12/05/2016 Epistaxis

8:30 – 10:30 Otorhinolaryngology

YL7: 9.12.01 Internal Medicine| Dr. Cesar de Leon

OUTLINE
I. Epistaxis D. Endoscopic
II. Nasal Anatomy Cauterization
A. Lateral Nasal Wall E. Arterial Ligation
B. Nasal Septum F. Embolization
C. Vascular Anatomy VIII. Patient Education
III. Causes of Epistaxis IX. Epistaxis Management
A. Local Algorithm
B. Systemic X. Anterior vs Posterior
IV. Red Flags Epistaxis
V. Physical Exam XI. Philosophy of
VI. Laboratory and Imaging Management
VII. Treatment XII. Important Notes
A. Cautery Review Questions
B. Anterior Nasal Freedom Space
Packing References
C. Posterior Nasal
Packing Figure 1. Lateral Nasal Wall

I. EPISTAXIS
B. NASAL SEPTUM
 Etymology: epi (upon) + stazein (to drip)
 Bony portion
 American Rhinologic Society definition  Made up of the perpendicular plate of the ethmoid bone,
 Bleeding from the nostril, nasal cavity or the vomer, and the nasal crest of the maxilla and palatine bones.
nasopharynx  Importance of the perpendicular plate
 History of epistaxis  It is connected to the cribriform plate so if this is
 Hippocrates reported about pinching the nose which damaged, may lead to bleeding and CSF leak
may stop bleeding  Inferoposteriorly the vomer is connected to sphenoid sinus
 Up to now this is still part of the management  In maxillary crest  septal spurs occur which needs to be
corrected if it obstructs the nasal cavity
 Other practices:
 Cartilaginous portion
 Writing magical words in the forehead
 Quadrangular cartilage
 Patients sniffing their own fried blood
 Wearing red amulets
 Three prominent people who identified the plexus of veins
situated on the anterior part of the cartaligious septum as
a source of epistaxis2
 Carl Michel (1871)
 James Lawrence Little (1879)
 Wilhelm Kiesselbach
 Most common otolaryngologic emergency
 Incidence is difficult to ascertain as most episodes go
unreported and resolve with conservative treatment
 Approximately 60% of the population will be affected by
epistaxis at some point in time, with 6% requiring
professional medical attention Figure 2. Nasal Septum
 According to the American Rhinologic Society
 Male (58%) > Female (42%) C. VASCULAR ANATOMY
 More common in colder months
 In colder months, decrease in humidity and higher  Compare arteries of lateral and septal wall
incidence of URTI which may lead to bleeding  Nasal cavity is supplied by the external and internal
 Two types of patients who seek medical attention for carotid systems
epistaxis:  External carotid terminates as the
 Multiple minor episodes  Superficial temporal artery
 Single severe prolonged episode  Internal maxillary artery
 and eventually the sphenopalatine artery
II. NASAL ANATOMY  Any of these arteries can bleed
 Sphenopalatine branch of the maxillary artery
A. LATERAL NASAL WALL  Supplies the posteroinferior septum
 Greater palatine artery
 Turbinates and their corresponding meati  Supplies the anteroinferior septum via the incisive canal
 Bleeding can occur in any part of the wall, however, most  Superior labial branch of the facial artery
of it affects the posterior part in the sphenopalatine area  Also contributes anteriorly
 If you compare the nasal septum and the lateral nasal  Anterior and posterior ethmoid arteries
wall, most of the bleeding will come from the septal wall

