Woodruff's plexus

Structure

Woodruff's area is present under the posterior end of inferior turbinate on the lateral nasal wall which is also called nasopharyngeal plexus. The sphenopalatine and posterior pharyngeal arteries anastamoses at the posterior end of inferior turbinate. Sphenopalatine artery enter the nasal cavity through the sphenopatine foramen located on lateral nasal wall within superior meatus usually between the middle turbinate and posterior horizontal end of the lamella of the superior turbinate. Generally this is just about the posterior end of the horizontal lamella of the middle turbinate and just posterior to the etmoidal crest of the perpendicular plate of the palatine bone.

Bleeding

Posterior epistaxis occur primarily in old adult.

Only about 5-10% of bleeding which occurs is from woodruffs area from the branches of internal maxillary artery including:

Anterior epistaxis is due to Kiesselbach's plexus and posterior epistaxis is due to Woodruff's plexus.

A posterior source present a greater risk of airway compromise,aspiration of blood,and greater difficulty in controlling bleeding.

Treatment

Posterior nasal packing is needed for posterior epistaxis.

Posterior nasal packing

Its required for patients bleeding posteriorly into the throat.A postnasal pack is first prepared by tying three silk ties to a piece of gauze rolled into the shape of cone. A rubber catheter is passed through the nose and its end brought out from the mouth.Ends of the silk threads tied to it and catheter withdrawal from nose.Pack which follows the silk thread, is now guided into nasopharynx with the index finger. Anterior nasal cavity is now packed and silk thread tied over the dental roll.The third silk thread is cut shorts and allowed to hang in the oropharynx, it helps in easy removal of the pack later.Patient requires postnasal pack should always be hospitalized.

Foley's catheter of size 12-14F can also be used to prevent posterior epistaxis. After insertion balloon is inflated with 5-10 ml of saline.The bulb is inflated with saline and pulled forward so that choana is blocked and then an anterior nasal balloons are also available. A nasal balloons has 2 bulbs,one for post nasal space and the other for nasal cavity.

Endoscopic cautery

Posterior bleeding point can sometimes be better located with an endoscope.It can be coagulated with the cautery. Local anesthesia with sedation may be required

Ligation of vessels

Ligation of this is done in uncontrollable posterior epistaxis. Approach is Caldwell-luc operation.Posterior wall of the maxillary sinus is removed and the maxillary artery or its branch are blocked by applying clips.