Review Question - QID 102613

This patient suffers from a case of intractable epistaxis given his persistent bleeding from his nares. It is most likely an anterior bleed from Kiesselbach plexus.

Epistaxis (or nose-bleeding) can have an anterior or posterior bleeding source. Most often, it originates in the anterior nasal cavity. Patients often have a history of activity in high heat and low humidity or minor nasal trauma such as nose-picking. An anterior bleed is most likely related to trauma to Kiesselbach plexus. Kiesselback plexus is composed of branches of the anterior ethmoidal artery, the sphenopalatine artery, the greater palatine artery, and the superior labial artery. The management of epistaxis first involves direct pressure. If this fails, topical tranexamic acid (anti-fibrinolytic) or oxymetazoline (alpha-1 agonist) can be used. If these measures fail, pressure with an epistaxis device that compresses the plexus can be used. If this fails, direct vessel coagulation may be needed. In severe or life-threatening bleeds, anticoagulation may need to be reversed.

Incorrect Answers:
Answer 1: Carotid artery is a major artery that may be damaged with a stab wound to the neck or when aspirating or draining a peritonsillar abscess. It can result in a rapidly fatal bleed.

Answer 2: Ethmoidal artery may give branches that feed into Kiesselbach plexus; however, it is not the most direct etiology of this patient's epistaxis.

Answer 4: Septal hematoma may occur in trauma and should be incised and drained with packing to ensure there is not a reaccumulation of blood.

Answer 5: Sphenopalatine artery (a branch of the maxillary artery) is the etiology of a posterior nasal bleed which may be associated with trauma, hypertension, cocaine abuse, surgery, or a mass. Treatment would involve coating the area with tranexamic acid or oxymetazoline and posterior nasal packing.

Bullet Summary:
An anterior nosebleed is commonly caused by injury to Kiesselbach plexus.