YL7: 09.12.01 Group 9: Balboa, Cabaddu, Demigillo, Dumadag, Garcia, Ladaga, Ong, Reyes, Tan 1 of 8
  Supply superiorly
Figure 3. Arteries of the lateral nasal wall and septal wall
Kiesselbach’s plexus
 aka Little’s area
 Vessels form a plexiform network in the mucosa which is
the most common site of epistaxis
 Located in the anterior part of the septum
 Area where the 4 arteries anastomose and form a
vascular plexus
 Anterior and posterior ethmoidal artery
 Comes from the internal carotid system
 Sphenopalatine artery
 Greater palatine artery
 Septal branch of the superior labial artery
Figure 4. Kiesselbach’s plexus
Woodruff’s plexus
 In 1949, Woodruff discovered a plexus of prominent
vessels inferior to the posterior end of the inferior
turbinate
 Aka: nasopharyngeal plexus
 Anastomosis of the sphenopalatine and posterior
pharyngeal arteries
 Around 5-10% of epistaxis
 Usually originate from the lateral wall and rarely from
the nasal septum
 In contrast with the Kiesselbach’s plexus
 Bleeding here normally can result in slow but prolonged
ooze
 The vessels come from veins and not arteries 
bleeding is continuous and not pulsatile
 Posterior packing may be necessary to control it
YL7: 09.12.01 Epistaxis and Obstruction: Otorhinolaryngology
Figure 5. Woodruff’s plexus
The nasal cavity has a very rich blood supply arising from
both the internal and external carotid arteries. A confluence
of these blood vessels supplying the nasal septum in the
front (“Kiesselbach plexus” in the “Little’s area”) is a common
source of nasal bleeding (epistaxis). This area can often be
cauterized in the office to stop nasal bleeding. The anterior
and posterior ethmoid arteries, both branches of the internal
carotid artery system supply the upper nasal septum and
nasal sidewalls. The superior labial branch of the facial artery
supplies the front part of the nose. The sphenopalatine
artery, a branch of the external carotid system supplies most
of the back of the nasal cavity. It enters the nasal cavity
through an opening located along the nasal sidewall called
the sphenopalatine foramen. When nasal bleeding is more
from the back part (posterior epistaxis), this artery is often
the culprit. When recurrent posterior epistaxis becomes a
problem, the sphenopalatine artery may need to be tied or
embolized.1
III. CAUSES OF EPISTAXIS
 Local
 Mechanical or traumatic
 Septal deformity
 Inflammatory disease
 Tumors
 Aneurysms
 Systemic
 Coagulation deficits
 Arteriosclerotic vascular disease
 Hereditary hemorrhagic telangiectasia
 Idiopathic
A. LOCAL
 Mechanical or traumatic
 Acute nasal trauma (e.g. elbow to the nose)
 Extensive facial trauma (e.g. vehicular accident)
 Bleeding after surgery
 If you enter the area of the frontal sinus during
endoscopic sinus surgery and injure the anterior
ethmoid arteries, you can have profuse bleeding
 Chronic nasal trauma (e.g. children picking their nose)
 Traumatize septal area
 Topical nasal steroid sprays
 Repeated irritation of the tip—if you spray it
incorrectly towards nasal septum abrading it will lead
to bleeding or
 Prolonged use (>3 months)will thin out nasal
mucosa and lead to occasional epistaxis
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  Warn long term users about epistaxis, although
episodes are short lived
 Chronic cocaine abuse
 Shabu more common in the Philippines (aka
methamphetamines)
 Very potent vasoconstrictor
 Vasoconstriction along area of the septum leads to
perforation of the septum because there is no blood
supply
 If you have a perforated septum, you will have
turbinate airflow dryness of mucosa and
crustingyou eventually pick it out and it bleeds until
cartilage resorts
 Foreign body
 Common in young children and patients with mental
retardation
 Children have habit of putting things in their nose
especially between 2-7 year olds
 Septal deformity
 Septal spurs and deviations can produce irregular
airflow, dryness and crusting with subsequent epistaxis
 Septal perforations can be a source of frequent
epistaxis
 Septal spurs
 Extra bony growth along natural preexisting
bones
 Occur along the floor of the nasal cavity most
commonly located in the maxillary crest
 Can cause turbinate airflow bleeding
 Inflammatory disease
 Viral URT, bacterial rhinosinusitis, allergic disease
 When prolonged can lead to epistaxis
 Usually blood streaked epistaxis (blood-streaked
mucus)
 Not profused bleeding
 Tumors
