Epistaxis Overview and Anatomy

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Questions and Answers

What is generally true about anterior epistaxis compared to posterior epistaxis?

It is usually more severe.

It is more common in older populations.

It can be easily controlled. (correct)

It is associated with hypertension.

Which of the following is NOT a local cause of epistaxis?

Nasal surgical procedure

Hypertension (correct)

Nasal intubation

Cold, dry air

What makes posterior epistaxis less alarming despite potentially significant bleeding?

It is always caused by trauma.

Blood is typically swallowed. (correct)

It usually occurs in younger individuals.

Blood is readily visible.

Which of the following is a systemic cause of epistaxis?

Hypertension Signup and view all the answers

What is a potential non-infectious inflammatory cause of nosebleeds?

Pyogenic granuloma Signup and view all the answers

What percentage of epistaxis episodes are classified as anterior?

90-95% Signup and view all the answers

Which anatomical area is primarily associated with the occurrence of anterior epistaxis?

Kiesselbach's plexus Signup and view all the answers

Which age groups have the highest incidence of epistaxis?

Children aged 2-10 and adults aged 50-70 Signup and view all the answers

Which factor is least likely to contribute to spontaneous epistaxis?

Frequent nose blowing Signup and view all the answers

What vascular structure is primarily involved in posterior nasal cavity bleeding?

Sphenopalatine artery Signup and view all the answers

Which factor is NOT associated with prolongation of epistaxis?

Young age Signup and view all the answers

What is typically the nature of epistaxis episodes in most cases?

Self-limited and self-resolving Signup and view all the answers

During which season does the incidence of epistaxis notably increase?

Winter Signup and view all the answers

Which of the following is a systemic cause of nasal bleeding?

Hereditary hemorrhagic telangiectasia Signup and view all the answers

What is a potential complication from internal carotid artery issues regarding nasal bleeding?

Pseudoaneurysm rupture Signup and view all the answers

Which investigation is NOT typically a part of the laboratory workup for epistaxis?

Liver ultrasound Signup and view all the answers

What should be the initial step in treating anterior epistaxis?

Sit the patient upright and apply pressure to the nose Signup and view all the answers

Which medication is most likely to contribute to nasal mucosal irritation causing epistaxis?

Antihistamines Signup and view all the answers

In the context of coagulopathies causing epistaxis, which condition is characterized by decreased platelet count?

Thrombocytopenic purpura Signup and view all the answers

What is the role of imaging such as CT scan in the evaluation of epistaxis?

Assess for sinonasal tumors Signup and view all the answers

Which of the following conditions would most likely lead to increased systemic venous pressure as a cause of epistaxis?

Coarctation of the aorta Signup and view all the answers

Study Notes

Epistaxis

Epistaxis is defined as bleeding from the nostril, nasal cavity, or nasopharynx.
Bleeding stems from the rupture of small blood vessels within the nose, or from any cause.
It's one of the most common ENT emergencies.
Bleeding is often self-limiting, but can be serious and life-threatening, requiring prompt intervention.
Epistaxis primarily originates from the lateral nasal wall or the septum.
Lateral nasal wall bleeding typically occurs near the sphenopalatine artery.
90-95% of epistaxis episodes are anterior.
The posterior nasal cavity is the source in roughly 5-10% of cases.

Epidemiology

Age distribution is bimodal, with most cases occurring in the 2-10 and 50-70 year age groups.
Incidence increases in winter.
True prevalence is unknown as most episodes are self-limiting and unreported.

Applied Anatomy

The nasal cavity is divided into anterior and posterior nasal cavities.
The most frequent bleeding site is the plexus of vessels at the anteroinferior aspect of the nasal septum within the anterior nasal cavity.
This area (Kiesselbach's plexus, also known as Little's area) is a common source of bleeding.

Pathophysiology

Epistaxis results from different predisposing factors.
Rupture of a blood vessel within the richly perfused nasal mucosa.
Rupture can be spontaneous or caused by trauma, systemic or local factors.
Increased blood pressure (like hypertension) prolongs spontaneous epistaxis.
Anticoagulant medication and blood clotting disorders promote and prolong bleeding.
Elder individuals are more susceptible to prolonged nosebleeds due to decreased blood vessel constriction function.

Anterior vs Posterior Epistaxis

Anterior:*
More common in younger individuals.
Often due to nasal dryness.
Usually readily visible bleeding, but generally less severe and easily controlled.
Posterior:*
More common in older individuals.
Hypertension is a frequent contributing factor.
Significant posterior bleeding that may not be readily observable because blood is swallowed.
More challenging to control.

Etiology

Idiopathic: Unknown cause
Local:
Trauma (nose picking, nose blowing, sneezing, nasal bone fracture, foreign bodies, nasal intubation, surgical procedure)
Inflammatory (infectious: Rhinitis/Rhinosinusitis [Bacteria, Viruses and/or Fungi]; Tuberculosis [Lupus vulgaris]; Syphilis [syphilitic ulcer of the nose]; Non-infectious: Pyogenic granuloma, allergic rhinitis)
Neoplasms (Benign: Juvenile nasopharyngeal angiofibroma, Haemangioma, Inverted papilloma; Malignant: Nasopharyngeal carcinoma, Sinonasal cancers)
Dessication (dry air, especially in winter; nasal oxygen administration; atrophic rhinitis)
Vascular (vascular malformations [arteriovenous malformations], internal carotid artery aneurysms [rupture/post-traumatic pseudoaneurysm])
Anatomical anomalies (septal deviation, septal perforation, septal varices, septal spurs)
Chemical irritants (cocaine, heroin, tobacco)
Medications (antihistamines, nasal corticosteroids)
Systemic:
Vascular (Hereditary hemorrhagic telangiectasia [Osler-Rendu-Weber Syndrome])
Cardiovascular (Mitral stenosis, Coarctation of the aorta due to elevated systemic venous pressure)
Coagulopathies (decreased platelet count [thrombocytopenia], idiopathic thrombocytopenic purpura; platelet dysfunction; systemic disease [uremia], drug-induced [anticoagulants, NSAIDs, antiplatelet drugs])
Clotting factor deficiencies (Hemophilia A, Hemophilia B, Von Willebrand's disease)
Hematologic malignancies (ALL, AML/CML, Aplastic anemia)
CKD Uremia
Liver failure

Diagnostic Evaluation

Medical history
Physical examination

Investigations

Laboratory Work Up: Complete Blood Count (including platelet count); Bleeding indices (PT, PTT, INR, thrombin time, bleeding time); Liver function tests (ASAT, ALAT); Renal function tests (serum creatinine, urea); Peripheral blood smear (to assess for hematological malignancies)
Bone marrow aspiration/trephine biopsy: To diagnose leukemia or aplastic anemia.
Clotting factors assays: To identify clotting factor deficiencies.
Biopsies: To analyze nasal tumors (inverted papilloma, pyogenic granulomas, lupus vulgaris, JNA).
Imaging Work Up: X-ray of paranasal sinuses; CT scan of paranasal sinuses

Treatment

Conservative: First aid measures (squeezing the nose, leaning forward); Cauterization; Nasal packing (anterior or posterior).
Surgical: Arterial ligation; Embolization

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Description

This quiz covers the essentials of epistaxis, including its definition, common causes, and anatomy related to nasal bleeding. Learn about the epidemiology and management of this common ENT emergency. Perfect for medical students and healthcare professionals.