Epistaxis

Epistaxis (nasal bleeding) is the commonest ENT emergency, ranging from a trivial trickle from Little's area to torrential, life-threatening posterior haemorrhage. NEET PG loves the vascular anatomy, the anterior-versus-posterior distinction, and the stepwise escalation of management — so anchor your revision around those three pillars.

Definition & classification

Epistaxis is bleeding from the nasal cavity, nasopharynx or paranasal sinuses draining through the nose. It has a bimodal age distribution — children/young adults (almost always anterior, benign) and the elderly (more often posterior, associated with hypertension and atherosclerosis).

The single most important clinical classification is by site of bleeding, because it dictates management.

Feature	Anterior epistaxis	Posterior epistaxis
Frequency	~90–95%	~5–10%
Usual age	Children, young adults	Elderly, hypertensives
Source	Little's area / Kiesselbach's plexus	Woodruff's plexus (posterior, sphenopalatine artery)
Bleed pattern	Out of the nostril (anterior)	Down the throat / both nostrils
Severity	Usually mild, self-limiting	Profuse, recurrent, hard to control
First-line control	Pinch/compress + anterior pack	Posterior pack / balloon, often admission

High-yield: ~90% of all epistaxis is anterior and arises from Little's area on the antero-inferior nasal septum.

Vascular anatomy — the most tested part

The nasal septum and lateral wall receive a dual blood supply from both the internal and external carotid systems, which anastomose anteriorly.

Internal carotid artery (ICA) → ophthalmic artery →

• Anterior ethmoidal artery
• Posterior ethmoidal artery

External carotid artery (ECA) → maxillary artery →

• Sphenopalatine artery (the principal artery of posterior epistaxis — the "artery of epistaxis")
• Greater palatine artery
• ECA → facial artery → superior labial artery (septal branch)

Kiesselbach's plexus (Little's area)

Located on the antero-inferior nasal septum, this is the confluence of five vessels — the classic anastomosis tested repeatedly:

Mnemonic — "LEGS-P" / Little's area contributors: L – superior Labial artery (septal branch, from facial) E – anterior Ethmoidal artery (from ophthalmic/ICA) G – Greater palatine artery (from maxillary) S – Sphenopalatine artery (from maxillary) ...these converge in Little's area (= Kiesselbach's plexus).

High-yield: Little's area is the site of the ICA–ECA anastomosis and the commonest source of anterior epistaxis, especially in children.

Woodruff's plexus

A venous plexus located on the lateral nasal wall posteriorly, below the posterior end of the inferior turbinate (in the inferior meatus / posterior choana region). It is the classic source of posterior epistaxis in the elderly hypertensive patient. Its principal arterial association is the sphenopalatine artery.

High-yield: Anterior bleed = Little's area (Kiesselbach's) = arterial = children. Posterior bleed = Woodruff's plexus = venous = elderly hypertensives.

Etiology

Causes are conventionally split into local and general (systemic).

Local causes	General/systemic causes
Trauma — nose picking (digital trauma), fractures, foreign body	Hypertension (esp. posterior bleeds)
Idiopathic (most common overall)	Coagulopathies — haemophilia, von Willebrand disease
Inflammation — rhinitis, sinusitis	Thrombocytopenia, leukaemia, aplastic anaemia
Atrophic rhinitis, septal deviation/spur, septal perforation	Drugs — aspirin, warfarin, heparin, NSAIDs, antiplatelets
Neoplasm — juvenile nasopharyngeal angiofibroma, carcinoma	Liver disease (impaired clotting factor synthesis)
Hereditary haemorrhagic telangiectasia (HHT)	Vitamin C / K deficiency
Iatrogenic — post-surgery, nasal sprays	Environmental — high altitude, low humidity

High-yield: A young adolescent male with recurrent profuse epistaxis + nasal obstruction → suspect juvenile nasopharyngeal angiofibroma (JNA). Biopsy is contraindicated (risk of torrential bleed); diagnose with contrast CT/MRI showing the Holman-Miller sign (anterior bowing of the posterior maxillary wall) and treat after embolisation.

