Epistaxis is common. Treating and managing such patients comprises a large proportion of the ENT clinician's practice. Bleeding from the nose affects a wide range of age groups and presents different challenges. The very young, trauma victims, and elderly patients are all at risk. It is often helpful to categorise bleeding from the nose by site, into anterior or posterior. Anterior bleeding often arises from the highly vascular Little's area of the nasal septum. This area represents the most accessible area for administering treatment.

Bleeding from the nose can be initially controlled by compression. This forms a part of the triad of techniques called Trotter's manoeuvre, designed to stop epistaxis. The techniques are compression, sitting forwards, and cold compress application (to the head). Experience has shown that after 10 to 15 minutes most nose bleeds will have settled. If evidence of a bleeding point is seen, either with anterior rhinoscopy or using a rigid endoscope, it may be possible to administer chemical (i.e. silver nitrate) or electrical cautery to the offending vessel. This can be done under local anaesthesia and particular forms, such as cocaine solution or phenylephrine would also assist via their vaso-contrictive properties.

If there is failure to achieve haemostasis or a bleeding point cannot be found, packing of the nose may be required. Many intra-nasal packing devices, such as Merocel® and Rapid Rhino® packs are available. If, despite all these techniques haemostasis is still not achieved, probably the best type of pack is ribbon gauze. It is impregnated with the antiseptic and haemostatic properties of bismuth iodoform paraffin paste (BIPP), and if placed well will fill the contours of the nasal cavity (see Fig. 1).

Almost all epistaxis can be controlled with a well placed BIPP pack, which may or may not be needed in conjunction with a posterior balloon. This balloon usually takes the form of a catheter device passed along the floor of the nasal cavity to the nasopharynx, inflated with water or air, retracted slightly to block the posterior choanae, and fixed in this position under tension. Prophylactic antibiotic cover should be given with posterior packing.

Fig. 1 Logan Turner's diseases of the nose, throat, and ear.

Ifthis type ofpacking does not control the haemorrhage, despite a safe period of observation, then surgical intervention may be required. This can take the form of a septoplasty and/or artery liga-tion. It has been postulated that a deviated nasal septum contributes to mucosal erosion and, therefore, a predisposition to bleeding on the deviated side. Following septoplasty, the resulting fibrosis created after raising the muco-perichondrial flaps may also help in reducing troublesome vascularity of the septum. Artery ligation can take the form ofsphenopalatine, ethmoidal, or maxillary depending on the site of bleeding in the nose. Sometimes, the external carotid artery may need to be ligated to stop a difficult maxillary artery bleed (see Fig. 2).

It is important to mention that as radiological techniques have improved, further treatment options have come to the fore. This includes embolisation to achieve haemostasis. In head and neck cases, especially trauma victims, potentially life-threatening haemorrhage from deep vessels may require significant or prolonged exploration, under a general anaesthetic, by expert head and neck vascular surgeons. Angiographic embolisation of bleeding vessels has been shown to be an alternative to head and neck exploration.5 Embolisation plays a role not only in trauma, but has also been used in patients with

Fig. 2 Rob and Smith's operative surgery — nose and throat.

bleeding from vascular malformations and tumours. In addition, it has been used in patients with aneurysmal bleeds.6

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