Epistaxis- Anatomy, Classification and Management

Epistaxis is bleeding from the nose.

Nose Arterial Supply

The septum, the lateral nasal wall, and the nasal cavity are supplied by the internal and external carotid arteries.  The anterior ethmoidal artery and the posterior ethmoidal artery supply the majority of the superior portion of the septum. The internal carotid artery gives rise to a branch known as the ocular artery.

The facial artery, in turn, gives birth to a branch called the superior labial artery, which supplies the anteroinferior part of the nasal septum, the floor of the nose, and the vestibule of the nose. The external carotid artery gives rise to two main branches: the internal maxillary artery and the facial artery.

Area Of Little and Kiesselbacha Plexeus

All the arteries that supply the nasal septum anastomose at the antero-inferior section of the septum, with the exception of the posterior ethmoidal artery.  This plexus is also known as the Kisselbach plexus because it was discovered by Kisselbach after James Little did.

External Carotid Artery

The external carotid artery supplies the nasal cavity via facial and maxillary branches. The facial artery in turn gives a branch- the superior labial artery that goes towards the upper lip. The branch that comes from the superior labial artery is called the septal branch of the superior labial artery; this supplies the anterior part of the nasal septum, the anterior part of the inlet or the vestibule.

The external carotid artery gives rise to the internal maxillary artery. This internal maxillary artery gives rise to the sphenopalatine artery near the posterior wall of the maxillary sinus, about 8-10 mm behind the posterior end of the middle turbinate. Behind ethmoidal crest, a foramen can be observed called the sphenopalatine foramen.

The sphenopalatine artery emerges from this sphenopalatine foramen and splits into the posteromedial nasal artery and the posterolateral nasal artery, which head toward the lateral wall of the nose and the septum, respectively. The posterior portion of the nose's floor is supplied by the posteromedial branch, while the inferior and intermediate turbinates are supplied by the posterolateral nasal artery. There is also another branch that points in the direction of the sphenoid's anterior phase.

The sphenopalatine foramen, which allows the sphenopalatine artery to pass through, is located close to the posterior end of the middle turbinate. Immediately behind it, at the same level, is the larger palatine artery. Rather than emerging from the foramen, the larger palatine artery descends toward the palate, penetrates it, and then rises to supply the nasal septum's anterior and somewhat posterior portions, which make up the nasal cavity's floor.

Internal Carotid Artery

The internal carotid artery gives rise to the anterior and posterior ethmoidal branches of the ophthalmic artery in the medial compartment of the orbit. The anterior ethmoidal artery runs below the superior oblique muscle and enters the anterior ethmoidal foramen.  The posterior ethmoidal branch runs above the superior oblique muscle and enters the foramen, called the posterior ethmoidal foramen.

Both these foramina are present at the medial wall of the orbit. On the medial wall of the orbit, the anterior lacrimal crest is present. Anterior ethmoidal foramen is at 24 mm from anterior lacrimal crest. Posterior ethmoidal foramen is at 12mm from Anterior ethmoidal foramen. The optic canal is about 6 mm behind the posterior ethmoidal foramen.

After this, the artery enters the septum, where it gives off a small meningeal branch that runs superiorly and a septal branch that runs inferiorly to the septum.  Posterior ethmoidal foramen is not present in some individuals, but it also gives a meningeal branch and a septal branch. Both the ethmoidal arteries will supply the upper portion of the septum and the superior part of the nasal cavity.

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Venous Drainage

The superior labial and larger palatine veins handle anterior drainage, whereas the pterygoid venous plexus and the internal jugular vein handle draining from the lateral wall. The external jugular system is the final destination of the drainage from the superior labial and larger palatine veins, which empty into the facial vein. The superficial retro-columellar vein can induce venous epistaxis (nosebleeds) in children. It is situated 2 mm behind and parallel to the columella.  

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Key-Clinical Areas

Woodruff’s Plexus

A plexus of conspicuous blood vessels located just inferior to the posterior end of the inferior turbinate was reported by Woodruff (1949).The existence of the plexus was verified by a more recent investigation using endoscopic photography and anatomical microdissection, however it was discovered to be a venous plexus and was therefore unlikely to play a significant role in epistaxis.

Anterior Ethmoidal Artery In Endoscopic Sinus Surgery and in Traumatic Epistaxis

The artery is frequently located in a mesentery between the lamina papyracea and the ethmoid fovea, directly below the base of the skull. Retraction of the bleeding end into the orbit following vascular transfer during sinus surgery may result in pressure hematoma and increase the risk of vision loss. Damage to this artery may result in severe and sporadic epistaxis in patients with orbit-ethmoidal fractures.

In these kinds of situations, open litigation might be required to stop the bleeding.  The vessels can be ligated endoscopically (trans-ethmoidally) or externally (media canthal). The most dependable and recommended technique for a medial orbital incision is the open approach.  It is possible to cut, bipolarize, or ligate the artery without going through the bulbar fascia.

Surgical Anatomy Of the Sphenopalatine Foramen

The sphenopalatine foramen is essential to the process of endonasal endoscopic sphenopalatine ligation (ESPAL). It is a U-shaped notch in the vertical portion of the palatine bone that is closed posterosuperiorly by the sphenoid bone. The foramen transmits the sphenopalatine artery, vein, and nasal palatine nerve (maxillary division of the trigeminal nerve). It can be difficult to find the foramen during surgery. Bolger et al. discovered that a tiny bony protrusion exists anterior to the foramen in 96% of the instances.

