The Nose

1. Bony and cartilaginous framework
2. Overlied by skin and fibrofatty tissue
3. Bones:
   • external: nasal bone + frontal process maxilla
   • Internal: nasal, frontal (crista galli), ethmoid, maxillary (palatine process), sphenoidal
   • Medial septum: vomer, ethmoid perpendicular plate
4. Divided into left and right nasal cavities by nasal septum (perpendicular plate of ethmoid bone)
5. Epithelium: respiratory (ciliated columnar)
6. Conchae/meatus/turbinates
   • Superior meatus: opening of posterior ethmoidal air cells
   • Middle meatus: frontal, maxillary, anterior and middle ethmoidal
   • Inferior meatus: nasolacrimal duct from eye

Blood Supply to the nose

(All derived from external carotid artery)

1. Anterior ethmoidal
2. Posterior ethmoidal
3. Sphenopalatine
4. Greater palatine
5. External branches of labial

Epistaxis

Management

1. Resuscitate
2. History
   • Duration of bleeding
   • Preceding injuries: nose picking, nasal trauma, infection, neoplasia
   • Medications - anticoagulants, antiplatelet agents
   • PMHx of bleeding diathesis, family history
   • Perpetuating factors - hypertension
3. Assess bleeding
   • FBC, U/Es, LFTs, Coag
4. Examination (personal protection - gown/apron/gloves/visor)
   • Patient should attempt to clear their nose
   • Spray local anaesthetic (with adrenaline as vasoconstrictor)
   • Identify source of bleeding by anterior rhinoscopy with Thudicum's speculum
   • Look at kisselbach's plexus (anterior part of septum in Little's area)
   • If bleeding not visible, may be posterior bleed
5. Emergency Treatment
   • Digital pressure to entire nose + cold compress/ice pack
   • Silver nitrate cautery / electrocautery coagulation of vessel (only one side of septum should be cauterised at once; small risk of septal perforation)
   • Pack nostril with nasal tampon (Merocel) / ribbon gauze (BIPP) - can pack both to increase tamponade effect; complications - sinusitism, airway obstruction, inhalation of pack, infection (risk of toxic shock syndrome)
   • Foley balloon catheter used for tamponade
6. Surgical treatment
   • Posterior nasal packing (under GA)
   • Submucosal resection which decreases blood flow to mucosa
   • Endoscopic visualisation of sphenopalatine artery and bipolar cautery/ ligation
   • Arterial ligation
   • Angiogram and embolisation
7. Follow up
   • BP check with GP
   • Further nasal examination to exclude neoplasia