 Benign or malignant lesions
 Angiofibroma
 Benign tumor but it is very aggressive and
dangerous if you do a biopsy
 Presents in mMale teen
 Malignant lesions angiogenesis, hence once irritated
(e.g. nose blowing and URTI) can bleed anytime
Figure 6. Septal spurs
B. SYSTEMIC
 Coagulation Deficits
 Patient may have history of bruising, bleeding, irregular
menstruation. Other patients have history of dental
extractions wherein the bleeding does not stop
immediately.
 Clues that epistaxis is a symptom of an underlying
bleeding disorder include lack of seasonal variation and
bleeding that requires medical evaluation or treatment,
including cauterization1
 Epistaxis is the most common symptom in boys with
Von Willebrand Disease1
YL7: 09.12.01 Epistaxis and Obstruction: Otorhinolaryngology
 Arteriosclertoic Vascular Disease
 Common among people with Hypertension
 The relationship between hypertension and epistaxis
is often misunderstood. Patients with epistaxis
commonly present with an elevated blood pressure.
Epistaxis is more common in hypertensive patients,
perhaps own to vascular fragility from long-
standing disease1
 This can cause epistaxis and bleeding with just a
spike of the BP
 Hypertension is rarely a direct cause of epistaxis.
 Hereditary Hemorrhagic Telangectasia (HHT)
 Also known as Osler-Weber-Rendu Disease2
 Rare autosomal dominant disorder that affects blood
vessels throughout the body (causing vascular
dysplasia) and results in a tendency for bleeding2
 Epistaxis is the most common symptom in HHT 1
 Recurrent and severe epistaxis is the most common,
presentation, frequently leading to severe anemia that
necessitates transfusion.2
 Clinical diagnosis based on Curacao criteria: epistaxis,
telangiectasias, visceral lesions, family history (1st
degree relative with HHT)
 3 or 4 criteria present: Definite
 Two criteria present: Possible or suspected
 Less than two criteria present: Unlikely
 Drugs
 You also need to ask patients about the use of aspirins,
NSAIDs, gingko biloba, or blood thinners as these can
eventually lead to epistaxis
IV. RED FLAGS
 These patients warrant further investiation
1. Signs of hypovolemia or hemorrhagic shock
2. Anticoagulant drug use (e.g. warfarin, aspirin)
3. Cutaneous signs of a bleeding disorder
4. Bleeding not stopped by direct pressure or
vasoconstrictor-soaked pledgets
5. Multiple recurrences, particularly with no clear cause
V. PHYSICAL EXAMINATION
 Approximately 90% of nose bleeds can be visualized
through either nasal speculum or fiberoptic endoscope
 Sometimes, patients will come in with plugs in their
nose. You need to ask the patient to hold his nose first
and remove the plugs so you can examine the inner
nose better
 Application of vasoconstrictors can help to lessen and
control the bleeding first.
 Nasal speculum
 Spreading the naris vertically
 Do not insert too much nor elevate too much as this
may cause extreme pain to the patient
 Look within the naris to locate where the exact point
of bleeding is
 Fiberoptic Endoscope
 Can be used to visualize the posterior part of the nose
 Topical anesthesia may be used to lessen the pain and
discomfort the patient may have
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Figure 7. Fiberoptic Endscopy
 Blood pressure measurement
 Part of the potential causes mentioned was
hypertension, however, hypertension is rarely a direct
cause of epistaxis
 Epistaxis and associated anxiety cause an acute
elevation of BP. Sometimes, when you start bleeding
you will get anxious and when you get anxious, your BP
elevates
 Thus, a very good history is needed.
 Ask the patient whether the blood pressure was
being controlled in the past week, which most likely
means the elevation of the BP may just be due to the
anxiety.
 Otherwise, if the patient has a history of uncontrolled
hypertension then it may be the cause.
 Therapy should be focused on controlling
hemorrhage and reducing anxiety as a primary
means of BP reduction.
 Do not just give antihypertensives right away.
 Stable patients should be instructed to grasp and pinch
the entire nose, maintaining pressure for at least 10-
15 minutes.
 Clotting time of the patient is within that time
 If the patient does not have any bleeding disorder, you
would expect that by doing this, the patient can already
stop the bleeding.
 Unless the patient has any bleeding disorder or
coagulopathies. Once they release the pinch, they will
