Otolaryngeal system (ENT)


Acute hemorrhage/nose bleed from the nasal cavity of the nostril.

Acute hemorrhage/nose bleed from the nasal cavity of the nostril.


About 60% of people have experienced a nosebleed during their life, and only 10% of nosebleeds are severe enough to warrant treatment/medical intervention. They occur most commonly in children of 1-10 years and 50-80 years old elderly.

Anterior epistaxis (> 90% cases):

Division lies at the piriform aperture anatomically. Supplied by Keisselbach’s plexus in Little’s area.
  • Keisselbach’s plexus: Anastomotic network of vessels located on the anterior cartilaginous septum. It receives blood supply from both internal and external carotid arteries.
  • Usually seen in children/adolescents, commonly caused by trauma, including nose picking

Posterior epistaxis: 10% cases

Posterior bleeds are most commonly arterial in origin. It presents with a greater risk of airway compromise, aspiration and difficulty in controlling the haemorrhage.
  • Woodruff’s plexus: Anastomosis of posterior and superior terminal branches of the sphenopalatine and posterior ethmoidal arteries
  • Usually seen in the elderly, associated with hypertension and atherosclerosis
Arterial supply of the nasal cavity
Arterial supply of the nasal cavity: The nasal cavity has a rich and highly varied blood supply arising from the internal and external carotid arteries with multiple anastomoses and a crossover between the left and right arterial systems. The internal maxillary artery (IMAX) supplies 80% of the nasal vault. The sphenopalatine artery (SPA) supplies most of the nasal septum and the turbinates, while the greater palatine artery (GPA) supplies the floor of the nasal septum. The ethmoidal arteries course through the cribriform plate to supply the roof of the nasal cavity. The ethmoidal arteries communicates with branches of the SPA posteriorly and several branches anteriorly


Anterior rhinoscopy

Differentiating an anterior or posterior is key in management. Imaging such as x-ray or computed tomography have no role in the urgent or emergent management of active epistaxis.
  • Anterior bleeding: Direct visualization using a nasal speculum and light source. Topical spray with anesthetic and epinephrine for vasoconstriction to help control bleeding and to aid in the visualization of the source.
  • Posterior bleeding: Diagnosed after measures to control anterior bleeding have failed. High-flow posterior bleeds may cause blood to emanate from both nares.

Lab studies:

  • Complete blood cell count (CBC), type and cross match
  • Coagulation studies

Differential diagnosis:

  • Pseudoepistaxis: Bleeding from nose due to other sources (but passing through the nasal cavity and exiting the nostrils)
    • eg. blood coughed up through the airway and ending up in the nasal cavity, then dripping out.


The treatment of epistaxis requires a structured interdisciplinary approach by the primary care physician, emergency physician, otorhinolaryngologist, and hospital ENT department.

Treatment algorithm for level 1 (primary care physician emergency physician), level 2 (otorhinolaryngologist), and level 3 care (hospital ENT department) | Beck, R., Sorge, M., Schneider, A., & Dietz, A. (2018). Current Approaches to Epistaxis Treatment in Primary and Secondary Care. Deutsches Arzteblatt international, 115(1-02), 12–22.

Primary management:

The aim is to slowly reduce the blood pressure over a period of 24-48 hours. In around 65-75% of cases, these steps combined with application of a decongestant, oxymetazoline-based nasal spray will succeed in stopping the bleeding. If bleeding does not restart during a 30-min observation period and the patient is hemodynamically stable, emergency specialist ENT treatment is not required.
  • Trotter’s method: Compress both sides of nose for 15-20 min, using two fingers or a nose clip. Patient should sit upright and lean slightly forward to prevent the blood from running down the pharynx.
  • Local application of ice: Encourage vasoconstriction of the blood vessels of the nose.

Nasal packing:

Packing takes different forms for anterior and posterior bleeding. Bilateral nasal packing produces a higher intranasal pressure than unilateral packing and its practice is therefore widespread
Selection of nasal packing products in common use: a) Bellocq posterior nasal pack, b) Nasopharyngeal balloon, c) Xomed catheter, d) Rubber-coated sponge tampons, e) Cotton ribbon gauze, f) Ribbon gauze pledgets for intranasal application of oxymetazoline | Beck, R., Sorge, M., Schneider, A., & Dietz, A. (2018). Current Approaches to Epistaxis Treatment in Primary and Secondary Care. Deutsches Arzteblatt international, 115(1-02), 12–22.


Most cases of epistaxis from an easily visible anterior source can be effectively treated by cauterization with silver nitrate or electrocoagulation.
Bleeding in the Kiesselbach area (right side) before and after bipolar cautery | Beck, R., Sorge, M., Schneider, A., & Dietz, A. (2018). Current Approaches to Epistaxis Treatment in Primary and Secondary Care. Deutsches Arzteblatt international, 115(1-02), 12–22.

Surgical management:

When conservative treatment fails, surgical hemostasis is generally required., The method of choice is endoscopic clipping or coagulation.
  • Sphenopalatine artery ligation
  • Anterior ethmoidal artery ligation
  • Posterior ethmoidal artery ligation
Endoscopic clipping of the left sphenopalatine artery. | Traboulsi, H., Alam, E., & Hadi, U. (2015). Changing Trends in the Management of Epistaxis. International journal of otolaryngology, 2015, 263987.

Transnasal endoscopic sphenopalatine artery ligation (TESPAL) surgery:

Although posterior nasal packing can be applied in patients with posterior epistaxis, both the morbidity and duration of hospitalization of these patients have been reduced through the transnasal endoscopic sphenopalatine artery ligation (TESPAL) and arterial embolization methods in recent years
The surgical steps of endoscopic sphenopalatine artery ligation. (a) Flap elevation on the lateral nasal wall (Arrow shows crista ethmoidalis). (b) Exposure of the sphenopalatine artery (black arrow) is shown after the crista ethmoidalis is removed with a curette or Kerrison punch (star shows the posterior fontanelle). (c) Sphenopalatine artery is clipped with hemoclips. (d) The flap elevated on the lateral nasal wall is laid in its place (black arrow) | İsmi, O., Vayisoğlu, Y., Özcan, C., Görür, K., & Ünal, M. (2016). Endoscopic Sphenopalatine Artery Ligation in Posterior Epistaxis: Retrospective Analysis of 30 Patients. Turkish archives of otorhinolaryngology, 54(2), 47–52.

Percutaneous embolization

Where surgical treatment fails or the patient has a high anesthetic risk, percutaneous embolization is a reasonable alternative.

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