During surgery, identifying the crista ethmoidalis might help locate the sphenopalatine foramen. This bone landmark is known by this name. • Crista ethmoidalis is a crucial landmark for the endoscopic surgeon; its size can fluctuate but its location anterior to the artery always stays the same. As part of the ESPAL technique, hemostatic clips were placed to the left main trunk of the sphenopalatine artery.

Classification

Epistaxis is categorized as either adult (over 16) or childhood (younger than 16). Primary: no established causative component. Secondary: substantiated cause. Front: bleeding prior to the piriform aperture;  Rear: bleeding point behind the piriform aperture; Childhood, under 16 years of age; Adulthood, above 16 years of age

Primary Or Secondary

Idiopathic spontaneous bleeding accounts for between 70% and 80% of all epistaxis instances, no clear precipitant or causative component has been identified. We can classify this kind of bleeding as primary epistaxis. A tiny percentage of cases—which fall under the category of secondary epistaxis—have a known etiology, such as trauma, surgery, or anticoagulant overdose.Due to coagulopathy, methods for managing original epistaxis are unlikely to be effective in treating secondary epistaxis.

Anterior and Posterior Epistaxis

The person made an effort to standardize the phrase "posterior epistaxis," which refers to bleeding that is difficult to identify even after using a suction, vasoconstrictors, and flashlight examination. In front of the pyriform aperture: bleeding.  Posterior: Point of bleeding behind the pyriform aperture

Patients with weak reflexes from age or neurological issues are more likely to aspirate blood. Sphenopalatine artery branches and venous plexus are the main causes of posterior epistaxis, which is typically severe..

Adult Primary Epitaxis

The majority of instances are mild, self-limiting, or easily treated anterior bleeding; however, a significant percentage necessitate hospital admission. The disorder can occur at any age, but it primarily affects the elderly.  Adult primary epistaxis can cause bleeding from both the anterior and posterior sites.

Aetioloy

Alcohol;  Hypertension; Non-steroidal anti-inflammatory medications (NSAIDs); Septal anomalies.  Liver pathologies: Modify coagulation factor production. Renal diseases: Resistant hypertension; Secondary abnormalities of the blood and blood arteries, such as hemophilia and WPW syndrome.

Management

The management of adult epistaxis should adhere to an incremental sequence of interventions for optimal efficacy.  Determining the bleeding point and directly controlling the bleeding at its source are necessary for the theoretically ideal course of treatment.  Prior to starting a treatment plan, the patient needs to have their breathing revived, their bleeding stopped, and their nasal cavity checked.

Resuscitation

Applying first aid (the Hippocratic bleeding) by pinching the ala nasi. As instructed by Trotter (pinching nose and bending forward), proceed.

Assessment

It is imperative to assess the patient in a semi-recumbent position with nursing assistance.  Wearing protective clothes and visors is advised for all participants, as blood aerosol contamination is prevalent, particularly during nasal packing insertion.

Standard supplies include of a recliner or sofa, headlamp, suction, vasoconstrictor solutions (cocaine solutions have been mostly replaced by lignocaine and pseudoephedrine solutions), various packs, tampons, and cautery tools.  Bipolar electrodiathermy and rod lens nasal endoscopic equipment have to be available in all specialized ENT units.

Direct Or Indirect Therapies

Indirect therapy include topical hemostatic medications, tranexamic acid, epsilon aminocaproic acid, hot water irrigation, nasal packing, and endoscopic control.  To locate the source of the bleeding, endoscopy is performed.

Surgical Management

Surgical management is performed in a progressive fashion and involves posterior packing, ligation procedures, septal surgery techniques, and embolization techniques.

Endonasal Endoscopic Sphenopalatine Artery Ligation (ESPAL)

Finding the central turbinate is the first step. A sphenopalatine artery is located approximately 8 to 10 mm behind the posterior end of the middle turbinate.  This region corresponds with the posterior wall of the maxillary sinus. Make a vertical incision starting from the posterior end of the middle turbinate and moving downward.

Raise the mucosal flap until the ethmoidal crest—a marker identified by this name—is visible.  The sphenopalatine artery can be found here. The artery can be found and then ligated.

Internal Maxillary Artery Ligation

The Caldwell approach and endoscopic approach are two methods for accessing the intermaxillary artery. To employ the Caldwell technique, raise the maxillary bone mucosa by making a sub-labial incision. The periosteum is also raised during this procedure. After that, create a hole in the maxilla's front wall. This makes the maxillary sinus apparent.

Now locate the maxilla's posterior wall and uncover it to reveal the internal maxillary artery. Maxillary artery ligation. An endoscopic method akin to this one can be used to detect the maxillary artery trans nasally by first opening the maxillary sinus and then the posterior wall of the sinus.

External Carotid Artery Ligation

The greater cornua of the thyroid bone in the neck is where ECA is found.  Cut a vertical incision at the anterior border of the sternocleidomastoid and a 2 cm incision below the mandibular angle.  By replacing muscle and tissue with elevated skin, the common carotid artery can be seen. The internal and external carotid arteries split off from this single carotid artery. The external carotid artery is the artery that branches; the internal carotid artery is one that does not branch in the neck.  Keep the artery open.

Septal Surgery

In order to reach the bleeding sites, septoplasty or submucosal resection (SMR) may be necessary when epistaxis arises behind a noticeable septal deviation or vomero-palatine spur. When packing fails, some experts have recommended septal surgery as the first line of treatment.  The idea of elevating the mucoperichondrial flap during septoplasty or SMR is to stop the blood flow to the septum and ensure hemostasis.

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