Samuel D. Cohen and James W. Mims

Anatomy

The blood supply of the nose comes from branches of both the internal and external carotid artery systems, and there are multiple anastomoses between the two systems. Knowledge of the nasal cavity’s blood supply affects how epistaxis is diagnosed and treated.

Fig. 29.1 Arterial supply of the lateral nasal wall.

— Lateral branches of the SPA (or posterior nasal artery): These are terminal branches of the SPA supplying the lateral nasal wall and the middle and inferior turbinates.

— Septal branch of the SPA: This branch crosses the anterior face of the sphenoid (inferior to the ostia) before branching onto the posterior septum.

Ascending pharyngeal artery branches: The ascending pharyngeal artery is a branch of the maxillary artery and supplies the inferoposterior lateral nasal wall.

Superior labial artery: Another branch by which the external carotid artery provides blood to the lateral nasal wall is the superior labial artery, which is a branch of the facial artery. It provides several nasal branches supplying the anterolateral nasal wall.

Vascular regions

— Woodruff region: Throughout the nose there are several areas of anastomosis between the many arteries that supply the mucosa. The Woodruff region, also known as the nasopharyngeal plexus, lies on the posterolateral nasal wall in the region of the inferior meatus (between the inferior turbinate and nasal floor). It comprises vessels from the pharyngeal and posterior nasal arteries.

Fig. 29.2 Arterial supply of the septum.

Vascular regions

— Little area: The Little area, also known as the Kiesselbach plexus, is an area of anastomosis on the anterior nasal septum. It is the major area of anastomosis between the external and internal carotid artery blood supply to the nose. The vessels in Little’s area come from the SPA, greater palatine, anterior ethmoidal, posterior ethmoidal, and nasal branches of the superior labial arteries.

— Woodruff plexus of the posterior septum: Some authors consider the Woodruff plexus as a region of the posterior septum where ethmoid artery branches anastomose with the septal branches of the SPA.

Diagnostic Factors to Consider in Epistaxis

Location

Anterior: Anterior epistaxis often originates from Little area (Kiesselbach plexus) on the nasal septum.

Posterior

Hemoptysis can be the presenting sign of epistaxis, particularly posterior epistaxis.

Hematemesis can also be the presenting sign of epistaxis, particularly posterior epistaxis. Patients with neurological disease involving a decreased gag reflex may be more prone to ingesting large quantities of blood, and patients who are supine for a long period of time (eg, an intubated patient in the intensive care unit) is at increased risk of ingesting or aspirating blood from epistaxis.

Frequency

Other factors in history

Other bleeding sites: A history of other bleeding, especially mucosal bleeding, can be indicative of a systemic cause of epistaxis.

Family history of bleeding

Medications: There are numerous medications that are associated with epistaxis. Antiplatelet drugs such as aspirin and clopidogrel, warfarin, and nasal sprays may play a role in epistaxis.

— Illicit intranasal drug use

— Trauma: external (eg, blunt trauma, fracture) and internal (eg, finger manipulation)

— Recent nasal surgery

Physical examination

Airway, breathing, and circulation: always important first steps in any patient with active bleeding or trauma

Nasal exam

— Always use personal protective equipment (eye protection, gloves, mask, etc.).

— Anterior rhinoscopy

Remove all blood clots.

Use topical decongestant for visualization and to slow or stop bleeding. Placement of a cotton pledget with a topical vasoconstrictor may be needed to allow visualization.