A 35-year-old woman awoke from sleep to find the side of her head in a puddle of blood on her pillow, with active bleeding from her right external nares. Upon arising, she noticed persistent bleeding, although blood was now flowing down the back of her throat in addition to the nares. She pinched her nose between her index finger and thumb and dressed with the assistance of her partner who drove her to the emergency department (ED). Breathing was difficult for the patient, and she kept her head flexed forward in an attempt to keep blood from entering her airway while breathing through her mouth.
At the ED, the patient was triaged immediately to a room outfitted for otolaryngologic emergencies. As the patient was worked up, she appeared pale and anxious but in no other obvious distress. Her vital signs revealed a BP of 90/60, HR 110, RR 20, temperature of 100.1 (oral) and pulse oximetry of 92% on room air. Brisk bleeding was observed from the external nares as well as into the posterior oropharynx from the nasopharyngeal region. The neck was otherwise supple, the heart rate and rhythm were tachycardic yet with a normal S1, S2 and no murmurs, extra heart sounds or gallops. The lungs were clear to auscultation. As the patient was wearing shorts and sandals, the physician noticed petechiae on the shins of both legs.
As an IV was being started, the ED physician had the patient express all clots from the nasal cavity. An active bleeding site could not be found while inspecting the anterior septal region, and the application of a topical vasoconstrictor diminished the flow of blood slightly but did not assist in revealing a bleeding site. The placement of an anterior nasal pack lessened bleeding from the nares but left the flow of blood into the pharynx unchanged. The emergency physician then placed a balloon-tipped catheter deep into the nasal cavity and after the balloon was inflated the bleeding stopped.
After the acute bleeding had been addressed, the ED physician began the process of taking a more detailed medical history from the patient. The history was free of any congenital or chronic conditions, and the patient had a long-standing record of seeing her primary care physician for annual wellness exams. Her only medications were over the counter vitamins C and D.. While denying any recent infections, the patient did reveal that she has been feeling more fatigued than normal for the past few months. She also noticed that she caught more colds than normal over the past winter season and that the most recent cold lingered longer than usual and that she had developed a bacterial sinus infection which had been treated successfully with oral antibiotics.
What is the likely diagnosis?
What are the bones that form the medial wall of the nasal cavity?
What is the arterial supply of the nasal cavity?
What is the sensory nerve supply of the nasal cavity?
What is Kiesselbach’s plexus?
What is an anterior nose bleed?
Where do posterior nasal bleeds occur, what is the artery most often involved, and what anatomical features make them challenging to treat?
In severe epistaxis that is unrelenting and refractive to customary therapy (rare), an intervention on the carotid system may be employed as a final option. Describe how this might be carried out.