An 18-year-old girl presents to the emergency department with a nosebleed that has persisted for the last two hours despite her attempts to pinch the nose and apply cold compresses. She also reports an episode of bloody emesis. She reports having multiple nose bleeds a day for the last week. Past medical history is unremarkable. She denies cocaine use. Vitals signs are within normal limits. On physical examination, she appears pale. An anterior nasal packing is placed but the bleeding persists.
Which of the following is the most likely source of this patient’s bleeding?
A) Anterior ethmoid artery
B) Greater palatine artery
C) Lesser palatine artery
D) Posterior ethmoid artery
E) Sphenopalatine artery
E) Sphenopalatine artery
Epistaxis is classified as anterior or posterior, depending on the source of bleeding. Anterior bleeds account for the vast majority of nosebleeds, and most occur within the vascular watershed area of the nasal septum known as Kiesselbach’s plexus. The septal branch of the anterior ethmoidal artery, the lateral nasal branch of the sphenopalatine artery, and the septal branch of the super labial branch of the facial artery anastamose in this area. Severe epistaxis with associated hematemesis suggests a posterior bleed, most commonly the sphenopalatine artery, the terminal branch of the maxillary artery. Initial management includes tilting the head forward and pinching the nose. Posterior packing and topical phenylephrine may also help with bleeding. In severe cases refractory to all treatment, endoscopic ligation of the sphenopalatine artery is the recommended.
Key Learning Point
Severe epistaxis most commonly originates from the sphenopalatine artery, representing a posterior bleed.
