Nasal Anatomy – Blood Supply समझें

नाक की Blood Supply

नाक एक highly vascular structure है – यानी इसमें बहुत सारी blood vessels होती हैं। यही कारण है कि नाक से खून आना common है।

Major Blood Vessels:

1. Kiesselbach’s Plexus (Little’s Area):

• Location: Anterior nasal septum पर, just inside nostril
• Composition: 5 arteries का anastomosis (junction):
  • Anterior ethmoidal artery
  • Sphenopalatine artery branches
  • Greater palatine artery
  • Superior labial artery
  • Septal branch of superior labial
• Clinical Significance: 90% anterior epistaxis यहीं से होता है
• Why Common:
  • Easily accessible (finger reach)
  • Mucosa thin है
  • Exposed to dry air
  • Trauma-prone area

2. Woodruff’s Plexus:

• Location: Posterior lateral nasal wall
• Source: Sphenopalatine और posterior ethmoidal arteries
• Clinical Significance: Posterior epistaxis का main source

Types of Epistaxis – Classification

1. Anterior Epistaxis (90%)

Characteristics:

• Usually from Little’s area
• More common in children और young adults
• Blood निकलता है noseसे बाहर
• Usually unilateral (one side)
• Generally easy to control
• Visible bleeding point often

Common Causes:

• Digital trauma (nose picking)
• Dry air, low humidity
• Minor trauma
• Upper respiratory infections
• Allergic rhinitis

2. Posterior Epistaxis (10%)

Characteristics:

• From Woodruff’s plexus या posterior vessels
• More common in elderly
• Blood flows backward into throat
• Often bilateral
• More severe, profuse bleeding
• Difficult to control
• May require hospitalization

Common Causes:

• Hypertension
• Atherosclerosis
• Bleeding disorders
• Anticoagulant use
• Post-surgical (nasal surgery)

Causes of Epistaxis – विस्तृत विवरण

A. Local Causes (Nasal में)

1. Trauma

Digital Trauma (Nose Picking):

• सबसे common cause, especially children में
• Little’s area को injure करता है
• Dry nose + picking = bleeding
• Can become habitual

External Trauma:

• Nasal fractures
• Facial injuries
• Sports injuries
• Road traffic accidents

Iatrogenic (Medical Procedures):

• Nasogastric tube insertion
• Nasal endoscopy
• Post-nasal surgery
• Nasotracheal intubation

2. Inflammatory Conditions

• Acute Rhinitis: Viral URI, cold – inflamed, friable mucosa
• Allergic Rhinitis: Chronic inflammation, itching → trauma
• Chronic Sinusitis: Mucosal changes
• Atrophic Rhinitis: Dry, crusted mucosa easily bleeds

3. Environmental Factors

• Dry Air:
  • Winter season (heating systems)
  • Low humidity climates
  • Air conditioning
  • Causes mucosal dryness, cracking
• Chemical Irritants:
  • Ammonia, chlorine
  • Cigarette smoke
  • Cocaine abuse (severe, recurrent bleeding)

4. Structural Abnormalities

• Deviated Nasal Septum: Turbulent airflow → dryness
• Septal Perforation: Edges bleed, crust formation
• Septal Spur: Trauma-prone projection

5. Tumors (Rare but Important)

• Benign:
  • Juvenile Nasopharyngeal Angiofibroma (teenage boys)
  • Nasal polyps (rarely bleed)
  • Hemangioma
• Malignant:
  • Squamous cell carcinoma
  • Nasopharyngeal carcinoma
• Red Flags: Unilateral bleeding, painless, recurrent, elderly patient

B. Systemic Causes (General Body में)

1. Cardiovascular

Hypertension (High BP):

• Major cause of posterior epistaxis in elderly
• Arterial bleeding, more severe
• Often nocturnal (night में)
• Uncontrolled HTN → recurrent bleeding
• BP control essential for prevention

Atherosclerosis:

• Brittle blood vessels
• Common in elderly

2. Hematological (Blood Disorders)

Coagulation Disorders:

