Causes and Treatment of Epistaxis

I. Introduction & Classification

• Definition: Bleeding from inside the nose.
• Anterior Epistaxis (90%): Arises from Little’s Area (Kiesselbach’s Plexus) on the anterior nasal septum. Most common in children.
• Posterior Epistaxis (10%): Arises from the Woodruff's plexus (sphenopalatine artery). More common in adults/hypertensives; severe and difficult to control.

II. Etiology (Causes)

Causes are broadly classified into Local and Systemic.

A. Local Causes (Most Common)

1. Trauma:
   • Digital Trauma (Nose picking): The #1 cause in children.
   • Nasal bone fractures.
   • Foreign bodies (unilateral foul-smelling discharge + bleeding).
2. Infection/Inflammation:
   • Acute Rhinitis / Vestibulitis.
   • Sinusitis.
3. Tumors:
   • Juvenile Nasopharyngeal Angiofibroma (JNA): Adolescent males with profuse recurrent bleeds.
   • Hemangioma.
4. Environmental: Dry air, low humidity (winter epistaxis).
5. Drugs: Topical steroid sprays (improper use directed at septum).

B. Systemic Causes

1. Hematological Disorders:
   • ITP (Immune Thrombocytopenia).
   • Leukemia.
   • Coagulation defects (Hemophilia, von Willebrand Disease).
2. Drugs: NSAIDs, Aspirin, Anticoagulants.
3. Cardiovascular: Hypertension (rarely the sole cause in children).
4. Vascular Malformations: Hereditary Hemorrhagic Telangiectasia (Osler-Weber-Rendu syndrome).

III. Treatment

Step 1: First Aid (Trotter’s Method)

• Position: Sit up and lean forward (to prevent aspiration/swallowing of blood).
• Compression: Pinch the soft part of the nose (ala) firmly against the septum for 10–15 minutes continuously.
• Ice: Cold compress on the bridge of the nose.

Step 2: Cauterization (If visible bleed point)

• Indicated if the bleeding vessel is identified (usually Little's area).
• Chemical Cautery: Silver Nitrate ($AgN{O}_3$) stick.
• Electrical Cautery: Bipolar diathermy (requires anesthesia).

Step 3: Nasal Packing (If cautery fails/diffuse bleeding)

• Anterior Packing:
  • Layered ribbon gauze with antibiotic ointment (BIPP/Paraffin).
  • Merocel: Compressed sponge that expands when wet.
• Posterior Packing:
  • Foley’s catheter (inflated in nasopharynx) + Anterior pack.
  • Specific posterior nasal balloons.
  • Note: Patients with posterior packing usually require admission and antibiotic cover (to prevent Toxic Shock Syndrome).

Step 4: Surgical / Interventional (Refractory cases)

• Endoscopic Ligation: Sphenopalatine artery ligation.
• Embolization: Angiographic embolization of feeding vessels (Internal maxillary artery).
• Septoplasty: If a septal spur is causing the bleed.

Step 5: General Management

• Treat underlying cause (correct coagulopathy, control BP).
• Avoid nose picking (cut nails).
• Apply saline nasal drops or petroleum jelly to keep mucosa moist.