Sunday, March 14, 2021

Epistaxis Case File

Posted By: Medical Group - 3/14/2021 Post Author : Medical Group Post Date : Sunday, March 14, 2021 Post Time : 3/14/2021
Epistaxis Case File
Eugene C. Toy, MD, Lawrence M. Ross, MD, PhD, Han Zhang, MD, Cristo Papasakelariou, MD, FACOG

CASE 51
A 22-year-old male presents to the emergency department complaining of severe, unstoppable nasal bleeding for the past 30 min. He denies any trauma, bleeding disorders, or use of medications such as aspirin or ibuprofen. The patient indicates that this nosebleed is unique because he is bleeding from both nostrils and blood is draining into his throat and choking him. He feels as though the blood were collecting in the back of his throat. He has tried pinching his nose, but the bleeding continues.

 What is the most likely anatomical explanation for this condition?


ANSWER TO CASE 51:

Epistaxis
Summary: A 22-year-old male has had a 30-min bilateral epistaxis with drainage of blood to the nasopharynx and choking. He denies trauma, bleeding disorders, or use of anticoagulant medications. Anterior nasal pinching did not help.

• Most likely anatomical explanation: Posterior epistaxis


CLINICAL CORRELATION
Epistaxis, or bleeding from the nose, is a common condition. Most cases arise from the anterior region of the nasal septum, and the bleeding site is fairly easy to visualize. Most anterior nosebleeds will respond to direct pressure, although other measures may be necessary, including topical vasoconstrictors such as cocaine, cautery, or nasal packing. This patient’s epistaxis is atypical in that it is bilateral, with posterior drainage that produces a choking sensation. These symptoms suggest a posterior source, which is more difficult to control. Treatment of this type is by posterior nasal pack or a balloon tamponade device. Antibiotics are usually required to prevent sinusitis or toxic shock syndrome. Persistent or atypical epistaxis should alert the clinician to bleeding abnormalities. Patients who have congenital conditions such as hemophilia or von Willebrand disease may develop epistaxis. Acquired processes, such as use of aspirin or nonsteroidal anti-inflammatory medication, or frank anticoagulation with heparin or warfarin sodium (Coumadin) may be causative. Disease processes such as hepatic failure may lead to decreased levels of vitamin K–dependent coagulation factors.


APPROACH TO:
The Nose

OBJECTIVES
1. Be able to list the features of the external nose and nasal cavity
2. Be able to describe the arterial supply to the nasal cavities

DEFINITIONS
EPISTAXIS: Bleeding from the nose, usually divided clinically into an anterior or a posterior source.

KIESSELBACH PLEXUS: Area on the anterior portion of the nasal septum that is very vascular because of the anastomosis of blood vessels; this is the most common site for epistaxis.

COAGULOPATHY: Abnormalities to the normal pathways of hemostasis that lead to bleeding. Causes are usually congenital or acquired.

ANTICOAGULANT: Chemical that interferes with the normal process of blood clotting.


DISCUSSION
The external nose is composed of the paired nasal bones, which form the bridge of the nose, and adjacent portions of the frontal bones and maxillae. The majority of the external nose is cartilaginous and is formed by the paired alar and lateral nasal cartilages and the unpaired septal cartilage. The anterior opening into the nasal cavity is the anterior nares. The nasal cavity is a somewhat pyramidal space within the skull located between the two orbits. It is subdivided into right and left nasal cavities by the nasal septum, which is formed by the vomer bone, perpendicular plate of the ethmoid bone, nasal crests of the maxilla and palatine bones, and the septal cartilage. The roof of each cavity is formed by the frontal, ethmoid, and sphenoid bones, and its floor is formed by the palatine portion of the maxilla and the horizontal plate of the palatine bone. The posterior openings of each nasal cavity
into the nasopharynx are the posterior choanae.

The complex lateral walls are formed by portions of the nasal, maxilla, ethmoid, and palatine bones. The surface area of the lateral walls is increased by the three nasal conchae. The superior and middle conchae are features of the ethmoid bone, whereas the inferior nasal concha is an individual bone. The posterosuperior portion of the nasal cavity, superior to the superior conchae, is the sphenoethmoid recess. Inferior to each of the conchae is a space named for the concha immediately superior to it. Thus, the superior, middle, and inferior nasal meatuses lie inferiorly to the superior, middle, and inferior nasal conchae, respectively. Each nasal cavity is lined with a highly vascular mucosa whose function is to warm and humidify inspired air (Figure 51-1).

Epistaxis anatomy

Figure 51-1. Arterial supply to the nose (septum).


Figure 51-2. Arterial supply to the nose (lateral wall).

Each nasal cavity is supplied by nasal branches of the sphenopalatine artery, anterior and posterior ethmoidal arteries, greater palatine artery, and superior labial and lateral nasal branches of the facial artery (Figure 51-2). These arteries anastomose at Kiesselbach area on the anterior portion of the nasal septum (opposite the anterior end of the inferior concha). This is the most common site for epistaxis.


COMPREHENSION QUESTIONS

51.1 A 55-year-old man has become anemic and hypotensive due to severe anterior epistaxis. An ear-nose-throat (ENT) surgeon has been called to address the bleeding. He states that he may need to occlude the major arterial supply. Which of the following arteries is most likely to be responsible?
    A. Ethmoidal
    B. Sphenopalatine
    C. Superior labial
    D. Greater palatine

51.2 An 18-year-old woman arrives in the emergency department complaining of persistent epistaxis. On examination, there is bleeding from the right nostril. Which of the following locations is the most likely source of the bleeding?
    A. Anterior nasal septum
    B. Posterior nasal septum
    C. Anterior turbinate
    D. Posterior turbinate
    E. Nasal floor

51.3 A 24-year-old woman is thrown from her car during a motor vehicle accident and hits her head against the pavement. She has lost consciousness but currently is alert and has equally reactive pupils. She is asymptomatic except for clear nasal leakage from the right nostril that has not abated over 24 h. Which of the following is the most likely etiology?
    A. Sympathetic sinus drainage
    B. Allergic rhinitis from the car’s airbag
    C. Damage to the cribriform plate
    D. Lacrimonasal fistula


ANSWERS
51.1 B. The major blood supply to the anterior septum is the sphenopalatine artery, a branch of which supplies the nasal septum. The sphenopalatine artery arises from the maxillary artery, which is a terminal branch of the external carotid artery.

51.2 A. The most common location of epistaxis is the region of the anterior septum known as Kiesselbach plexus, which has a rich anastomosis of arteries.

51.3 C. This patient likely has cerebrospinal fluid (CSF) rhinorrhea, which is not unusual following head trauma. The cribriform plate and meninges are disrupted, thus allowing CSF to leak through the nose. This predisposes one to meningitis.


ANATOMY PEARLS
 The anterior portion of the nasal septum is cartilaginous.
 The superior and middle nasal conchae are features of the ethmoid bone.
 The most common site for epistaxis is where the several arteries that supply the nasal cavity anastomose on the anterior nasal septum (Kiesselbach area).

References

Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy, 2nd ed. New York: Thieme Medical Publishers; 2012:554−555. 

Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy, 7th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2014:959−960, 964. 

Netter FH. Atlas of Human Anatomy, 6th ed. Philadelphia, PA: Saunders; 2014: plates 36−40.

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