Clinical Manifestation

The nose has a rich blood supply derived from the internal and external carotid

arteries. The anterior part of the nasal septum has an anastomosis of vessels named

Kiesselbach’s plexus or more commonly termed Little’s area. This is the site of most anterior

bleeds. Less commonly and usually in older patients, posterior bleeding can occur usually

from branches of the sphenopalatine artery (a branch of the external carotid artery). [1]

There are two types of epistaxis which are anterior and posterior. Anterior epitaxis

comprise 90% of nose bleeds. Most commonly originates from Kiesselbach's plexus, located

in 'picking zone' which is a confluence of arteries on the posterior superior nasal septum.

Epistaxis near the front of the nose are very common since this is the most accessible area to

injury. The most frequent location is the nasal septum. In anterior epitaxis, the bleeding is

unilateral and the patient denies a sensation of blood in the back of the throat. In most cases,

this type of epistaxis is not serious. It usually can be stopped with some local pressure. [2,3]

Posterior epistaxis comprise approximately 10% of epistaxis in the emergency

department. Posterior epistaxis is more common in elderly patients and is thought to be

secondary to atherosclerosis of the arteries supplying the posterior nasopharynx. In posterior

epitaxis, bllod may be seen effluxing from both nares or down the posterior oropharynx.

Visulaization of the bleeding usually require use of a fiber-optic laryngoscope. Bleeding is

often more severe than with an anterior bleed. [2]

Only rarely is an epistaxis life threatening or fatal. In these cases, the hemorrhage

(severe bleeding) is usually from an artery in a posterior location, higher and deeper in the

nose. Posterior bleeds usually drain down the back of the throat, but can also bleed out of

both nostrils. Also, in most cases of severe nosebleeds, the person has another health

problem, such as high blood pressure or a bleeding disorder, or the person takes a blood-

thinning medication that slows down the blood-clotting process. [3]

Nosebleeds usually involve one nostril, but occasionally both nostrils are involved. If

one nostril becomes partially blocked with a blood clot, the blood might flow out the other

nostril or down the back of the throat. In a posterior nosebleed (higher up in the nose), large

amounts of blood typically flow down the back of the throat. The amount of bleeding from a

nosebleed can vary with posterior bleeds usually bleeding significantly more. [3]

References

1. Taylor C. 2009. Epistaxis, InnovAiT; 2(3):178 – 181.

2. Stead GS, Stead SM and Kaufman MS. 2006. First Aid for the Emergency Medicine

Clerkship, Head and Neck Emergencies. 2nd edition. McGraw-Hill Medical, United

States of America: 120-122.

3. Cullen MM and Leopold DA. Emergencies of the Head and Neck, Chapter 17: Nasal

Emergencies, Epistaxis. Mosby, United States of America: 239-245.