Epistaxis for NEET PG: Little's Area, Woodruff's Plexus, and the Management Ladder

Epistaxis questions are really three questions in a row: where is the bleeding coming from, why is it happening, and which rung of the management ladder comes next. Get the anatomy right and the rest follows, because almost every answer in this topic is decided by whether the bleed is anterior or posterior.

Blood Supply of the Nasal Cavity: Two Arterial Systems

The nose is supplied by both the internal and the external carotid systems, and that dual supply is why bleeding can come from so many places. The internal carotid contributes through the ophthalmic artery, whose anterior and posterior ethmoidal branches supply the upper part of the nasal cavity and septum. The external carotid contributes through the maxillary artery, whose terminal branch, the sphenopalatine artery, is the main blood supply of the nasal cavity, and through the greater palatine artery. The facial artery adds the superior labial artery, whose septal branch reaches the front of the septum.

Little's Area and Kiesselbach's Plexus

The front of the nasal septum, just inside the vestibule, is where four arteries meet and form a rich anastomosis called Kiesselbach's plexus. The area it occupies is known as Little's area. The mnemonic LEGS names the four contributors: Labial (superior labial artery), Ethmoidal (anterior ethmoidal artery), Greater palatine artery and Sphenopalatine artery. Little's area is the commonest site of nosebleeds overall, particularly in children and young adults, because the mucosa here is thin, closely applied to the septal cartilage, exposed to dry inspired air and easily traumatised by nose picking.

Woodruff's Plexus and Posterior Bleeds

Posterior epistaxis usually arises from the back of the lateral nasal wall, in the region of Woodruff's plexus, a network of vessels under the posterior end of the inferior turbinate that is fed largely by branches of the sphenopalatine artery. Posterior bleeds are more common in older adults and are often heavy. Blood tends to run down the back of the throat rather than out of the nostril, which is why the patient may complain of swallowing blood or vomiting it rather than noticing a nosebleed. Hypertension is commonly associated with these bleeds in the elderly, although whether it truly causes them is debated.

Anterior vs Posterior Epistaxis

Feature	Anterior	Posterior
Usual source	Little's area (Kiesselbach's plexus)	Woodruff's plexus and sphenopalatine branches
Typical patient	Children and young adults	Older adults, often hypertensive
Bleeding pattern	Usually one nostril, slower	Often heavy, down the throat, may be bilateral
Can it be seen?	Yes, on anterior rhinoscopy	Often only with an endoscope
First-line control	Pinching, cautery, anterior pack	Posterior pack or balloon, with admission
If it persists	Anterior ethmoidal artery control	Sphenopalatine artery ligation or embolisation

Causes Worth Recognising

Local causes are the commonest: digital trauma from nose picking, dry mucosa, fractures, septal deviation with spurs, foreign bodies in children, and tumours. Systemic causes include bleeding disorders such as haemophilia, von Willebrand disease and thrombocytopenia, liver disease, and anticoagulant or antiplatelet drugs.

Three specific associations are heavily tested. Juvenile nasopharyngeal angiofibroma presents in adolescent boys with profuse, recurrent, usually unilateral epistaxis and nasal obstruction, and it should not be biopsied because of the risk of torrential bleeding. Hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu disease), an autosomal dominant condition, causes recurrent spontaneous epistaxis with mucocutaneous telangiectasias and a family history. A unilateral foul-smelling discharge with bleeding in a child points to a nasal foreign body.

Assess the Patient Before the Nose

Nosebleeds can be dangerous in the elderly or the anticoagulated, so the first job is not to look in the nose but to assess airway, breathing and circulation. Check the pulse and blood pressure, establish intravenous access if the bleeding is heavy, and send a full blood count, blood group and clotting profile when there is significant blood loss or an anticoagulant history. Only then is the source sought, with good light, suction, a topical vasoconstrictor and anaesthetic, and either a nasal speculum or an endoscope. A CT scan is reserved for suspected tumour, recurrent unilateral bleeding or sinus disease. It is not a routine test for a simple anterior bleed.

First Aid: What to Do at the Bedside

Have the patient sit upright and lean forward so blood does not run down the throat. Pinch the soft, cartilaginous part of the nose, not the bony bridge, firmly for 10 to 15 minutes without releasing to check. The patient should breathe through the mouth and spit out any blood, and a cold compress over the nose is commonly added. Pinching the soft part matters because it compresses Little's area against the septum, which is where most bleeds start.