continue to bleed.
 You have to ask the patient how they control their
nose bleed.
 Make sure they compress the soft tissue (anterior
part since 90% of bleeding comes from this area) of
the nose against the nasal septum
 Never tell the patient to tilt their head back. This is a
common mistake.
 The patient may swallow the blood! The blood will then
go to the stomach and irritating gastric contents
causing reflux and eventually the patient can vomit
 When the patient vomits, they get more anxiety. Then
when the patient comes to you bleeding from both the
nose and the mouth, you will have a harder time
determining the primary cause. You may end up
considering a gastric ulcer as well.
 If direct pressure is not sufficient, gauze moistened with
epinephrine or phenylephrine may be placed in the
YL7: 09.12.01 Epistaxis and Obstruction: Otorhinolaryngology
affected nostril to help vasoconstrict and achieve
hemostasis4
Figure8. Compressing the nose and tilting the head
forward should be done by the patient to control
epistaxis
VI. LABORATORIES AND IMAGING
 Routine laboratory testing is not required
 CBC, PT, and PTT (to evaluate the clotting factors and
coagulation cascade) should be done in the following:
 Patients with symptoms or signs of a bleeding disorder
 Patients with severe or recurrent epistaxis
 Do not insert too deep or elevate too much as this
may cause extreme pain to the patient
 If a coagulopathy is determined, you have to seek
referral to a hematologist to help with the management
of the patient.
 CT may be done if a foreign body, tumor, or sinusitis is
suspected
VII. TREATMENT
 Accurate history is necessary
 Onset, trigger, presence of fever with the bleeding,
presence of URTI, any history of allergies and/or
trauma
 May need to be done in conjunction with maneuvers to
control bleeding
 Laboratory examination
 Not usually done unless you see a need
 Sinus films and CT or MRI
 Before you see the patient, you have to be prepared
 Gowns, gloves, and protective eyewear should be worn
 Prevent exposure to a possibly infected patient
 Adequate light source
 Since you will be inspecting the nose
 Patients seated comfortably with a basin under their
chin
 Since patient may be spitting out blood
A. CAUTERY3
 Chemical Cautery
 Bleeding from the Kiesselbach plexus is frequently
treated with silver nitrate cauterization
 Silver nitrate is placed on an applicator stick and
applied to the vessels leading to the site, not the
bleeding site itself
 Electrocatuerization
 With an insulated suction cautery unit can also be
used
 This method is usually reserved for more severe
bleeding and for bleeding in more posteriorly located
sites
 Often requires anesthesia
 Laser photocoagulation is also useful
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 Avoid random and aggressive cauterization and avoid
cautery on opposing surfaces of the septum
B. ANTERIOR NASAL PACKING3
 Nasal packing can be used to treat epistaxis that is not
responsive to cauterization
 Adequate anesthesia and vasoconstriction is necessary
(for both anterior and posterior packing)
 Administer prophylactic antibiotics to all patients with
packing, and instructed to avoid physical strain for 1
week
 Need to ensure patient is comfortable with this, since
putting anything inside the nose is uncomfortable. It will
also interfere with eating.
 Gauze packing
 Vaseline gauze packing is filled with an antibiotic
ointment
 Layered tightly and far enough posteriorly to private
adequate pressure (accordion layered)
 Both ends of the packing should be retained anteriorly
 Blind packing with loose gauze is to be avoided
 Removed in 2-5 days
Figure 9. Vaseline gauze packing
Figure 10. Anterior Nose Gauze Packing
 Merocel sponges
 Can be placed relatively easily and quickly but may not
provide adequate pressure.
 Should also be coated with an antibiotic ointment and
can be hydrated with a topical vasoconstrictor
 Removed in 2 days
Figure 11. Merocel Sponge Packing
YL7: 09.12.01 Epistaxis and Obstruction: Otorhinolaryngology
 Ensure that bleeding is controlled before removal
 For patients with coagulopathy
 Cautery and packing may not be preferred
 Microfibrillar collagen or oxidized cellulose can be
placed directly on the bleeding site
C. POSTERIOR NASAL PACKING3
 Epistaxis that cannot be controlled by anterior packing can
be managed with posterior packing
 Regardless of the type of posterior pack used, an anterior