Hereditary haemorrhagic telangiectasia (Osler–Weber–Rendu disease)

• Autosomal dominant; mutations in endoglin (ENG) and ALK1 (ACVRL1) genes.
• Recurrent epistaxis is the commonest presenting feature.
• Curaçao criteria (≥3 of 4 = definite): (1) spontaneous recurrent epistaxis, (2) mucocutaneous telangiectasias, (3) visceral AVMs (pulmonary, hepatic, cerebral, GI), (4) first-degree relative affected.
• Treatment of nasal lesions: laser ablation, septodermoplasty (Saunders' operation), Young's procedure (closure of nostril), and antifibrinolytics/oestrogen.

Pathophysiology

The nasal mucosa is highly vascular and thin, particularly over the anterior septum where Little's area sits exposed at the airflow turbulence point — explaining its vulnerability to drying, crusting and digital trauma. In the elderly, arteriosclerotic, friable posterior vessels that have lost their ability to contract, combined with raised arterial pressure (hypertension) and frequent anticoagulant use, produce profuse posterior bleeds that do not tamponade easily. Hypertension is more a perpetuating/aggravating factor than a sole cause; the bleed often will not stop until the BP and the patient's anxiety are controlled.

Clinical features

• Bleeding from one or both nostrils, or trickling into the throat.
• Anterior: visible bleeding from the nostril, usually unilateral, often controllable with pressure.
• Posterior: blood in the oropharynx, swallowed blood causing haematemesis or melaena, difficult to localise, bilateral, recurrent.
• Signs of hypovolaemia in severe cases — tachycardia, hypotension, pallor.
• Look for clues to cause: telangiectasias (HHT), bruising/petechiae (coagulopathy), septal mass, hypertension.

Assessment & investigation

Stepwise approach to the bleeding patient:

1. Resuscitate (ABC) → secure airway, IV access, fluids/blood if shocked → 2. Position the patient sitting up, leaning forward → 3. First aid (pinch the soft cartilaginous part of the nose for 10–15 min, ice, spit out blood) → 4. Examine with good light, suction and a nasal speculum after a topical vasoconstrictor + anaesthetic → 5. Localise anterior vs posterior → 6. Control by escalation → 7. Treat the underlying cause.

Investigations (guided by severity & suspected cause):

• CBC, platelet count — anaemia, thrombocytopenia, leukaemia.
• Coagulation profile — PT/INR, aPTT, bleeding time (anticoagulants, coagulopathy).
• Blood grouping & cross-match in severe bleeds.
• Nasal endoscopy — localising posterior bleeders, identifying masses.
• CT with contrast / MRI / angiography — for tumours (JNA), and as a prelude to embolisation.

High-yield: First aid = Trotter's method — sit up, lean forward, pinch the soft part (cartilaginous lower third) of the nose, breathe through the mouth. (Tilting the head back is wrong — it causes swallowing/aspiration of blood.)

Management — the escalation ladder

This sequence is the exam favourite. Move down the ladder only if the previous step fails.

1. First aid — Trotter's pinch, ice pack, topical vasoconstrictor (oxymetazoline / adrenaline-soaked pledget).
2. Chemical cautery — for a visible anterior septal bleeding point. Use silver nitrate stick (or electrocautery). Never cauterise both sides of the septum simultaneously → risk of septal perforation.
3. Anterior nasal packing — ribbon gauze impregnated with liquid paraffin/BIPP (bismuth iodoform paraffin paste), Merocel sponge, or a nasal tampon. Layered from the floor upwards. Leave 24–48 h with antibiotic cover.
4. Posterior nasal packing — for posterior bleeds: traditional postnasal pack (gauze roll secured by three threads / a Foley catheter balloon) or a purpose-made double-balloon catheter (Brighton/Epistat).
5. Endoscopic cautery / ligation — endoscopic sphenopalatine artery ligation (ESPAL) is now the preferred surgical step for refractory posterior bleeds.
6. Arterial ligation — maxillary artery ligation (transantral, Caldwell-Luc approach), external carotid artery ligation (above the superior thyroid artery), anterior + posterior ethmoidal artery ligation (for ethmoidal/superior bleeds, via medial orbital incision).
7. Angiographic embolisation — for intractable bleeding, JNA, or poor surgical candidates; embolise branches of the maxillary artery. (Avoid embolising ICA branches → stroke/blindness risk.)

Source of bleed	Vessel to ligate/target
Posterior / Woodruff / Little's area	Sphenopalatine artery (± maxillary)
Superior septum / roof (ethmoidal)	Anterior & posterior ethmoidal arteries
Refractory, multi-source	External carotid artery ligation / embolisation

High-yield: Anterior ethmoidal artery is a branch of the ophthalmic artery (ICA) — so it cannot be controlled by external carotid ligation; it must be ligated separately or via ethmoidal ligation.

