ANATOMY OF NASAL BLOOD SUPPLY
Blood supply to the nose arises from the internal and external carotid artery systems. The external carotid provides arterial flow by way of the facial and internal maxillary arteries. The facial artery forms the superior labial artery, supplying the septum and nasal alae. The internal maxillary artery terminates in five branches, three of which supply the nasal cavity: the sphenopalatine, pharyngeal, and greater palatine branches. The internal carotid artery supplies the nose via terminal branches of the ophthalmic artery and the anterior and posterior ethmoid arteries.
Two anastomotic regions within the nose are particularly common for epistaxis—the Woodruff area and the Kiesselbach plexus. The Kiesselbach plexus is located in the anteroinferior nasal septum and is the source of the majority of nosebleeds. The posterior location of the Woodruff area makes it a common source for severe, nontraumatic bleeds.
Epistaxis can be categorized into local and systemic etiologies. Local etiologies include trauma, anatomic deformities, inflammatory reactions, and intranasal tumors. In children, the most common cause of epistaxis is digital trauma to the Kiesselbach plexus causing anterior septal nosebleeds. The improper use of topical nasal sprays, trauma from a foreign body, and nasal cannula can also cause epistaxis due to local irritation. In the operating room, insertion of nasal trumpets and nasal endotracheal tubes can cause trauma leading to nosebleeds. Anatomic deformities may disturb airflow, and the turbulent flow desiccates nasal mucosa, leading to epistaxis. Inflammatory or granulomatous disease such as allergic rhinitis, nasal polyposis, Wegner granulomatosis, and tuberculosis can also cause bleeding. Recurrent, unilateral bleeds without a clear etiology should raise suspicion of intranasal neoplasms or vascular malformations.
Systemic causes of epistaxis include hypertension, coagulopathy, and vascular disease. Hypertension is the most commonly associated finding in the case of severe or refractory bleeding. Anticoagulation medications and liver dysfunction are also common systemic factors affecting epistaxis. Aspirin, clopidogrel, NSAIDs, warfarin and heparin are medications that can singly, or in combination, increase the risk for epistaxis. The most common inherited bleeding disorders associated with epistaxis are hemophilia A, hemophilia B, and von Willebrand disease. Finally, vascular and cardiovascular diseases such as congestive heart failure, arteriosclerosis, and collagen abnormalities can contribute to epistaxis. Specifically Osler–Rendu–Weber disease leads to fragile, injury-prone vessels with deficiencies in elastic tissue and smooth muscle.
Initial management includes assessment of airway, breathing, and circulation as well as resuscitation, and should be immediately followed by direct therapy, tamponade, and vascular intervention. While epistaxis is typically not an immediate threat to the airway, patients should be placed in a sitting position and encouraged to lean forward to clear clots from the pharynx. Venous access should be established. One of the first priorities is to identify the site of bleeding.
In anterior nasal bleeding, anterior nasal compression for 10-60 minutes, in conjunction ...