There are three key points to remember regarding epistaxis:
1. Epistaxis is common and usually arises from Little’s area.
2. Endoscopic sphenopalatine artery (SPA) ligation will resolve most non-traumatic spontaneous epistaxis, if not resolved by conservative measures.
3. Traumatic epistaxis may be due to nasal trauma involving the vomer and the superior portion of the nasal septum which is supplied by a branch of the anterior ethmoidal artery (AEA). Ligation of both the AEA and SPA may therefore be required in traumatic epistaxis.
1. Local causes:
• Iatrogenic. Probably the commonest cause as every endonasal surgical procedure including turbinate surgery will cause some epistaxis. Medical treatment with nasal steroids is another common iatrogenic cause, by virtue of mucosal irritation.
• Traumatic (fractures, foreign body, nose picking).
• Inflammatory (rhinitis, particularly from an upper respiratory tract infection [URTI] or allergic rhinitis, sinusitis).
• Neoplastic (benign, such as a pyogenic granuloma of the septum and juvenile angiofibroma, a wide range of malignancy of the nose, sinuses and nasopharynx).
• Environmental (high altitude, air conditioning).
• Endocrine (menstruation, pregnancy).
2. General causes:
• Anticoagulants (warfarin, aspirin, clopidogrel and apixaban).
• Diseases of the blood (haemophilia, leukaemia).
• Hereditary haemorrhagic telangiectasia (Osler–Weber–Rendu disease).
• Raised venous pressure, for example, due to paroxysms of coughing (as in chronic obstructive pulmonary disease [COPD] or whooping cough).
20.2 Blood Vessels Involved
The upper parts of the nose are supplied by branches from the internal carotid artery (anterior and posterior ethmoidal arteries which are branches of the ophthalmic artery) and the rest from branches of the external carotid artery, namely, the greater palatine (from the maxillary artery), the sphenopalatine (terminal branch of the maxillary artery), and the septal branch of the superior labial (a branch of the facial artery). Little’s area (Kiesselbach’s plexus) is the commonest site of bleeding. It is named after James Little, an American surgeon, who in 1879 described an area ‘about half an inch from the middle of the column (septum)” as a common site for epistaxis. It was Kiesselbach (a German otolaryngologist practicing in Erlangen) who published a paper in 1884 pointing out that at Little’s area four arteries anastomose to form a vascular plexus. These arteries are the anterior ethmoidal, sphenopalatine, greater palatine and the septal branch of the superior labial artery. Woodruff, in 1949 described a venous plexus within the posterior part of the inferior meatus (Woodruff’s plexus) as a possible source of posterior epistaxis. McGarry showed there are vessels at this site, but there is no evidence the site is a cause of epistaxis.
20.3 Sites Affected
Little’s area is the commonest site of epistaxis but the majority are minor and are ignored by the patient or treated in primary care. Its frequency is due to multiple factors; it is a site prone to trauma from nose picking and wiping, Little’s area is prone to drying if the anterior septum is deviated, which leads to irritation and then trauma. It is a site with a vascular plexus so will bleed easily if traumatised.
Studies have looked at the site of an epistaxis in patients coming to A&E and assessed by an ear, nose and throat (ENT) registrar. Only a third had a Little’s bleeding source, 40% had a posterior septal bleeding source, and the remainder were on the lateral nasal wall, often from within the middle meatus.