• Hemophilia: Factor VIII/IX deficiency, severe bleeding
• Von Willebrand Disease: Most common inherited bleeding disorder
• Thrombocytopenia: Low platelet count
  • ITP (Immune thrombocytopenic purpura)
  • Dengue, viral infections
  • Leukemia, bone marrow disorders

Anticoagulant/Antiplatelet Medications:

• Warfarin: INR monitoring essential
• Aspirin: Even low-dose increases risk
• Clopidogrel, other blood thinners
• Elderly on these medications → higher risk posterior epistaxis

3. Liver Disease

• Decreased clotting factor production
• Thrombocytopenia
• Portal hypertension

4. Renal Disease

• Platelet dysfunction
• Uremia affects hemostasis

5. Hereditary Hemorrhagic Telangiectasia (HHT)

• Genetic disorder – abnormal blood vessel formation
• Recurrent nosebleeds from childhood
• Telangiectasias on nose, lips, fingers
• AVMs in lungs, liver, brain

When is Nosebleed an Emergency?

⚠️ Seek Immediate Medical Help If:

• Profuse Bleeding: Doesn’t stop with 20 minutes of pressure
• Posterior Bleeding: Blood flowing down throat, gagging
• Hemodynamic Instability:
  • Dizziness, lightheadedness
  • Weakness, fatigue
  • Rapid heartbeat
  • Pallor, sweating
  • Signs of shock
• Recurrent Bleeding: Multiple episodes in short time
• Associated with Trauma: Facial injury, head injury
• Elderly Patient: Especially on blood thinners
• Bleeding Disorder Known: Hemophilia, liver disease, etc.
• Inability to Breathe: Nose completely blocked with clots

First Aid at Home – Immediate Steps

✅ DO’s – Correct Method

Step-by-Step First Aid:

1. Stay Calm: Anxiety increases BP → more bleeding
2. Sit Upright:
   • Lean FORWARD slightly (not backward!)
   • Reduces blood flow to nose
   • Prevents blood going to throat
3. Pinch Nose:
   • Use thumb और index finger
   • Pinch soft part of nose (not bridge)
   • Firm, continuous pressure
   • Duration: At least 10-15 minutes WITHOUT checking
   • Breathe through mouth
4. Apply Cold:
   • Ice pack या cold compress on nose bridge
   • Vasoconstriction helps
5. Spit Out Blood: Don’t swallow (causes nausea)

❌ DON’Ts – Common Mistakes

• DON’T Tilt Head Backward:
  • Blood flows to throat
  • Can be swallowed (nausea, vomiting)
  • Risk of aspiration into lungs
• DON’T Pack Nose with Tissue/Cotton:
  • Removal can restart bleeding
  • Fibers stick to clot
• DON’T Keep Checking:
  • Disturbs clot formation
  • Need continuous pressure for 10-15 min
• DON’T Blow Nose: For several hours after bleeding stops
• DON’T Pick Nose: For at least 24 hours

After Bleeding Stops:

• Rest quietly for 30-60 minutes
• Avoid hot drinks, alcohol
• Don’t bend, strain, or lift heavy
• Sleep with head elevated (2-3 pillows)
• Avoid nose blowing for 24 hours
• Apply petroleum jelly inside nose gently (keeps moist)

Treatment at Prime ENT Center

Initial Assessment

1. History Taking:

• Onset: Sudden या gradual? Provoking factor?
• Side: Unilateral या bilateral?
• Duration & Severity: How much blood? (quantify if possible)
• Frequency: First time या recurrent?
• Direction: Anterior (out of nose) या posterior (throat)?
• Associated Symptoms: Trauma, dizziness, other bleeding sites?
• Medical History:
  • Hypertension, bleeding disorders
  • Liver/kidney disease
  • Medications: Blood thinners, aspirin, NSAIDs
  • Recent nasal surgery/procedures

2. Physical Examination:

• Vital Signs: BP, pulse, oxygen saturation – assess hemodynamic status
• General Examination: Pallor, signs of blood loss
• Anterior Rhinoscopy:
  • After adequate lighting और suction
  • Identify bleeding point if possible
  • Little’s area inspection
• Nasal Endoscopy: For posterior bleeding या when source not visible