pack should also be placed
 May be a traditional gauze pack or an inflatable balloon
 Applied using a catheter
 Pack should be of adequate size to occlude the
posterior choanae, but not interfere with swallowing
 Admit all patients with posterior packing to the ICU
 For close monitoring of oxygenation (via pulse
oximetry since nasal packing can lead to
hypoxemia), fluid status, and pain control
 Monitor for and prevention of complications
 Sinusitis due to blockage of sinus outflow
 Eustachian tube dysfunction due to blockage of
Eustachian tube area
 Serous otitis media also due to Eustachian tube
blockage
 Antibiotics should also be given
 Rhinosinusitis and possible toxic shock syndrome or
Staphylococcal scalded skin syndrome, both normally
caused by Staphylococcus
Figure 12. Posterior Nose Gauze Packing
C. ENDOSCOPIC CAUTERIZATION
 If bleeding site cannot be visualized
 Rigid or flexible endoscopes may be used
 Suction and irrigation devices facilitate localization of
bleeding
 Topical anesthesia and topical vasoconstrictors need to
be applied
 Success rate is 80-90%
C. ARTERIAL LIGATION
 Traditionally has been the management of choice if
packing fails
 Choice of specific vessel to ligate usually is dictated by
the observed site or the most likely site of bleeding
based on history
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  In general, the closer the ligation is to the bleeding site,
the more effective the procedure tends to be
 External Carotid Artery (ECA)
 Has been advocated because it can be performed
under local anesthesia and without special
instruments
 Horizontal skin incision between hyoid bone and
superior border of thyroid cartilage  subplatysmal skin
flaps raised  SCM retracted  carotid sheath opened
and contents exposed  ECA identified by following
ICA  ligated distal to superior thyroid artery3
 Rebleeding can occur in 45%
 High chance of bleeding because of cross-
anastamosis coming from the other sites or coming
from the internal carotid system
 Internal Maxillary Artery (IMA)
 Most popular method over the past several decades
 Usually approached transantrally
 Posterior sinus wall removed  posterior periosteum
opened  terminal branches of IMA in
pterygopalatine fossa3
 Preoperative assessment of antral size is important so
you have to do a sinus x-ray
 Some patients may have hypoplastic maxillary
sinuses
 Reported success rate: 75-100%
 Sphenopalatine Artery
 Key point in understanding posterior nosebleeds since
most posterior epistaxis is from this area
 Approached intranasally during endoscopic
visualization
 Incision made just posterior to posterior
attachment of middle turbinate  mucosal flap
elevated to reveal sphenopalatine artery coming out
of sphenopalatine foramen3
 Ethmoid Artery
 May be indicated if the bleeding is superior to the
middle turbinate
 Ligation of anterior, posterior, or both ethmoid arteries 4
 Can be approached externally through external
incision (incision around the area of the nasal bridge
and go through lacrimal fossa) or intranasally (just
behind frontal sinus ostium) through endoscopes
endoscope)
C. EMBOLIZATION
 Due to increasing availability of interventional radiologists
 Transfemoral route is usually selected
 Preoperative angiography
 To check where to embolize
 To check for the presence of any unsafe
communications between the ICA and ECA systems
 Selective angiography of the IMA may also be
performed
 Uniltateral embolization is usually done unless the
bleeding site cannot be clearly identified
 Post-operative angiography
 To determine if bleeding is controlled
 Bleeding may still occur due to cross-anastomoses
 Most common reason for failure is continued
bleeding from the ethmoid arteries
 To evaluate degree of occlusion
 Success rate: 70-96%
VIII. PATIENT EDUCATION
 Saline spray
 Epecially for patients with dry nasal mucosa
 Use isotonic nasal spray to avoid irritation of mucus
membrane
 Avoid nose blowing
 Avoid digital manipulation
 Especially for patients with children
 Avoid hot spicy foods and hot showers
 These can lead to vasodilation and eventual bleeding
 Avoid aspirins, NSAIDS, and gingko biloba
IX. EPISTAXIS MANAGEMENT ALGORITHM
 Mild Epistaxis  pinching the nose (10-15 minutes)  if
bleeding continues do anterior nasal packing
 Profuse Epistaxis  anterior nasal packing  if bleeding
continues  anterior nasal packing + posterior nasal
packing

