A 28-year-old man presents to the emergency department with a 45-minute history of persistent bleeding from his right nostril. He reports that the bleeding began spontaneously while he was sitting at home. He has tried applying pressure to the bridge of his nose for 10 minutes without success. He denies any recent trauma, easy bruising, or family history of bleeding disorders. Past medical history is negative. On physical examination, after clearing the clots, brisk arterial bleeding is noted from the anterior nasal septum. The patient is otherwise hemodynamically stable with normal vital signs.
Which of the following is the most likely source of this patient's bleeding?
The correct answer is:
B) Kiesselbach plexus
The vast majority (approximately 90%) of epistaxis episodes are anterior and originate from the Kiesselbach plexus. This is a highly vascularized region of the anteroinferior nasal septum where four arteries anastomose: the anterior ethmoidal artery, the sphenopalatine artery, the greater palatine artery, and the septal branch of the superior labial artery. Anterior bleeds are typically triggered by mucosal dryness, digital trauma (nose picking), or low humidity and can usually be managed with direct pressure, topical vasoconstrictors, or silver nitrate cautery.
Answer choice A: Ethmoidal arteries, is incorrect. While the anterior and posterior ethmoidal arteries (branches of the ophthalmic artery) supply the superior portion of the nasal cavity, they are less common sources of isolated, spontaneous epistaxis in healthy young adults compared to the Kiesselbach plexus.
Answer choice C: Palatine artery, is incorrect. The greater palatine artery contributes to the Kiesselbach plexus, but it is not the name of the plexus itself. Isolated bleeding from the palatine artery is rare in this clinical context.
Answer choice D: Sphenopalatine artery, is incorrect. The sphenopalatine artery is the primary source of posterior epistaxis. Posterior bleeds are more common in older patients with risk factors like hypertension or atherosclerosis. They are characterized by brisk bleeding that is difficult to visualize anteriorly and often results in blood dripping down the posterior oropharynx.
Answer choice E: Woodruff plexus, is incorrect. The Woodruff plexus is a venous plexus located over the posterior end of the middle turbinate. It is the most common site for posterior epistaxis, which usually requires posterior packing or arterial ligation for management.
Key Learning Point
Anterior epistaxis most commonly originates from the Kiesselbach plexus on the nasal septum and is usually managed with conservative measures such as pressure and/or vasoconstrictors. Posterior epistaxis most commonly originates from the sphenopalatine artery (Woodruff plexus) and often requires specialized packing or surgical intervention because it can lead to significant blood loss and airway compromise.