The Management Ladder

Management proceeds stepwise, moving up only when the previous step fails. Learn the order, because vignettes ask what to do next.

Step	Intervention	Notes
1	Pressure while sitting forward, plus a topical vasoconstrictor such as oxymetazoline	First aid; check airway, pulse and blood pressure
2	Find the bleeding point after clearing clots and applying topical anaesthetic and vasoconstrictor	Anterior rhinoscopy or nasal endoscope
3	Cautery with silver nitrate or electrocautery	One side of the septum at a time to avoid perforation
4	Anterior nasal packing (ribbon gauze, expandable sponge or balloon)	Usually removed after 24 to 48 hours
5	Posterior pack or balloon catheter, with admission	Monitor oxygen saturation
6	Endoscopic sphenopalatine artery ligation, anterior ethmoidal artery ligation for bleeding above the middle turbinate, or embolisation	For bleeding that persists despite packing

Two points on the ladder are classic traps. First, silver nitrate is applied to only one side of the septum at a time, because cauterising both sides opposite each other can destroy the septal cartilage's blood supply and cause a perforation. Second, posterior packing carries real physiological risk, including hypoxia, partly through the nasopulmonary reflex, which is why these patients are admitted and monitored rather than sent home.

Complications of Packing

Packs stop bleeding, but they are not benign. An anterior pack can cause sinusitis or otitis media by blocking drainage, septal pressure necrosis and, rarely, toxic shock syndrome, which is why packs are removed within the usual 24 to 48 hours. Posterior packs add the risk of hypoxia, palate necrosis and eustachian tube blockage. Any patient with a posterior pack should be admitted.

Special Situations

• Child with recurrent bleeding: usually digital trauma or dry mucosa. Treat with humidification and ointment, and stop the picking.
• Adolescent boy with unilateral obstruction and profuse epistaxis: think angiofibroma, and do not biopsy.
• Elderly hypertensive with heavy bleeding down the throat: think posterior bleed, and check and manage the blood pressure.
• Patient on anticoagulants: check the clotting profile, and stop or reverse the drug only if bleeding is severe and after weighing why it was prescribed.
• Recurrent bleeding with telangiectasias and a family history: think hereditary haemorrhagic telangiectasia.

Preventing Recurrence

Most recurrent anterior bleeds settle with simple measures: humidification, petroleum jelly or antibiotic ointment applied to the septum, short nails, avoiding nose picking, and treating any underlying allergy or infection. Blood pressure should be controlled in older patients. Recurrent bleeding in a young patient with a normal nose, or with bleeding at other sites, warrants a bleeding disorder work-up.

Hereditary Haemorrhagic Telangiectasia: The Curaçao Criteria

Hereditary haemorrhagic telangiectasia is diagnosed using the Curaçao criteria, which give one point each for four features: recurrent spontaneous epistaxis, multiple mucocutaneous telangiectasias (typically on the lips, tongue, fingertips and nasal mucosa), visceral lesions such as pulmonary, cerebral or hepatic arteriovenous malformations, and a first-degree relative with the disease. Three or more features make the diagnosis definite, two make it possible or suspected, and fewer than two make it unlikely. The nosebleeds are the commonest presenting problem and are often severe enough to cause iron-deficiency anaemia, so management includes iron replacement alongside local nasal treatment, and the visceral malformations need screening in their own right.

Why the Sphenopalatine Artery Is the Target

The sphenopalatine artery is the terminal branch of the maxillary artery and enters the nasal cavity through the sphenopalatine foramen, behind the middle turbinate. Because it supplies most of the lateral nasal wall and the septum, controlling it stops the great majority of severe posterior bleeds, which is why endoscopic ligation or cautery of this vessel is the surgical step examiners expect after failed packing. The anterior ethmoidal artery is the other named target, used when the bleeding point is high, above the level of the middle turbinate.

How Vignettes Are Built

Read the vignette for three things: the patient's age, the side and character of the bleeding, and what has already been tried. A child with a small anterior bleed needs first aid and cautery, not surgery. An elderly patient who keeps bleeding despite anterior packing needs a posterior pack or balloon and admission, and if that fails, sphenopalatine artery ligation. Nearly every wrong answer in this topic skips a rung or applies the wrong rung to the wrong site.

For another high-yield ENT topic, see our guide to the Rinne and Weber test, and for how much of the paper ENT carries, our subject-wise weightage breakdown.