Table1. Summary of Arterial Ligation Methods X. ANTERIOR VS POSTERIOR EPISTAXIS

Site of Approach Other Information
Ligation Table2. Comparison of Anterior and Posterior Epistaxis
External External (via skin Local anesthesia Anterior Posterior
Carotid Artery incision between Incidence More common Less common
hyoid bone and No special Site Mostly from Little’s Mostly from
superor border of instruments needed area or anterior part of posterosuperior part
thyroid cartilage)3 lateral wall of nasal cavity
Rebleeding can Age Children or young After 40 years of age
occur in 45% adults
Internal Transantral Most popular Cause Mostly trauma Spontaneous; often
Maxillary Artery method due to hypertension
or arteriosclerosis
Preoperative Bleeding Mild Severe
assessment of
antral size (via sinus Easily controlled by Requires
x-ray) local pressure or hospitalization
Sphenopalatine Intranasal (via Key point in anterior pack
Artery endoscope) understanding Postnasal pack often
posterior
nosebleeds XI. PHILOSOPHY OF MANAGEMENT
Ethmoid Artery External (via For bleeding
external superior to middle
 Establish the site of bleeding
ethmoidectomy turbinate
excision)  Stop the bleeding
 Treat the cause
Intranasal (via

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 XIV. IMPORTANT NOTES  However hypertension is rarely a direct cause of
epistaxis
 Most common otolaryngologic emergency  Hereditary Hemorrhagic Telangiectasia (HHT)
 Male (58%) > Female (42%)  Drugs
 More common in colder months  Red Flags
 Two types of patients who seek medical attention for  Signs of hypovolemia or hemorrhagic shock
epistaxis:  Anticoagulant drug use
 Multiple minor episodes  Signs of bleeding disorder
 Single severe prolonged episode  Bleeding not stopped by direct pressure or
 Nasal anatomy vasoconstrictor-soaked pledgets
 Lateral nasal wall  Multiple recurrences
 Turbinates and their corresponding meati  Physical Exam
 Nasal septum  90% can be visualized
 Bony: perpendicular plate of the ethmoid bone,  Anterior Rhinoscopy
vomer, and the nasal crest of the maxilla and  Fiberoptic Endoscope
palatine bones.  Blood pressure measurement
 Quadrangular cartilage  As patient to control their nosebleed
 Vascular anatomy  Grasp and pinch the entire nose for 10-15 minutes
 Nasal cavity is supplied by the external and internal  Laboratories and Imaging
carotid systems  Routine lab tests are not required
 External carotid terminates as the superficial temporal  Treatment
artery, internal maxillary artery and eventually the  Cautery
sphenopalatine artery  Anterior Nasal Packing
 Sphenopalatine branch of the maxillary artery  Posterior Nasal Packing
 Supplies the posteroinferior septum  Endoscopic Cauterization
 Greater palatine artery  Arterial Ligation
 Supplies the anteroinferior septum via the incisive  Embolization
canal  Patient Education
 Superior labial branch of the facial artery  Epistaxis Management Algorithm
 Also contributes anteriorly  Mild Epistaxis  pinching the nose (10-15 minutes) 
 Anterior and posterior ethmoid arteries if bleeding continues do anterior nasal packing
 Supply superiorly  Profuse Epistaxis  anterior nasal packing  if
 Kiesselbach’s plexus (Little’s area) bleeding continues  anterior nasal packing + posterior
 most common site of epistaxis nasal packing
