Head and Neck Surgery

Saturday, August 16, 2008


Although in the majority of patients this is a relatively easy clinical problem to deal with, this may not always be the case and in certain situations the haemorrhage may be life threatening. The most common site of bleeding is from Kiesselbach’s plexus in Little’s area of the anterior portion of the septum . The usual cause is microtrauma to these blood vessels sandwiched between the mucosa and the underlying cartilage. In young children, heavy bleeding sometimes occurs from an engorged retro-columellar vein. Less often bleeding arises from the lateral nasal wall. Anterior bleeding is common in children and young adults as a result of nose blowing or picking. In the elderly, arteriosclerosis and hypertension are the underlying causes of arterial bleeding from the posterior part of the nose. The degeneration of the muscle layer of small arteries with age and the gradual replacement with collagen and calcification hinder post­traumatic vasoconstriction and prolong bleeding. Less common causes are trauma, foreign bodies within the nose, blood diseases, disorders of coagulation and malignant tumours of the nose or sinuses. Nasopharyngeal angiofibroma is a rare condition that affects boys and may lead to massive life-threatening attacks of bleeding. Hereditary haemorrhagic telangiectasia (Osler’s disease) gives rise to recurrent multifocal bleeding from thin-walled vessels deficient in muscle and elastic tissue .

Management of epistaxis
Bleeding from Kiesselbach’s plexus may be controlled by silver nitrate cautery under local anaesthesia. Bleeding from further back in the nose, as seen in the elderly, may require anterior nasal packing with Vaseline-impregnated ribbon gauze. The packing is inserted in layers starting on the floor of the nasal cavity. Sometimes hypoxia can be induced by nasal packing and may be exacerbated in patients with chronic obstructive airways disease. The packing is usually kept in place for 48 hours and the patient commenced on a broad-spectrum antibiotic. An alternative to anterior packing is the use of an epistaxis balloon catheter (Fig. 39.9). The catheter is inserted in the nose and the distal balloon is inflated first within the choana to secure the catheter and then the proximal balloon, which is sausage shaped, is inflated within the nasal cavity proper. These catheters are usually effective but can be quite uncomfortable.
Sometimes anterior nasal packing alone is not sufficient to control haemorrhage and posterior nasal packing may be required. This is usually carried out under general anaes­thesia inserting a gauze pack into the naso pharynx, which is then secured by tapes passed through each side of the nose and tied together across a protected columella. A third tape is brought out through the mouth and taped to the patient’s cheek. The nasal fossae are then packed with anterior nasal packs. All packs are left in for 48 hours and prophylactic antibiotics are given. The tape attached to the cheek is to facilitate removal of the pack usually without a general anaesthetic.
In uncontrolled life-threatening epistaxis where the above methods have proved ineffective, haemostasis is achieved by vascular ligation. Depending on the origin of bleeding itmay be necessary to ligate the internal maxillary artery in the pterygopalatine fossa and the anterior and posterior eth­moidal arteries within the orbit. An alternative measure is external carotid artery ligation above the origin of the lingual artery.
In Osler’s disease anterior nasal packing is best avoided if at all possible because it is most likely to lead to further mucosal trauma and bleeding. High-dose oestrogen induces squamous metaplasia of the nasal mucosa and has been used effectively in treating this condition. In some cases however, it may be necessary to resort to excision of the diseased nasal mucosa via a lateral rhinotomy and replace it with a split skin graft — a procedure known as septodermoplasty. It is not unknown, however, for the grafted skin to undergo similar abnormal vascular change over time.

Epistaxis — summary
•Young people bleed from the anterior septum —Kiesselbach’s plexus
•Older people bleed from the posterior part of the nose
•Silver nitrate cautery is good for controlling anterior septal bleeding
•Moderate bleeding may require anterior nasal packing
•Severe bleeding may require anterior and posterior nasal packing
•Persistent bleeding will probably require arterial ligation