High-yield: Endoscopic sphenopalatine artery ligation (ESPAL) has largely replaced internal maxillary artery and external carotid ligation as the surgical procedure of choice for refractory posterior epistaxis (higher success, fewer complications).

Packing pearls & precautions

• Posterior packing can precipitate the nasopulmonary reflex → hypoxia and bradycardia/arrhythmia, especially in the elderly; monitor SpO₂ and consider admission.
• Always give antibiotic cover with packs in situ to prevent toxic shock syndrome (TSS) and sinusitis.
• Foley catheter balloon: inflate in the nasopharynx, pull forward to seat in the choana, then anterior pack in front of it; pad the nostril to prevent alar necrosis.

Complications

• Hypovolaemic shock and anaemia from blood loss.
• Aspiration of blood → airway compromise (especially supine patients).
• From packing: sinusitis, toxic shock syndrome, alar/columellar necrosis, hypoxia (nasopulmonary reflex).
• From cautery: septal perforation (especially bilateral cautery).
• From surgery/embolisation: facial pain/numbness, palatal numbness, ophthalmoplegia, and the feared stroke/blindness with inadvertent ICA-territory embolisation.

Key differentials & lookalikes

• Haemoptysis (from lower airway/lung) vs haematemesis (GI) — posterior epistaxis can mimic both because blood is swallowed or aspirated; bright red, frothy, no melaena favours respiratory; coffee-ground favours GI.
• JNA vs simple recurrent epistaxis in adolescents — JNA has nasal obstruction + a mass; biopsy contraindicated.
• Sinonasal malignancy in an elderly patient with unilateral blood-stained discharge.
• HHT / coagulopathy in recurrent bilateral bleeds — look for telangiectasias, family history, drug history.

Recently asked / exam angle

• Little's area constituents and which vessels arise from ICA vs ECA (single-best-answer staple).
• Woodruff's plexus location = posterior, below inferior turbinate; source of posterior epistaxis in elderly.
• Artery of epistaxis = sphenopalatine artery; preferred surgical step now = ESPAL.
• Anterior ethmoidal artery is an ICA (ophthalmic) branch → not controlled by ECA ligation — a recurring trick.
• First aid (Trotter's method) — sit up, lean forward, pinch soft part; tilting head back is wrong.
• JNA: adolescent male, recurrent epistaxis, biopsy contraindicated, Holman-Miller sign, treat after embolisation.
• HHT: autosomal dominant, endoglin/ALK1, Curaçao criteria, Young's procedure / septodermoplasty.
• Complications of posterior packing: hypoxia (nasopulmonary reflex), toxic shock syndrome.
• Do not cauterise both sides of septum → septal perforation.
• Image-based: identifying Little's area on a septal diagram, or the Foley/balloon postnasal pack.

Rapid revision

1. ~90% of epistaxis is anterior, from Little's area (Kiesselbach's plexus) on the antero-inferior septum.
2. Little's area = anastomosis of superior labial, anterior ethmoidal, greater palatine and sphenopalatine arteries (ICA–ECA junction).
3. Posterior epistaxis arises from Woodruff's plexus (venous, lateral wall below posterior inferior turbinate) — elderly, hypertensive.
4. Sphenopalatine artery = "artery of epistaxis"; branch of maxillary artery (ECA).
5. Anterior & posterior ethmoidal arteries are branches of the ophthalmic artery (ICA) — not controlled by ECA ligation.
6. First aid = Trotter's method: sit up, lean forward, pinch the soft (cartilaginous) part of the nose 10–15 min.
7. Chemical cautery with silver nitrate for a visible anterior bleeder — never bilaterally (septal perforation).
8. Escalation: first aid → cautery → anterior pack → posterior pack/balloon → ESPAL → arterial ligation/embolisation.
9. Posterior packing risks nasopulmonary reflex (hypoxia) and toxic shock syndrome — give antibiotics, monitor SpO₂.
10. JNA: adolescent male, biopsy contraindicated, Holman-Miller sign, embolise then excise.
11. HHT (Osler–Weber–Rendu): AD, endoglin/ALK1, Curaçao criteria, treated by Young's procedure/septodermoplasty.
12. Surgical procedure of choice for refractory posterior bleed today = endoscopic sphenopalatine artery ligation (ESPAL).