 Located in the anterior part of the septum  Anterior vs Posterior Epistaxis
 Area where the 4 arteries anastomose and form a Anterior Posterior
vascular plexus
Incidence More common Less common
 Anterior and posterior ethmoidal artery
Site Mostly from Little’s Mostly from
o Comes from the internal carotid system
area or anterior part of posterosuperior part
 Sphenopalatine artery lateral wall of nasal cavity
 Greater palatine artery Age Children or young After 40 years of age
 Septal branch of the superior labial artery adults
 Woodruff’s plexus (nasopharyngeal plexus) Cause Mostly trauma Spontaneous; often
 prominent vessels inferior to the posterior end of due to hypertension
the inferior turbinate or arteriosclerosis
 Usually originate from the lateral wall and rarely Bleeding Mild Severe
from the nasal septum
o In contrast with the Kiesselbach’s plexus Easily controlled by Requires
 Bleeding here normally can result in slow but local pressure or hospitalization
prolonged ooze anterior pack
 Causes Postnasal pack often
 Local  Philosophy of Management
 Mechanical or traumatic  Establish the site of bleeding
 Acute nasal trauma  Stop the bleeding
 Extensive facial trauma  Treat the cause
 Bleeding after surgery
 Chronic nasal trauma REVIEW QUESTIONS
 Topical nasal steroid sprays
 Chronic cocaine abuse 1. Four arteries that compose the Kiesselbach’s plexus,
 Foreign body except:
 Septal deformities (spurs, deviations and a. Anterior ethmoidal artery
perforations) b. Internal maxillary artery
 Inflammatory disease (Viral URT, bacterial c. Sphenopalatine artery
rhinosinusitis, allergic disease) d. Greater palatine artery
 Tumors (Angiofibroma) 2. Woodruff’s plexus is found in which part of the nasal
 Systemic cavity?
 Coagulation deficits a. Posterior lateral wall
 Areteriosclerotic Vascular Disease b. Anterior lateral wall
 Common among people with hypertension c. Posterior nasal septum
d. Anterior nasal septum

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3. True or false. Chronic drug use can lead to septal
perforation
a. True
b. False
4. True about posterior nasal packing
a. Need not be given antibiotics
b. First line for profuse epistaxis
c. Anterior packing should also be done
d. Patient may be managed as an outpatient
5. Most popular site of arterial ligation?
a. External carotid artery
b. Internal maxillary artery
c. Sphenopalatne artery
d. Ethmoid artery
6. Which ligation site and approach are matched
incorrectly?
a. Sphenopalatine artery : intranasal
b. Ethmoid artery : external or intranasal
c. Internal maxillary artery : transantral
d. External carotid artery : transantral

Answers: b, a, a, c, d, b

REFERENCES

1. Kasper DL, Fauci AS, Longo DL, Hauser SL, Jameson JL,
Loscalzo J, eds. Harrison’s Principles of Internal
Medicine. 19th ed. New York, NY: McGraw-Hill Education;
2015.
2. Lessnau, K-D. Osler-Weber-Rendu Disease (Hereditary
Hemorrhagic Telangiectasia).
http://emedicine.medscape.com/article/2048472-overview.
Published July 12, 2016. Accessed Dec 06, 2016.
3. Nguyen Q. Epistaxis.
http://emedicine.medscape.com/article/863220. Published
May 04, 2016. Accessed Dec 06, 2016.
4. http://care.american-rhinologic.org/nasal_anatomy.
5. Alexander’s Surgical Procedures book

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