of bleeding is identified the silver nitrate stick is applied for approximately 10 seconds or the bipolar diathermy used. (15, 16).

For all patients attending with an epistaxis a full patient history is required this should be taken from the patient quickly and comprehensively and must include the following points

History of nasal trauma

family history of bleeding

hypertension, current medications and how well it is controlled

history of hepatic diseases

Use of anticoagulants

Other medications e.g. for diabetes or coronary artery disease

If cautery fails anterior nasal packing needs to be considered. Additional equipment required includes ribbon gauze impregnated with bismuth iodoform paraffin paste (BIPP), Vaseline gauze or Merocel® packs. Another pack on the market is the Rapid Rhino® which in a clinical trial has been proved as effective as the Merocel® packs but has shown significantly lower scores for discomfort during its insertion and removal (17).

If there is continued bleeding after insertion of an anterior pack then postnasal packing is to be considered and senior assistance should be sought. For this procedure there are various post nasal packs available.

If after 24 hours there are still signs of bleeding through the pack or the patient re bleeds, the patient is a case for surgery. Surgery depends on the vessel that is bleeding and involves ligation of the said vessel. This initially requires an examination under general anaesthesia with further cauterisation with bipolar diathermy and endoscopic sphenopalatine artery ligation. This is the treatment of choice so long as the patient is fit for a general anaesthetic. This procedure has been deemed safe and of a low morbidity in comparison to ligation of the maxillary or external carotid arteries (19).

Embolisation is another technique which can be used for intractable epistaxis and is particularly good for use in patients who are unable or unfit to have a general anaesthetic and surgery or for whom surgery has failed. It does however carry its own risks and complications.

Aim 3

Specific treatments for posterior bleeds

The treatments involved in severe posterior epistaxis can include any of the methods previously mentioned and morbidity among the different treatments has been found to vary (21).

Angiographic embolisation is a treatment method adopted in some cases of intractable epistaxis but due to its availability is not always possible for all patients. The aim of embolisation is to decrease arterial inflow and aid haemostasis by allowing clotting and epithelial repair.

Literature regarding angiographic embolisation dates back to 1974 when Sokoloff first described the method in 2 cases (22).

Many different reviews have been written on the procedure, its efficacy, success and complications yet the procedure still remains a last resort treatment for the majority of patients suffering intractable epistaxis and would be offered repeated ligation of the vessel involved this in part is due to it not being widely available due to the requirement of an experienced neuroradiologist institutions therefore only being able to offer ligation treatments. Complications of the various treatments are going to be reviewed with the aim to determine the best course of treatment for patients.

Description of the procedure - angiographic embolisation

To begin the procedure the patient must first undergo a diagnostic angiography to locate the exact source of the haemorrhage. In epistaxis this is angiography paying particular attention to the external carotid artery and its branch to the internal maxillary artery.

The usual approach is femoral, with the administration of local anaesthetic. A 4-6 French gauge guiding catheter is used and is advanced up to the internal or external carotid arteries bilaterally. A diagnostic angiogram is performed using a contrast medium and the ipsilateral internal maxillary artery is identified and catheterised.

Diagnostic angiograms are extremely important and must be carefully analysed prior to proceeding due to potential "dangerous anastamosis". These include connections between the internal and external carotid arteries which could potentially allow embolic material to pass from one vessel to the other and become a potential infarction risk.

Once the angiograms have been analysed and no "dangerous anastamosis identified bleeding vessels are identified and their arterial supply is then micro catheterised.

Embolisation is then performed on the identified vessel. If the vessel cannot be identified or visualised then bilateral internal maxillary arteries are embolised.

Embolisation is stopped when flow in the distal branches of the embolised vessel are significantly slow and repeat angiography is performed to ascertain the extent of embolisation achieved (21, 23, 24).

Embolisation is carried out using a variety of embolic agents coils, polyvinyl alcohol and gelfoam being the most common used in epistaxis.

Embolic agents and materials


Coils are subdivided into micro and macro coils. Microcoils are the coils used to embolise in epistaxis. The big advantage of embolising using coils is that they can be placed precisely under fluoroscopic control. Occlusion of the vessel occurs due to thrombosis induced by the coil and to increase the thrombotic effect Dacron wool is attached to the end of the coils. An advantage for the use of coils is due to them being highly thrombogenic and radiopaque. A disadvantage of coils is the potential to for collateralisation and the resulting persistence of bloodflow to the embolised vessel and difficulty in repeating the procedure (25, 26).

Polyvinyl Alcohol (PVA)

Polyvinyl alcohol is available in a variety of sizes up to ~710μm and is used with a micro catheter for delivery. It is usually delivered in a mixture of contrast medium and sodium chloride. PVA embolisation depends on thrombus formation where the vessel is embolised via the thrombus rather than the particle itself. It causes an inflammatory reaction which is therefore responsible for the thrombus. It is a permanent embolic agent and recanalization only has a low frequency. It is not absorbed and this adds to the permanent occlusion formed.


Gelfoam is a water soluble gelatine sponge. It can be cut to size and absorbs many times its own weight in fluids. It is absorbed fully within a few weeks and is intended for temporary vessel occlusion while further collateral vessels are formed.

Other materials are used and include balloons and collagen but are less common.

Aim 4

Embolisation, contraindications and complications


Contraindications for embolisation include dangerous anastamoses between the internal carotid artery and the external carotid artery which could cause embolic materials to pass across the vessels and cause infarction within the brain. It is also contraindicated in cases where bleeding is found to be from the anterior or posterior ethmoidal artery. Embolisation is contraindicated in these cases due to the risk of embolising the ophthalmic artery which would carry a very high risk of blindness (4, 25).