3. Investigations:

• Complete Blood Count: Hemoglobin, platelets
• Coagulation Profile: PT, aPTT, INR (if on warfarin)
• Blood Group & Cross-match: If severe bleeding
• Imaging: CT scan if trauma suspected

Treatment Modalities

1. Chemical Cautery

Silver Nitrate Cautery:

• For: Anterior bleeding, visible bleeding point, not actively bleeding
• Procedure:
  1. Topical anesthesia और decongestant application
  2. Silver nitrate stick applied to bleeding point
  3. 3-5 seconds application
  4. White eschar forms
  5. Surrounding area also cauterized
• Advantages:
  • Office procedure
  • Quick, effective
  • Low cost
  • Immediate relief
• Precautions:
  • Never cauterize both sides of septum together (perforation risk)
  • Wait 6 weeks if other side needs cautery

2. Electrocautery

• For: Recurrent bleeding from specific point
• Advantage: More precise, controlled
• Need: Local anesthesia

3. Anterior Nasal Packing

When Used:

• Active anterior bleeding not controlled by cautery
• Bleeding point not visible
• Multiple bleeding points

Types:

• Non-absorbable (Ribbon Gauze):
  • Bismuth iodoform paraffin paste (BIPP) impregnated
  • Layered insertion from floor to roof
  • Stays 24-48 hours
  • Needs removal
• Absorbable (Merocel, Rapid Rhino):
  • Compressed sponge, expands when moistened
  • Biodegradable
  • No removal needed
  • More comfortable

Post-packing Care:

• Oral antibiotics (prevent sinusitis, toxic shock)
• Pain management
• Rest
• Avoid straining

4. Posterior Nasal Packing

Indication: Posterior epistaxis not controlled by anterior packing

Procedure:

• More complex than anterior
• Balloon catheter या gauze pack inserted
• Pack positioned in nasopharynx
• Secured with anterior packing too

Hospitalization Usually Needed:

• Monitoring required (BP, oxygen)
• Risk of complications
• Stays 48-72 hours typically
• IV antibiotics

5. Endoscopic Vessel Ligation

When Used:

• Refractory bleeding (packing failed)
• Recurrent severe posterior epistaxis
• Contraindication to packing (elderly, cardiac/respiratory issues)

Procedure at Prime ENT Center:

• General anesthesia
• Endoscopic approach
• Vessels ligated:
  • Sphenopalatine artery (most common)
  • Anterior/posterior ethmoidal arteries
  • Maxillary artery branches
• Definitive treatment
• Same-day या overnight stay

6. Embolization (Interventional Radiology)

• For severe, life-threatening bleeding
• When surgery not possible
• Catheter-based procedure
• Particles injected to block vessel

Prevention of Recurrent Nosebleeds

1. Humidification

• Home Humidifier: Especially in winter
• Maintain 40-50% humidity
• Nasal Saline Spray: 2-3 times daily keeps mucosa moist
• Petroleum Jelly: Apply inside nose at bedtime

2. Avoid Trauma

• No Nose Picking: Keep nails trimmed (children)
• Gentle Nose Blowing: One nostril at a time
• Avoid Forceful Sneezing: Keep mouth open

3. Medical Management

• Control Hypertension: Regular BP monitoring, medications
• Anticoagulant Review: Discuss with doctor – adjust dose if frequent bleeding
• Treat Allergies: Reduces inflammation
• Iron Supplements: If anemic from recurrent bleeding

4. Lifestyle Modifications

• Avoid alcohol (dilates blood vessels)
• Limit caffeine
• Avoid hot, spicy foods if sensitive
• Stay hydrated

5. Environmental Control

• Avoid smoke, chemical irritants
• Use mask in dusty environments
• AC temperature not too low

6. Regular Follow-up

If you have recurrent epistaxis, regular ENT checkups at Prime ENT Center help identify और treat underlying causes।