Epistaxis
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Direct answer
Ninety per cent of nosebleeds start at Little's area on the anteroinferior septum, where Kiesselbach plexus — an anastomosis of five arteries from both the internal and external carotid systems — sits under thin mucosa. First aid is simple and effective: sit the patient up, lean forward, and pinch the soft cartilaginous nose firmly for ten minutes with ice; most anterior bleeds stop, and the site can then be cauterised with silver nitrate. Posterior bleeds, seen mainly in older hypertensive or anticoagulated patients, need a posterior pack or balloon and admission, with endoscopic sphenopalatine artery ligation for refractory cases.
What you must remember
- Kiesselbach plexus is formed by the anterior ethmoidal, sphenopalatine, greater palatine, superior labial arteries and a septal branch — the five-vessel answer examiners want.
- Anterior bleeds occur in the young (nose picking, dry air, trauma); posterior bleeds at Woodruff plexus occur in the elderly with hypertension, atherosclerosis and anticoagulants, and they are the dangerous ones.
- First-aid sequence: upright posture, lean forward (not back — swallowing blood causes vomiting), pinch the alae for ten full minutes, ice pack, and spit blood out.
- If pressure fails: cotton pledget with lidocaine and adrenaline (1:10,000), then chemical cautery with silver nitrate or trichloroacetic acid — never both sides of the septum in one sitting (perforation risk).
- Anterior packing with Merocel or ribbon gauze stays 24–48 hours with antibiotic cover; a posterior balloon (Foley catheter or Bellocq pack) means admission, monitoring and analgesia.
- Refractory or recurrent severe bleeds: endoscopic sphenopalatine artery (and where needed anterior ethmoidal artery) ligation or selective embolisation.
- Recurrent childhood bleeds with telangiectasia on lips, tongue and fingers suggest hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu, autosomal dominant); refractory cases have been treated with septal dermoplasty or Young operation (nostril closure).
Stepwise control of the bleeding nose
Work the ladder in order, and nearly every patient never reaches its top. A young man arrives actively bleeding after a dry summer evening. Step one: gloves, gown, suction, and a headlight; sit him up leaning forward over a bowl and pinch the nasal alae against the septum yourself for ten minutes while checking pulse, blood pressure and, if severe, intravenous access. Step two: inspect. Remove clots by suction, insert a pledget soaked in lidocaine with adrenaline, wait five minutes, and look for the bleeding point with a nasal speculum — it is usually a vessel on Little's area, visible as a prominence or fresh clot. Step three: cauterise that point with a silver nitrate stick held a few seconds, circumferentially working from the edge of the vessel, and avoid the cartilage. Step four: if the field defeats you, pack the nose with an anterior pack, start antibiotic cover, and review in 24 to 48 hours in a dry, humidified room.
The older patient on aspirin with blood trickling both from the nose and down the pharynx is a different creature: this is a posterior bleed at Woodruff plexus, and first-aid pinching will fail. Control the airway and circulation, correct anticoagulation, insert a posterior balloon, admit, and plan endoscopic evaluation and sphenopalatine artery ligation if bleeding recurs after pack removal. Two special situations complete the pathway: recurrent unilateral bleeds with progressive obstruction in an adolescent boy suggest juvenile nasopharyngeal angiofibroma — image with CT angiography and never biopsy in the clinic; and a child bleeding nearly daily from multiple telangiectatic spots deserves inspection of the oral mucosa and family history for HHT before yet cautery session.
How the exam frames it
Anatomy first: the five arteries of Kiesselbach plexus and the fact that the nose is supplied by both carotid systems are repeatedly tested. Management second: the ordered ladder — pressure, vasoconstrictor pledget, cautery, anterior pack, posterior pack, ligation — is asked as an ordered sequence, and "lean forward, not backward" is a favourite true-or-false. Third, syndromes: HHT with its autosomal dominant telangiectasias, and the adolescent-boy-bleed-plus-obstruction stem pointing to juvenile nasopharyngeal angiofibroma, whose golden rule is image, then excise — biopsy is contraindicated because it bleeds ferociously.
Frequently asked questions
What is Little's area and which vessels form it?
The anteroinferior nasal septum, site of about 90 percent of bleeds, where the anterior ethmoidal, sphenopalatine, greater palatine, superior labial arteries and a septal branch anastomose as Kiesselbach plexus.
When is posterior packing required?
When bleeding continues despite an adequate anterior pack, classically from Woodruff plexus in elderly hypertensive or anticoagulated patients; such patients need admission.
Why is bilateral septal cautery avoided?
Opposing cauterised areas devascularise the septal cartilage and lead to perforation; one side per sitting is the rule.
What is the management of refractory severe epistaxis?
Endoscopic sphenopalatine (and anterior ethmoidal) artery ligation, or selective arterial embolisation in unfit patients, after failed packing.
Which tumour causes recurrent epistaxis in adolescent boys?
Juvenile nasopharyngeal angiofibroma — vascular, biopsy contraindicated; diagnose by CT/MR angiography and treat by surgical excision, often after embolisation.